Journal of Athletic Training 2009;44(4):434–448

g by the National Athletic Trainers’ Association, Inc

www.nata.org/jat
consensus statement

Consensus Statement on Concussion in Sport: The 3rd

International Conference on Concussion in Sport Held
in Zurich, November 2008
Paul McCrory, MBBS, PhD*; Willem Meeuwisse, MD, PhD!; Karen Johnston,
MD, PhD`; Jiri Dvorak, MD‰; Mark Aubry, MDI; Mick Molloy, MD";
Robert Cantu, MD!!#
*University of Melbourne, Parkville, Australia; 3University of Calgary, Calgary, Alberta, Canada; 4Toronto
Rehabilitation Institute, Toronto, Ontario, Canada; 1FIFA Medical Assessment and Research Center and Schulthess
Clinic, Zurich, Switzerland; IInternational Ice Hockey Federation, Hockey Canada, and Ottawa Sport Medicine
Centre, Ottawa, Ontario, Canada; "International Rugby Board, Dublin, Ireland; #Emerson Hospital, Concord, MA

Preamble The following focus questions formed the foundation for

the Zurich concussion consensus statement:
This paper is a revision and update of the recommen-
dations developed following the 1st (Vienna) and 2nd Acute Simple Concussion
(Prague) International Symposia on Concussion in
Sport.1,2 The Zurich Consensus statement is designed to N Which symptom scale and which sideline assessment
build on the principles outlined in the original Vienna and tool is best for diagnosis and/or follow-up?
Prague documents and to develop further conceptual N How extensive should the cognitive assessment be in
understanding of this problem using a formal consensus- elite athletes?
based approach. A detailed description of the consensus N How extensive should clinical and neuropsychological
process is outlined at the end of this document under the (NP) testing be at non-elite level?
background section (see Section 11). This document is N Who should do/interpret the cognitive assessment?
developed for use by physicians, therapists, certified
athletic trainers, health professionals, coaches, and other
N Is there a sex difference in concussion incidence and
outcomes?
people involved in the care of injured athletes, whether at
the recreational, elite, or professional level. RTP Issues
While agreement exists pertaining to principal messages
conveyed within this document, the authors acknowledge N Is provocative exercise testing useful in guiding RTP?
that the science of concussion is evolving and, therefore, N What is the best RTP strategy for elite athletes?
management and return-to-play (RTP) decisions remain in N What is the best RTP strategy for non-elite athletes?
the realm of clinical judgment on an individualized basis. N Is protective equipment (eg, mouthguards and helmets)
Readers are encouraged to copy and distribute freely the useful in reducing concussion incidence and/or severity?
Zurich Consensus document and the Sports Concussion
Assessment Tool (SCAT2) card, and neither is subject to Complex Concussion and Long-Term Issues
any copyright restriction. The authors request, however, N Is the simple versus complex classification a valid and
that the document and the SCAT2 card be distributed in useful differentiation?
their full and complete format. N Are there specific patient populations at risk of long-
term problems?
{{
Footnote: Consensus panelists (listed in alphabetical order): In N Is there a role for additional tests (eg, structural and/or
addition to the authors above, the consensus panelists were Broglio S, functional magnetic resonance [MR] imaging, balance
Davis G, Dick R, Dvorak J, Echemendia R, Gioia G, Guskiewicz K,
Herring S, Iverson G, Kelly J, Kissick J, Makdissi M, McCrea M, Ptito A,
testing, biomarkers)?
Purcell L, Putukian M. Also invited but not in attendance: Bahr R, N Should athletes with persistent symptoms be screened
Engebretsen L, Hamlyn P, Jordan B, Schamasch P. for depression/anxiety?
This statement is also being published in the Clinical Journal of Sport
Medicine, Journal of Clinical Neuroscience, Journal of Clinical Sport Pediatric Concussion
Medicine, Journal of Science & Medicine in Sport, Neurosurgery,
Physical Medicine & Rehabilitation, and Scandinavian Journal of
N Which symptom scale is appropriate for this age group?
Science & Medicine in Sport. The manuscript was prepared by the N Which tests are useful, and how often should baseline
authors and is printed here without editing. testing be performed in this age group?

