BLOG

Summary of the Consensus statement on concussion in sport - the 5th international conference on concussion in sport

Posted September 27, 2017

By Elizabeth L. Augustine, MS, LAT, ATC

The following are the main modifications made to the Consensus statement on concussion in sport. The 2016 statement includes the modification in italics and I attempted to highlight the most updated info that was agreed upon in, within the update’s respective section. Please see the actual report for reference and further detail. There is a downloadable PDF.

RECOGNISE: The term “sport related concussion (SRC)” is more specifically defined in the latest consensus statement to read as simply “a traumatic brain injury induced by biomechanical forces”. In the 2012 statement, a much more extensive description was used. It does then go on to explain, clinically, how the injury will present, such as:

  • SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
  • SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
  • SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged. These clinical findings are the same as the 2012 statement, with the use of SRC instead of concussion.
  • The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical inju­ries, peripheral vestibular dysfunction, etc) or other comorbidities (eg, psychological factors or coexisting medical conditions).This is also an addition.

The statement comments on the use of biomechanical studies to aid in description of SRC:

“Although current helmet-based measurement devices may provide useful information for collision sports, these systems do not yet provide data for other (non-collision) sports, limiting the value of this approach. Furthermore, accelerations detected by a sensor or video-based systems do not necessarily reflect the impact to the brain itself, and values identified vary considerably between studies”. The use of helmet-based or other sensor systems to clinically diagnose or assess SRC cannot be supported at this time.

The best way to asses SRC is still through a multi-dimensional approach, with the SCAT5 being the best to utilize and does have research to support its use.It is most helpful immediately after injury, but has been shown to decrease its utility after 3-5 days, whereas the symptom checklist continues to demonstrate utility in tracking recovery. Baseline testing for symptoms can be helpful, but is not necessary.The consensus statement noted the use of video review as being a potential new tool for managing SRC.

REMOVE: This statement maintains that a player suspected of SRC be removed for evaluation by a physician or other qualified healthcare provider. The biggest update suggests that SRC evaluation should be given adequate time to conduct the evaluation, stating that the SCAT5 alone takes about 10 min to administer. Adequate facilities should be provided to complete the evaluation.It also suggests that some sports may need to modify their rules to better allow for SRC evaluation without interrupting the flow of game or penalizing the injured player’s team.

The statement also spoke about acute neurobiological effects of SRC on brain structure and function, stating “Advanced neuroimaging, fluid biomarkers and genetic testing are important research tools, but require further validation to determine their ultimate clinical utility in evaluation of SRC.”

REFER: The consensus statement defined persistent symptoms following SRC should reflect failure of normal clinical recovery - that is, symptoms that persist beyond expected time frames (ie, >10–14 days in adults and >4 weeks in children) and does not reflect a single pathophys­iological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/ or confounding factors, which do not necessarily reflect ongoing physiological injury to the brain.A detailed clinical approach is the best way to assess these cases and at minimum should include comprehensive history, focused physical examination, and special tests where indicated (eg, graded aerobic exercise test).

Treatment should be individualized and target-specific medical, physical and psychosocial factors identified on assessment. There is preliminary evidence supporting the use of:

  • an individualized symptom-limited aerobic exercise pro­gram in patients with persistent post-concussive symp­toms associated with autonomic instability or physical deconditioning, and
  • a targeted physical therapy program in patients with cervical spine or vestibular dysfunction, and
  • a collaborative approach including cognitive behavioral therapy to deal with any persistent mood or behavioral issues.

RECOVERY: The strongest and most consistent predictor of slower recovery from SRC is the severity of a person’s initial symptoms in the first day, or initial few days, after injury. Conversely, and impor­tantly, having a low level of symptoms in the first day after injury is a favorable prognostic indicator. Those with attention deficit hyperactivity disorder or learning disabilities might require more careful plan­ning and intervention regarding returning to school, but they do not appear to be at substantially greater risk of persistent symp­toms beyond a month.

Establishing time of recovery for SRC-The consensus group concluded that establishing a time of recovery, as it is based on so many potential factors.Moreover, recent literature suggests that the physiological time of recovery may outlast the time for clinical recovery.

RETURN TO PLAY: The recommendation is still a gradual return to play and the consensus statement has been modified to be more specific and improve clarity. Click on the following chart to enlarge it.

It is noted that children should not start return to sport protocol until they have returned to school.Included is a Graduated Return to School Strategy, that is in Table 2 on page 4 of the paper.

PREVENTION: The evidence to support the protective effect of helmets continues to be limited.There is some literature supporting the overall reduction in head injuries for snowboarding/skiing. Mouthguard use in preventing concussions research is still mixed. Restricting body checking in youth hockey has proven to reduce head injury in that sport. There is potential for vision training to help prevent, but there is no concrete evidence to support.

If you get a chance to check out the statement, it is worth your time! There is more information than is included in links in this Blog and are good tools to support what we do to manage sport related concussion.

References

McCory, P, Meeuwisse W, Dvorak J et al. Consensus statement on concussion in sport - the 5th international conference on concussion in sport held in Berlin, October 2016.British Journal of Sports Med, 2017; 0:1–10. doi:10.1136/bjsports-2017-097699.


About the Author

Elizabeth augustine

Elizabeth L. Augustine, MS, LAT, ATC has been an Athletic Trainer since 2006 and lives in Claypool, Indiana. She graduated from Manchester College with degrees in Athletic Training and Exercise Science and a minor in Spanish in 2006. She received her Master’s in Organizational Leadership and Supervision for Indiana-Purdue Fort Wayne in 2009. She currently works as an Athletic Trainer for a Sports Medicine doctor in Warsaw, Indiana. Her athletic training interests include concussions, creating policies and procedures, and injury rehabilitation. In her spare time, she enjoys running, playing tennis, doing puzzles, and spending time with her husband and two young daughters.