- Supine position, rest for 2 min and take measurements.
- Follow with the standing position, measure again after 1 min.
Symptoms brought on by a change in postural position (eg, lightheaded, dizzy or motion sensation) should be noted in the patient’s record.
New content discussed at the dedicated Tools workshop (Day 4 of the Amsterdam Conference) led to additional recommended items for the Child SCOAT6 including:
- Additional symptoms for child and parent reports that capture multiple subacute domains.
- An age-appropriate measure of cognitive reaction time such as the Symbol Digit Modalities Test.
- Validated paediatric measures of (1) orthostatic tachycardia, (2) orthostatic intolerance, (3) vestibular and oculomotor function and (4) child mental health and sleep questionnaires.
It is not unusual to have athletes experience fear, anxiety or depression associated with concussion or as preinjury conditions exacerbated by concussion injury. Where deemed appropriate, HCPs are encouraged to screen for these symptoms using validated mental health screening instruments 26–28 such as those included in the Sport Mental Health Assessment Tool (SMHAT). 29
Neurocognitive test batteries, where accessible, may add value to assessing SRC and its sequelae. Computer-based test batteries, especially in comparison of reaction times against patient baseline and community norms, may be useful. The results of these tests should be interpreted in the context of broader clinical findings and are not to be used in isolation to inform management or diagnostic decisions. 25
The components of the SCOAT6/Child SCOAT6, many of which have been previously validated on their own and are typically used in clinical practice as individual tests, form a multimodal assessment that is designed to better inform the HCP’s assessment and management of concussion and may be augmented by additional clinical measures and investigations. Where available, HCPs are further encouraged to make use of a multidisciplinary network to provide additional specialised diagnostic input, particularly in cases of persisting symptoms. In reviewing studies informing the SCOAT6, the period defined for the included papers was 3-30 days. HCPs may choose to use the SCOAT6 beyond this time frame but should be aware of the parameters of the review.
REST and exercise
The best available evidence shows that recommending strict rest until the complete resolution of concussion-related symptoms is not beneficial following SRC. Relative (not strict) rest, which includes activities of daily living and reduced screen time, is indicated immediately and for up to the first 2 days after injury.30 Individuals can return to light-intensity physical activity (PA), such as walking that does not more than mildly exacerbate symptoms, during the initial 24–48 hours following a concussion.30
- Clinicians are encouraged to recommend early (after 24–48 hours) return to PA as tolerated (eg, walking or stationary cycling while avoiding the risk of contact, collision or fall).30
- The best data on cognitive exertion show that reduced screen use in the first 48 hours after injury is warranted but may not be effective beyond that.31 32
- Individuals can systematically advance their exercise intensity based on the degree of symptom exacerbation experienced during the prior bout of aerobic exercise.
- HCPs with access to exercise testing can safely prescribe subsymptom threshold aerobic exercise treatment within 2–10 days after SRC, based on the individual’s heart rate threshold (HRt) that does not elicit more than mild symptom exacerbation during the exercise test (eg, ‘mild’=testing stops with an increase of more than two points on a 0–10 point scale when compared with the pre-exercise resting value). Subsymptom threshold aerobic exercise treatment can be progressed systematically based on the determination of the new HRt on repeat exercise testing (every few days to every week).33 34
Athletes may continue/advance the duration and intensity of PA or prescribed aerobic exercise provided there is no more than mild (increase of no more than 2 points vs the pre-exercise value) and brief ( 30
PA/exercise and cognitive exertion should be stopped if concussion symptom exacerbation is more than mild and brief and may be resumed once symptoms have returned to the prior level. Clinicians should inform their patients that mild symptom exacerbation during PA, prescribed aerobic exercise treatment or during cognitive activity is typically brief (under an hour) and does not delay recovery. Prescribed subsymptom threshold aerobic exercise within 2–10 days of SRC is effective for reducing the incidence of persisting symptoms after concussion (symptoms >1 month) and is also effective for facilitating recovery in athletes suffering from symptoms lasting longer than 1 month. 34 Importantly, individuals should be advised to avoid the risk of reinjury (ie, contact, collision or fall) until determined by a qualified HCP to be safe for higher risk activities. 30
Sleep disturbance in the 10 days after SRC is associated with an increased risk of persisting symptoms and may warrant evaluation and treatment. 35 36
REFER
Where the clinical environment allows, referral to clinicians with specialised knowledge and skills in concussion management should be considered for the targeted treatment of persisting symptoms.37 This may include the management of cervicogenic symptoms, migraine and headache, cognitive and psychological difficulties, balance disturbances, vestibular signs and oculomotor manifestations.