434 Volume 44 N Number 4 N August 2009

N What are the most appropriate RTP guidelines for elite entities. The panel, however, unanimously retained the
and non-elite child and adolescent athletes? concept that the majority (80%–90%) of concussions
resolve in a short (7- to 10-day) period, although the
Future Directions recovery time frame may be longer in children and
N What is the best method of knowledge transfer and adolescents.2
education?
N Is there evidence that new and novel injury prevention 2) CONCUSSION EVALUATION
strategies work (eg, changes to rules of the game, fair
play strategies, etc)? 2.1 Symptoms and Signs of Acute Concussion
The panel agreed that the diagnosis of acute concussion
The Zurich document additionally examines the management
usually involves the assessment of a range of domains,
issues raised in the previous Prague and Vienna documents
including clinical symptoms, physical signs, behaviour,
and applies the consensus questions to these areas.
balance, sleep, and cognition. Furthermore, a detailed
concussion history is an important part of the evaluation,
SPECIFIC RESEARCH QUESTIONS AND both in the injured athlete and when conducting a
CONSENSUS DISCUSSION preparticipation examination. The detailed clinical assess-
ment of concussion is outlined in the SCAT2 form, which is
1) CONCUSSION an appendix to this document.
The suspected diagnosis of concussion can include one
or more of the following clinical domains:
1.1 Definition of Concussion
Panel discussion regarding the definition of concussion (a) Symptoms: somatic (eg, headache), cognitive (eg,
and its separation from mild traumatic brain injury (mTBI) feeling ‘‘like in a fog’’) and/or emotional symptoms
was held. Although there was acknowledgment that the (eg, lability),
terms refer to different injury constructs and should not be (b) Physical signs (eg, loss of consciousness, amnesia),
used interchangeably, it was not felt that the panel would (c) Behavioural changes (eg, irritability),
define mTBI for the purpose of this document. There was (d) Cognitive impairment (eg, slowed reaction times),
unanimous agreement, however, that concussion is defined (e) Sleep disturbance (eg, drowsiness).
as follows:
If any one or more of these components is present, a
Concussion is defined as a complex pathophysiological concussion should be suspected and the appropriate
process affecting the brain, induced by traumatic management strategy instituted.
biomechanical forces. Several common features that
incorporate clinical, pathologic, and biomechanical 2.2 On-Field or Sideline Evaluation of
injury constructs that may be utilized in defining the Acute Concussion
nature of a concussive head injury include When a player shows ANY features of a concussion
1. Concussion may be caused by a direct blow to the
(a) The player should be medically evaluated onsite using
head, face, neck, or elsewhere on the body with an
standard emergency management principles, and
‘‘impulsive’’ force transmitted to the head.
particular attention should be given to excluding a
2. Concussion typically results in the rapid onset of
cervical spine injury.
short-lived impairment of neurologic function that
(b) The appropriate disposition of the player must be
resolves spontaneously.
determined by the treating health care provider in a
3. Concussion may result in neuropathologic changes,
timely manner. If no health care provider is available,
but the acute clinical symptoms largely reflect a
the player should be safely removed from practice or
functional disturbance rather than a structural injury.
play and urgent referral to a physician arranged.
4. Concussion results in a graded set of clinical symptoms
(c) Once the first aid issues are addressed, then an
that may or may not involve loss of consciousness.
assessment of the concussive injury should be made
Resolution of the clinical and cognitive symptoms
using the SCAT2 or other similar tool.
typically follows a sequential course; however, it is
(d) The player should not be left alone following the
important to note that in a small percentage of cases,
injury, and serial monitoring for deterioration is
postconcussive symptoms may be prolonged.
essential over the initial few hours following injury.
5. No abnormality on standard structural neuroimaging
(e) A player with diagnosed concussion should not be
studies is seen in concussion.
allowed to RTP on the day of injury. Occasionally, in
adult athletes, there may be RTP on the same day as
1.2 Classification of Concussion the injury. See section 4.2.
There was unanimous agreement to abandon the It was unanimously agreed that sufficient time for
‘‘simple’’ versus ‘‘complex’’ terminology that had been assessment and adequate facilities should be provided for
proposed in the Prague agreement statement, as the panel the appropriate medical assessment, both on and off the
felt that the terminology itself did not fully describe the field, for all injured athletes. In some sports, this may

