By Dr. Don Kirkendall

To say that our understanding of sport-related concussive injury continues to evolve is an understatement. The number of research articles has exploded. A mere 176 papers were published in 2000. In 2016, a total of 1310 papers on ‘concussion OR mild traumatic brain injury’ were published – a nearly 650% increase in 16 years.

(For the curious, the first paper on head injury in soccer that I could find was a case series of 6 players with ‘footballer’s migraine’ by the British Medical Journal 1972, back in the leather ball era.)

In 2001, a group of concerned physicians in soccer, ice hockey, and horse racing organized the Concussion in Sport group and held their first meeting in Vienna. This group has continued to promote research to improve our recognition, treatment, and recovery of athletes who have suffered a mild traumatic brain injury (concussion).

Periodic meetings in Prague (2004), Zurich (2008 and 2012) have released evidence-based consensus statements to advance both the science and the practice of handling a concussion from initial recognition to clearance to return to sport. Anyone who is involved in sport has experienced what this group has advanced. Those who have been involved in sport since 2000 has seen a seismic shift in awareness and understanding of concussion, in part due to the efforts of the Concussion in Sport group (and the NFL).

The 5th meeting of this group took place in 2016 in Berlin. Past meeting consisted of invited presentations by individuals doing novel and innovative work in brain injury. Afterwards, the primary speakers and organizers spent a couple days locked away to develop a consensus statement that, if followed, would improve how players, parent, coaches, and physicians would deal with the injured player.

The Berlin meeting took a different slant. The CIS scientific committee started out by identifying active researchers from multiple professions (sport medicine physicians, neurologists and neurosurgeons, a physiotherapist, neuropsychologists, athletic trainers, epidemiologists, neuropathologists, and imaging scientists). From this list, a group of 35 experts (from Australia, Canada, England, Japan, the Netherlands, Norway, South Africa, Switzerland and the USA) were invited to serve on a panel.

This panel gathered to identify the most important and relevant questions related to concussion. Using a structured method of communication (Delphi Method), this group initially identified 45 questions in 11 main categories. The next step was for each member to grade each of the 45 questions as ‘essential’, ‘desirable’, or ‘not a priority.’ At this round, the original 45 questions were distilled down to 14 questions that still included all 11 categories.

In the third round, the panel was asked to rank the 14 questions in order of importance. The panel could also submit any new questions. The fourth round involved just the scientific committee who reviewed the ranking and made some minor wording adjustments; two questions (about Paralympic athletes and policy) were eliminated as being beyond the scope of the conference. In the last round, the 12 questions were posted by the British Journal of Sports Medicine for public viewing and response. This five-round process took four months to complete.

Once the 12 questions had been identified and viewed by the sports medicine community, the scientific committee selected a lead author from the panel for each of the 12 questions. Co-authors from the panel were also selected. The job of each author team was to prepare a systematic review (a very rigorous method of selecting, analyzing, and consolidating research) for each question.

The final products are contained in the 2017 British Journal of Sports Medicine (volume 51, issue 11) that was released on May 30, 2017. At that link is the table of contents for the issue. Articles with the ‘FREE’ at the end of the title can be downloaded as a PDF to your computer. Issue 12 of BJSM will contain systematic reviews of remaining 12 questions.

Most of the articles are complex and need a decent understanding of the science behind each topic. The one to look at is the Consensus Statement that summarizes the work of the scientific committee and panel of experts. This paper is organized according to the 11 R’s of concussion management: Recognize, Remove, Re-evaluate, Rest, Rehabilitation, Refer, Recover, Return to sport, Reconsider, Residual effects and sequelae, and Risk Reduction. While there is plenty of content that can be found in earlier statements, pay close attention to the text in italics, which contains information that is new to the Berlin statement.

I have said on multiple occasions, here and elsewhere, the coach, parent, and player only have one responsibility and that is to recognize when a concussion might have occurred (not ‘did’, just ‘might have’). What follows is out of their hands as this is now a medical and a legal issue (all states require medical clearance for all sport-related concussive injuries). While much of the issue contains information about what happens after the injury, There is still much to be read and digested.

This issue of BJSM also contains important assessment tools that would be good reading as these are what clinicians use to help assess the injured player:

Sport Concussion Assessment Tool 5th edition. The SCAT5. This is a sideline tool most anyone can learn to use. This 5th edition is a modification of earlier version of the SCAT and is designed for use with athletes 13 years and older. Any errors should alert the user to get the player to a physician. Better to make a mistake by being too picky about responses. Sending a concussed player back to play is not to be done. What if a mistake is made and a player sits out for part of a match? Well, I like Taylor Twellman’s response to that: “Big deal.”

Child SCAT5. This is a version of the SCAT designed specifically to evaluate a player 12 years old or younger. Same concept, slightly different presentation.

Concussion Recognition Tool 5. A one-page summary of what to look for when a concussion is suspected.

Click on any of those links. A popup window will show the first page of each tool. Click the circled x in a top corner. Then click on the red PDF link in the top right corner of the BJSM page to download the full form and save to your computer.

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