Persisting symptoms (>4 weeks across all age groups) may be pre-existing, concussion-related or both. Serial multimodal evaluation using a tool such as the SCOAT6/Child SCOAT6, and additional detailed clinical evaluations for specific symptoms (eg, headaches, dizziness, cognition) can help guide referrals. Specialist clinicians whose diagnostic assessments, clinical evaluations and treatment interventions for SRC may be of use as part of a clinician network may vary depending on the region, practice culture and local healthcare environment, and available areas of competency and expertise.25 This SRC clinician network may include sports medicine physicians, athletic trainers/therapists, physiotherapists, occupational therapists, sports chiropractors, neurologists, neurosurgeons, neuropsychologists, ophthalmologists, optometrists, physiatrists, psychologists and psychiatrists.
Specific recommendations include:
- The term ‘persisting symptoms’ is used for symptoms that persist >4 weeks across children, adolescents and adults.
- Persisting symptoms can be assessed using standardised and validated symptom rating scales. However, evidence-based recommendations regarding the use of other specific tests or measures in the clinical diagnosis of persisting symptoms in any age group are not possible based on existing research.37
- A multimodal clinical assessment, ideally by a multidisciplinary team, is indicated to characterise individuals with persisting symptoms, including the types, pattern and severity of symptoms, and any associated conditions or other factors that may be causing or contributing to the symptoms.
Symptoms attributed to concussion are non-specific, commonly also reported by healthy individuals and those with conditions other than concussion, and can be exacerbated by a variety of biopsychosocial factors aside from concussion, which should be assessed in the context of persisting symptoms. Other problems may exist prior to injury (but can be exacerbated by a concussion), co-occur with persisting symptoms or mimic persisting symptoms but do not arise from concussion. Common considerations in the context of persisting symptoms include mental health issues; learning or attention difficulties; visual, oculomotor, cervical and vestibular problems; headache disorders and migraine; sleep disturbance; dysautonomia, including orthostatic intolerance and postural orthostatic tachycardia syndrome; and pain.
REHABILITATION
If dizziness, neck pain and/or headaches persist for more than 10 days, cervicovestibular rehabilitation is recommended. 38 If symptoms persist beyond 4 weeks in children and adolescents, active rehabilitation and collaborative care may be of benefit. For children, adolescents and adults with dizziness/balance problems, either vestibular rehabilitation or cervicovestibular rehabilitation may be of benefit. The inclusion of subsymptom threshold aerobic exercise (as outlined above) in combination with other treatments should be considered. In the case of a recurrence of symptoms when progressing through the return-to-learn (RTL) or return-to-sport (RTS) strategies, re-evaluation and referral for rehabilitation may be of benefit to facilitate recovery. 38
Rehabilitation may be targeted to individual symptoms or maybe more general and focus on overall recovery. The effects of combinations of rehabilitation, optimal timing for initiation of rehabilitation and modifying factors (such as age and sex) are not yet well established and require further evaluation.
RECOVERY
Assessment of clinical recovery
The determination of clinical recovery was found to vary across research studies and healthcare practices and depended on the research question under evaluation. Primary recovery outcomes include symptom ratings, specific clinical tests or groups of tests and functional domains such as RTL and RTS. In some investigations, only one clinical recovery outcome is reported, and these different outcomes make it difficult to compare results across studies. It is important to consider functional outcomes that are meaningful to athletes/patients such as a return to their preinjury levels of function and performance.38 Thus, we recommend that clinical evaluation and future research include three components in the determination of recovery:
- Assessment of symptom reports (including concussion-related symptom resolution at rest, with cognitive activities and following physical exertion).