Journal of Athletic Training 435

require rule change to allow an off-field medical assessment situations may include prolonged disturbance of conscious
to occur without affecting the flow of the game or unduly state, focal neurologic deficit, or worsening symptoms.
penalizing the injured player’s team. Newer structural MR imaging modalities, including
Sideline evaluation of cognitive function is an essential gradient echo, perfusion, and diffusion imaging, have greater
component in the assessment of this injury. Brief neuro- sensitivity for structural abnormalities. However, the lack of
psychological test batteries that assess attention and published studies as well as absent preinjury neuroimaging
memory function have been shown to be practical and data limits the usefulness of this approach in clinical
effective. Such tests include the Maddocks questions3,4 and management at the present time. In addition, the predictive
the Standardized Assessment of Concussion (SAC).5–7 It is value of various MR abnormalities that may be incidentally
worth noting that standard orientation questions (eg, time, discovered is not established at the present time.
place, person) have been shown to be unreliable in the Other imaging modalities such as functional magnetic
sporting situation when compared with memory assess- resonance imaging (fMRI) demonstrate activation patterns
ment.4,8 It is recognized, however, that abbreviated testing that correlate with symptom severity and recovery in
paradigms are designed for rapid concussion screening on concussion.9–13 While not part of routine assessment at the
the sidelines and are not meant to replace comprehensive present time, they nevertheless provide additional insight to
neuropsychological testing, which is sensitive to detecting pathophysiologic mechanisms. Alternative imaging tech-
subtle deficits that may exist beyond the acute episode, nor nologies (eg, positron emission tomography, diffusion
should they be used as a stand-alone tool for the ongoing tensor imaging, magnetic resonance spectroscopy, func-
management of sports concussions. tional connectivity), while demonstrating some compelling
It should also be recognized that the appearance of findings, are still at early stages of development and cannot
symptoms might be delayed several hours following a be recommended other than in a research setting.
concussive episode.
3.2 Objective Balance Assessment
2.3 Evaluation in Emergency Room or Office by
Published studies using both sophisticated force plate
Medical Personnel
technology as well as those using less sophisticated clinical
An athlete with concussion may be evaluated in the balance tests (eg, Balance Error Scoring System [BESS])
emergency room or doctor’s office as a point of first have identified postural stability deficits lasting approxi-
contact following injury or may have been referred from mately 72 hours following sport-related concussion. It
another care provider. In addition to the points outlined appears that postural stability testing provides a useful
above, the key features of this exam should encompass tool for objectively assessing the motor domain of
neurologic functioning and should be considered a reliable
(a) A medical assessment including a comprehensive and valid addition to the assessment of athletes suffering
history and detailed neurologic examination, includ- from concussion, particularly when symptoms or signs
ing a thorough assessment of mental status, cognitive indicate a balance component.14–20
functioning, and gait and balance.
(b) A determination of the clinical status of the patient, 3.3 Neuropsychological Assessment
including whether there has been improvement or
The application of neuropsychological (NP) testing in
deterioration since the time of injury. This may concussion has been shown to be of clinical value and
involve seeking additional information from parents, continues to contribute significant information in concus-
coaches, teammates, and eyewitnesses to the injury. sion evaluation.21–26 Although in most cases cognitive
(c) A determination of the need for emergent neuroim- recovery largely overlaps with the time course of symptom
aging in order to exclude a more severe brain injury recovery, it has been demonstrated that cognitive recovery
involving a structural abnormality. may occasionally precede or more commonly follow
clinical symptom resolution, suggesting that the assessment
In large part, the points above are included in the SCAT2 of cognitive function should be an important component in
assessment, which is included in the Zurich consensus any RTP protocol.27,28 It must be emphasized, however,
statement. that NP assessment should not be the sole basis of
management decisions; rather, it should be seen as an aid
3) CONCUSSION INVESTIGATIONS to the clinical decision-making process in conjunction with
A range of additional investigations may be utilized to a range of clinical domains and investigational results.
assist in the diagnosis and/or exclusion of injury. These Neuropsychologists are in the best position to interpret
include the following. NP tests by virtue of their background and training.
However, there may be situations where neuropsycholo-
gists are not available and other medical professionals may
3.1 Neuroimaging
perform or interpret NP screening tests. The ultimate RTP
It was recognized by the panelists that conventional decision should remain a medical one, in which a
structural neuroimaging is normal in concussive injury. multidisciplinary approach, when possible, has been taken.
Given that caveat, the following suggestions are made: In the absence of NP and other (eg, formal balance
Brain computed tomography (CT) (or, where available, assessment) testing, a more conservative return-to-play
MR brain scan) contributes little to concussion evaluation approach may be appropriate.
but should be employed whenever suspicion of an In the majority of cases, NP testing will be used to assist
intracerebral structural lesion exists. Examples of such RTP decisions and will not be done until the patient is

436 Volume 44 N Number 4 N August 2009

Table 1. Graduated Return-to-Play Protocol
Rehabilitation Stage Functional Exercise at Each Stage of Rehabilitation Objective of Each Stage
1. No activity Complete physical and cognitive rest Recovery
2. Light aerobic exercise Walking, swimming, or stationary cycling, keeping intensity Increase heart rate
to ,70% of maximum predicted heart rate; no resistance training
3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer; no head impact activities Add movement
4. Non-contact training Progression to more complex training drills, eg, passing drills in football Exercise, coordination,
drills and ice hockey; may start progressive resistance training and cognitive load
5. Full-contact practice Following medical clearance, participate in normal training activities Restore athlete’s confidence;
coaching staff assesses
functional skills
6. Return to play Normal game play

symptom free.29,30 There may be persons (eg, child and a stepwise RTP strategy.57 During this period of recovery
adolescent athletes) in whom testing may be performed while symptomatic following an injury, it is important to
early while the patient is still symptomatic to assist in emphasize to the athlete that physical AND cognitive rest
determining management. This will normally be best is required. Activities that require concentration and
determined in consultation with a trained neuropsycholo- attention (eg, scholastic work, video games, text messaging,
gist.31,32 etc) may exacerbate symptoms and possibly delay recovery.
In such cases, apart from limiting relevant physical and
3.4 Genetic Testing cognitive activities (and other risk-taking opportunities for
reinjury) while symptomatic, no further intervention is
The significance of apolipoprotein (Apo) E4, ApoE
required during the period of recovery, and the athlete
promotor gene, tau polymerase, and other genetic markers
typically resumes sport without further problem.
in the management of sports concussion risk or injury
outcome is unclear at this time.33,34 Evidence from human
and animal studies in more severe traumatic brain injury 4.1 Graduated RTP Protocol
demonstrates induction of a variety of genetic and cytokine Return-to-play protocol following a concussion follows
factors, such as insulin-like growth factor-1 (IGF-1), IGF a stepwise process as outlined in Table 1.
binding protein-2, fibroblast growth factor, Cu-Zn super- With this stepwise progression, the athlete should
oxide dismutase, superoxide dismutase-1 (SOD-1), nerve continue to proceed to the next level if asymptomatic at
growth factor, glial fibrillary acidic protein (GFAP), and S- the current level. Generally each step should take 24 hours,
100. Whether such factors are affected in sport concussion so that an athlete would take approximately 1 week to
is not known at this stage.35–42 proceed through the full rehabilitation protocol once
asymptomatic at rest and with provocative exercise. If
3.5 Experimental Concussion Assessment Modalities any postconcussion symptoms occur while in the stepwise
Different electrophysiologic recording techniques (eg, program, then the patient should drop back to the previous
evoked response potential [ERP], cortical magnetic stim- asymptomatic level and try to progress again after a further
ulation, and electroencephalography) have demonstrated 24-hour period of rest has passed.
reproducible abnormalities in the postconcussive state.
However, not all studies reliably differentiated concussed 4.2 Same-Day RTP
athletes from controls.43–49 The clinical significance of With adult athletes, in some settings, where there are
these changes remains to be established. team physicians experienced in concussion management
In addition, biochemical serum and cerebrospinal fluid and sufficient resources (eg, access to neuropsychologists,
markers of brain injury (including S-100, neuron specific consultants, neuroimaging, etc) as well as access to
enolase [NSE], myelin basic protein [MBP], GFAP, tau, immediate (ie, sideline) neurocognitive assessment, RTP
etc) have been proposed as means by which cellular
management may be more rapid. The RTP strategy must
damage may be detected if present.50–56 There is currently
still follow the same basic management principles: namely,
insufficient evidence, however, to justify the routine use of
full clinical and cognitive recovery before consideration of
these biomarkers clinically.
RTP. This approach is supported by published guidelines,
such as those from the American Academy of Neurology,
4) CONCUSSION MANAGEMENT US Team Physician Consensus Statement, and US
The cornerstone of concussion management is physical National Athletic Trainers’ Association position state-
and cognitive rest until symptoms resolve and then a ment.58–60 This issue was extensively discussed by the
graded program of exertion prior to medical clearance and consensus panelists, and it was acknowledged that there is
RTP. The recovery and outcome of this injury may be evidence that some professional American football players
modified by a number of factors that may require more are able to RTP more quickly, with even same-day RTP
sophisticated management strategies. These are outlined in supported by National Football League studies without a
the section on modifiers below. risk of recurrence or sequelae.61 There are data, however,
As described above, the majority of patients will recover demonstrating that at the collegiate and high school levels,
spontaneously over several days. In these situations, it is athletes allowed to RTP on the same day may demonstrate
expected that an athlete will proceed progressively through NP deficits postinjury that may not be evident on the