- Other outcomes relevant to ongoing symptoms or a specific research question (eg, response to physical exertion, post-traumatic headaches, standing balance, dynamic balance, vestibulo-ocular reflex (VOR) function, oculomotor (OM) function, symptom reproduction with VOR and OM testing (eg, VOMS), cognition, dual tasking).
- Measures of return to activity such as RTL and RTS (see below).
Role of biomarkers and technology in assessing recovery
Advanced neuroimaging, fluid-based biomarkers, genetic testing and other emerging technologies are useful for research focused on SRC diagnosis, prognosis, and recovery. However, further research is required to validate their use in clinical practice to assess recovery and aid in the clinical management of SRC. 39
In the research setting, the employment of advanced neuroimaging, fluid-based biomarkers, electrophysiological measures and modalities assessing autonomic dysfunction show promising sensitivity to acute neurobiological effects and changes over the course of SRC recovery. Moreover, evidence across multiple biomarker domains suggests that a time window of physiological change may extend beyond clinical recovery (ie, resolution of clinical signs and symptoms). However, it remains unknown whether residual alterations are pathological, adaptive or benign processes given insufficient longitudinal data linking neurobiological change to clinical indices of recovery. 39
RETURN-TO-LEARN and RETURN-TO-SPORT
Since the introduction of the RTL and RTS strategies, there has been a fivefold increase in the time to unrestricted RTS.40 Many questions remain about how to optimise RTL and RTS. Importantly, measures used to assess recovery have moved beyond symptoms, cognitive function and balance, to include measures of oculomotor and vestibular function, as well as biobehavioural and physical examination findings (as per SCOAT6/Child SCOAT6).25 While immediate and early postinjury symptoms remain the most robust predictor of recovery, the emergence of new assessment tools and variability in recovery endpoints underscores the importance of consistent definitions and measurement approaches. The systematic review of RTL and RTS found that continuing to play and delayed access to HCPs after SRC are associated with longer recovery.41 In addition, similar RTL and RTS management strategies can be implemented in different cohorts (eg, age, sex) with minimal differences in the time for recovery.41
The systematic review revealed wide variability in clinical time points for recovery from SRC, making the integration and interpretation of results from multiple studies challenging, and limiting our ability to develop recommendations applicable to the individual athlete. 41 To improve our clinical recommendations, the following definitions have been adopted by the Amsterdam consensus panel:
- Symptom resolution at rest: resolution of symptoms associated with the current concussion at rest.
- Complete symptom resolution: resolution of symptoms associated with the current concussion at rest with no return of symptoms during or after maximal physical and cognitive exertion.
- Return-to-learn (RTL): return to preinjury learning activities with no new academic support, including school accommodations or learning adjustments.
- Return-to-sport (RTS): completion of the RTS strategy with no symptoms and no clinical findings associated with the current concussion at rest and with maximal physical exertion.41
RETURN-to-learn (RTL)
The transition back to learning and to school following SRC is an important consideration for children, adolescents and young adults. The systematic review revealed that the vast majority of athletes (93%) of all ages have a full RTL with no additional academic support by 10 days.41 While many students can quickly return to learning with no or minimal difficulty, the RTL process can be more challenging for those who have specific considerations (eg, high acute symptom severity, a prior learning disability) that may affect recovery. To minimise academic and social disruptions during the RTL strategy, HCPs should avoid recommending complete rest and isolation, even for the initial 24–48 hours, and instead recommend a period of relative rest. Early return to activities of daily living should be encouraged provided that symptoms are no more than mildly and briefly increased (ie, an increase of no more than 2 points on a 0–10 point scale for less than an hour). In consultation with educators, and accounting for social determinants of health, some students may be offered academic supports to promote RTL including:
- Environmental adjustments, such as modified school attendance, frequent rest breaks from cognitive/thinking/deskwork tasks throughout the day and/or limited screen time on electronic devices.