Journal of Athletic Training 437

sidelines and are more likely to have delayed onset of Table 2. Concussion Modifiers
symptoms.62–68 Yet it should be emphasized that the young Factors Modifier
(less than 18 years old) elite athlete should be treated more
Symptoms Number
conservatively, even though the resources may be the same
Duration (.10 d)
as for an older professional athlete (see section 6.1). Severity
Signs Prolonged loss of consciousness (.1 min),
4.3 Psychological Management and Mental amnesia
Health Issues Sequelae Concussive convulsions
Temporal Frequency: repeated concussions over time
In addition, psychological approaches may have poten- Timing: injuries close together in time
tial application in this injury, particularly with the ‘‘Recency’’: recent concussion or traumatic brain
modifiers listed below.69,70 Caregivers are also encouraged injury
to evaluate the concussed athlete for affective symptoms, Threshold Repeated concussions occurring with
such as depression, as these symptoms may be common in progressively less impact force or slower
concussed athletes.57 recovery after each successive concussion
Age Child or adolescent (,18 y old)
Comorbidities and Migraine, depression, or other mental health
4.4 The Role of Pharmacologic Therapy premorbidities disorders, attention deficit hyperactivity
Pharmacologic therapy in sports concussion may be disorder (ADHD), learning disabilities (LDs),
sleep disorders
applied in 2 distinct situations. The first of these situations
Medication Psychoactive drugs, anticoagulants
is the management of specific, prolonged symptoms (eg, Behaviour Dangerous style of play
sleep disturbance, anxiety, etc). The second situation is Sport High-risk activity, contact and collision sport, high
where drug therapy is used to modify the underlying sporting level
pathophysiology of the condition with the aim of
shortening the duration of the concussion symptoms.71 In
broad terms, this approach to management should only be
considered by clinicians experienced in concussion man- preparticipation concussion evaluation allows for modifi-
agement. cation and optimization of protective behaviour and an
An important consideration in RTP is that concussed opportunity for education.
athletes should not only be symptom free but also should
not be taking any pharmacologic agents or medications 5) MODIFYING FACTORS IN
that may mask or modify the symptoms of concussion. CONCUSSION MANAGEMENT
Where antidepressant therapy may be commenced during
the management of a concussion, the decision to RTP The consensus panel agreed that a range of ‘‘modifying’’
while still on such medication must be considered carefully factors may influence the investigation and management of
by the treating clinician. concussion and, in some cases, may predict the potential
for prolonged or persistent symptoms. These modifiers
4.5 The Role of Preparticipation would also be important to consider in a detailed
Concussion Evaluation concussion history and are outlined in Table 2.
In this setting, there may be additional management
Recognizing the importance of a concussion history and considerations beyond simple RTP advice. There may be a
appreciating the fact that many athletes will not recognize more important role for additional investigations including
all the concussions they may have suffered in the past, a formal NP testing, balance assessment, and neuroimaging.
detailed concussion history is of value.72–75 Such a history It is envisioned that athletes with such modifying features
may identify early those athletes who fit into a high-risk would be managed in a multidisciplinary manner coordi-
category and provides an opportunity for the health care nated by a physician with specific expertise in the
provider to educate the athlete in regard to the significance management of concussive injury.
of concussive injury. A structured concussion history The role of female gender as a possible modifier in the
should include specific questions as to previous symptoms management of concussion was discussed at length by the
of a concussion, not just the perceived number of past panel. There was not unanimous agreement that the
concussions. It is also worth noting that dependence upon current published research evidence is conclusive that this
the recall of concussive injuries by teammates or coaches should be included as a modifying factor, although it was
has been demonstrated to be unreliable.72 The clinical accepted that sex may be a risk factor for injury and/or
history should also include information about all previous influence injury severity.76–78
head, face, and cervical spine injuries, as these may also
have clinical relevance. It is worth emphasizing that in the
5.1 The Significance of Loss of Consciousness
setting of maxillofacial and cervical spine injuries, coexis-
tent concussive injuries may be missed unless specifically In the overall management of moderate to severe
assessed. Questions pertaining to disproportionate impact traumatic brain injury, duration of loss of consciousness
versus symptom severity may alert the clinician to a (LOC) is an acknowledged predictor of outcome.79 While
progressively increasing vulnerability to injury. As part of published findings in concussion describe LOC associated
the clinical history, it is advised that details regarding with specific early cognitive deficits, it has not been noted
protective equipment employed at time of injury be sought, as a measure of injury severity.80,81 Consensus discussion
both for recent and remote injuries. A comprehensive determined that prolonged (greater than 1 minute in

438 Volume 44 N Number 4 N August 2009

duration) LOC would be considered as a factor that may who may need more sophisticated assessment strate-
modify management. gies.31,32,101
The panel strongly endorsed the view that children
5.2 The Significance of Amnesia and Other Symptoms should not be returned to practice or play until clinically
completely symptom free, which may require a longer time
There is renewed interest in the role of posttraumatic frame than for adults. In addition, the concept of
amnesia and its role as a surrogate measure of injury ‘‘cognitive rest’’ was highlighted, with special reference to
severity.67,82,83 Published evidence suggests that the nature, a child’s need to limit exertion with activities of daily living
burden, and duration of the clinical postconcussive and to limit scholastic and other cognitive stressors (eg,
symptoms may be more important than the presence or text messaging, video games, etc) while symptomatic.
duration of amnesia alone.80,84,85 Further, it must be noted School attendance and activities may also need to be
that retrograde amnesia varies with the time of measure- modified to avoid provocation of symptoms.
ment postinjury and, hence, is poorly reflective of injury Because of the different physiological response and
severity.86,87 longer recovery after concussion and specific risks (eg,
diffuse cerebral swelling) related to head impact during
5.3 Motor and Convulsive Phenomena childhood and adolescence, a more conservative RTP
A variety of immediate motor phenomena (eg, tonic approach is recommended. It is appropriate to extend the
posturing) or convulsive movements may accompany a amount of time of asymptomatic rest and/or the length of
concussion. Although dramatic, these clinical features are the graded exertion in children and adolescents. It is not
generally benign and require no specific management appropriate for a child or adolescent athlete with
beyond the standard treatment of the underlying concus- concussion to RTP on the same day as the injury,
sive injury.88,89 regardless of the level of athletic performance. Concussion
modifiers apply even more to this population than to adults
and may mandate more cautious RTP advice.
5.4 Depression
Mental health issues (such as depression) have been 6.2 Elite Versus Non-Elite Athletes
reported as a long-term consequences of traumatic brain
The panel unanimously agreed that all athletes, regard-
injury, including sports-related concussion. Neuroimaging
less of level of participation, should be managed using the
studies using fMRI suggest that a depressed mood
same treatment and RTP paradigm. A more useful
following concussion may reflect an underlying patho-
construct was agreed to, whereby the available resources
physiologic abnormality consistent with a limbic-frontal
and expertise in concussion evaluation were of more
model of depression.52,90–100
importance in determining management than a separation
between elite and non-elite athlete management. Although
6) SPECIAL POPULATIONS formal baseline NP screening may be beyond the resources
of many sports or individuals, it is recommended that in all
6.1 The Child or Adolescent Athlete organized high-risk sports, consideration be given to
There was unanimous agreement by the panel that the having this cognitive evaluation, regardless of the age or
evaluation and management recommendations contained level of performance.
herein could be applied to children and adolescents down
to the age of 10 years. Below that age, children report 6.3 Chronic Traumatic Brain Injury
different concussion symptoms from adults and would Epidemiologic studies have suggested an association
require age-appropriate symptom checklists as a compo- between repeated sports concussions during a career and
nent of assessment. An additional consideration in late-life cognitive impairment. Similarly, case reports have
assessing the child or adolescent athlete with a concussion noted anecdotal cases in which neuropathologic evidence
is that in the clinical evaluation by the health care of chronic traumatic encephalopathy was observed in
professional, there may be the need to include both patient retired football players.108–112 Panel discussion was held,
and parental input, as well as teacher and school input, and no consensus was reached on the significance of such
when appropriate.101–107 observations at this stage. Clinicians need to be mindful of
The decision to use NP testing is broadly the same as in the potential for long-term problems in the management of
the adult assessment paradigm. However, timing of all athletes.
testing may differ in order to assist planning in school
and home management (and may be performed while the 7) INJURY PREVENTION
patient is still symptomatic). If cognitive testing is
performed, then it must be developmentally sensitive
until the late teen years, due to the ongoing cognitive 7.1 Protective Equipment: Mouthguards and Helmets
maturation that occurs during this period, which, in turn, There is no good clinical evidence that currently
makes the utility of comparison to either the person’s own available protective equipment will prevent concussion,
baseline performance or to population norms limited.20 although mouthguards have a definite role in preventing
In this age group, it is more important to consider the use dental and orofacial injury. Biomechanical studies have
of trained neuropsychologists to interpret assessment shown a reduction in impact forces to the brain with the
data, particularly in children with learning disorders use of head gear and helmets, but these findings have not
and/or attention deficit hyperactivity disorder (ADHD), been translated to show a reduction in concussion

Journal of Athletic Training 439

incidence. For skiing and snowboarding, there are a Federation (IIHF), who initiated this endeavor, have
number of studies to suggest that helmets provide enormous value and must be pursued vigorously. Fair
protection against head and facial injury and, hence, play and respect for opponents are ethical values that
should be recommended for participants in alpine should be encouraged in all sports and sporting associa-
sports.113–116 In specific sports such as cycling, motor, tions. Similarly coaches, parents, and managers play an
and equestrian sports, protective helmets may prevent important part in ensuring these values are implemented on
other forms of head injury (eg, skull fracture) that are the field of play.57,136–148
related to falling on hard road surfaces, and these may be
an important injury prevention issue for those sports.116–128 9) FUTURE DIRECTIONS
The consensus panelists recognize that research is needed
7.2 Rule Change across a range of areas in order to answer some critical
Consideration of rule changes to reduce the head injury research questions. The key areas for research identified
incidence or severity may be appropriate where a clear-cut include
mechanism is implicated in a particular sport. An example
of this is in football (soccer), in which research studies
N Validation of the SCAT2
demonstrated that upper limb-to-head contact in heading
N Sex effects on injury risk, severity, and outcome
contests accounted for approximately 50% of concus- N Paediatric injury and management paradigms
sions.129 As noted earlier, rule changes also may be needed N Virtual reality tools in the assessment of injury
in some sports to allow an effective off-field medical N Rehabilitation strategies (eg, exercise therapy)
assessment to occur without compromising the athlete’s N Novel imaging modalities and their role in clinical
welfare, affecting the flow of the game, or unduly assessment
penalizing the player’s team. It is important to note that N Concussion surveillance using consistent definitions and
rule enforcement may be a critical aspect of modifying outcome measures
injury risk in these settings, and referees play an important N Clinical assessment when no baseline assessment has
role in this regard. been performed
N ‘‘Best practice’’ neuropsychological testing
7.3 Risk Compensation N Long-term outcomes
An important consideration in the use of protective N On-field injury severity predictors
equipment is the concept of risk compensation.130 This is
where the use of protective equipment results in behav-
ioural change, such as the adoption of more dangerous 10) MEDICAL-LEGAL CONSIDERATIONS
playing techniques, which can result in a paradoxical This consensus document reflects the current state of
increase in injury rates. This may be a particular concern in knowledge and will need to be modified according to the
child and adolescent athletes, in whom head injury rates development of new knowledge. It provides an overview of
are often higher than in adult athletes.131–133 issues that may be of importance to health care providers
involved in the management of sports-related concussion.
7.4 Aggression Versus Violence in Sport It is not intended as a standard of care and should not be
interpreted as such. This document is only a guide, and is
The competitive/aggressive nature of sport that makes it of a general nature, consistent with the reasonable practice
fun to play and watch should not be discouraged. of a health care professional. Individual treatment will
However, sporting organizations should be encouraged to depend on the facts and circumstances specific to each
address violence that may increase concussion risk.134,135 individual case.
Fair play and respect should be supported as key elements It is intended that this document will be formally
of sport. reviewed and updated prior to December 1, 2012.

8) KNOWLEDGE TRANSFER 11) STATEMENT ON BACKGROUND TO

As the ability to treat or reduce the effects of concussive CONSENSUS PROCESS
injury after the event is minimal, education of athletes, In November 2001, the 1st International Conference on
colleagues, and the general public is a mainstay of progress Concussion in Sport was held in Vienna, Austria. This
in this field. Athletes, referees, administrators, parents, meeting was organized by the IIHF in partnership with
coaches, and health care providers must be educated FIFA and the Medical Commission of the IOC. As part of
regarding the detection of concussion, its clinical features, the resulting mandate for the future, the need for
assessment techniques, and principles of safe RTP. leadership and future updates was identified. The 2nd
Methods to improve education, including Web-based International Conference on Concussion in Sport was
resources, educational videos, and international outreach organized by the same group, with the additional
programs, are important in delivering the message. In involvement of the IRB, and was held in Prague, Czech
addition, concussion working groups plus the support and Republic, in November 2004. The original aims of the
endorsement of enlightened sport groups such as Fédéra- symposia were to provide recommendations for the
tion Internationale de Football Association (FIFA), improvement of safety and health of athletes who suffer
International Olympic Commission (IOC), International concussive injuries in ice hockey, rugby, football (soccer),
Rugby Board (IRB), and International Ice Hockey and other sports. To this end, a range of experts were

440 Volume 44 N Number 4 N August 2009

invited to both meetings to address specific issues of 4. Maddocks DL, Dicker GD, Saling MM. The assessment of
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systems, cognitive assessment, new research methods, 1995;5(1):32–35.
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2008, and was designed as a formal consensus meeting 7. McCrea M, Randolph C, Kelly J. The Standardized Assessment of
following the organizational guidelines set forth by the US Concussion (SAC): Manual for Administration, Scoring and Inter-
National Institutes of Health. (Details of the consensus pretation. 2nd ed. Waukesha, WI: 2000.
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flicts of interest and included researchers in clinical 11. Chen JK, Johnston KM, Collie A, McCrory P, Ptito A. Association
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Address correspondence to Paul McCrory, MBBS, PhD, Centre for Health, Exercise & Sports Medicine, University of Melbourne,
Parkville, Australia 3010. Address e-mail to paulmccr@bigpond.net.au.

APPENDIX. POCKET SPORT CONCUSSION ASSESSMENT TOOL 2 (SCAT2) AND SCAT2.

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