- Physical adjustments to avoid any activities at risk of contact, collision or falls, such as contact sports or game play during physical education classes or after-school activities, while allowing for safe non-contact PA (eg, walking).
- Curriculum adjustments, such as extra time to complete assignments/homework and/or preprinted class notes.
- Testing adjustments, such as delaying tests/quizzes and/or permitting additional time to complete them.41
Return-to-learn recommendations
Facilitating RTL (table 1) is a vital part of the recovery process for student-athletes. HCPs should work with stakeholders on education and school policies to facilitate academic support, including accommodations/learning adjustments for students with SRC when needed. Academic support should address factors that may prolong RTL (eg, social determinants of health, higher symptom burden) by adjusting environmental, physical, curricular and testing factors as needed. Not all athletes will need an RTL strategy or academic support. If symptom exacerbation occurs during cognitive activity or screen time, difficulties with reading, concentration or memory or other aspects of learning are reported, clinicians should consider the implementation of an RTL strategy at the time of diagnosis and during the recovery process. When the RTL strategy is implemented, it can begin following an initial period of relative rest (Step 1: 24–48 hours following injury), with an incremental increase in cognitive load (Steps 2–4). 41 Progression through the strategy is symptom limited (ie, no more than a mild and brief exacerbation of current symptoms related to the current concussion) and its course may vary across individuals based on tolerance and symptom resolution. Further, while the RTL and RTS strategies can occur in parallel, student-athletes should complete full RTL before unrestricted RTS.41
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Return-to-learn (RTL) strategy
RETURN-to-sport (RTS)
Evidence from applied research and improved awareness of SRC have enhanced SRC policies and legislation, removal from play and medical oversight that allows athletes adequate time to achieve recovery before full RTS (table 2). Research is clear that HCPs should avoid prescribing absolute physical and cognitive rest (ie, ‘cocooning’) after SRC; instead, they should allow athletes to engage in activities of daily living (including walking) immediately following injury, even during the initial period of 24–48 hours of relative rest.30 33 Light PA as well as prescribed subsymptom threshold aerobic exercise treatment in a safe and supervised environment can be used therapeutically (ie, as part of the treatment plan as outlined in the Rest and Exercise section). Athletes may begin Step 1 (ie, symptom-limited activity) within 24 hours of injury, with progression through each subsequent step typically taking a minimum of 24 hours. Progression through the later RTS strategy (Steps 4–6) should be monitored by an HCP. Incremental progression of the cognitive and physical load on the athlete, using the magnitude of symptom exacerbation as a guide, provides the athlete with the opportunity to increase confidence throughout recovery,42 supporting psychological readiness to return to competitive play43–46 and fostering a shared RTS decision-making model.44 47 48 Unrestricted RTS following SRC typically occurs within 1 month of injury in children, adolescents and adults, with an estimated pooled mean time to RTS of 19.8 days (95% CI: 18.8 to 20.7 days, n=57 studies, I-squared=99.3%, Q-statistic <0.01).41 Providers should manage athletes on an individual basis, accounting for specific factors that may affect their recovery trajectory, such as pre-existing factors (eg, migraine history, anxiety) or postinjury factors (eg, aggravation of injury, psychological stress, social factors) that impact recovery. When symptoms are persisting, worsen or are not progressively resolving 2–4 weeks postinjury, a multimodal evaluation25 and referral for rehabilitation (see Rehabilitation section) is recommended.38
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Return-to-sport (RTS) strategy—each step typically takes a minimum of 24 hours
Return-to-sport recommendations
RTS participation after SRC follows a graduated stepwise strategy, as outlined in table 2 . RTS occurs in conjunction with RTL (see RTL strategy) and under the supervision of a qualified HCP. Following an initial period of relative rest (Step 1: approximately 24–48 hours following injury), clinicians can implement Step 2 (ie, light (Step 2A) and then moderate (Step 2B) aerobic activity) of the RTS strategy as a treatment of acute concussion. 30 41 The athlete may then advance to Steps 3–6 on a time course dictated by symptoms, cognitive function, examination findings and clinical judgement. Differentiating early activity (Step 1), aerobic exercise (Step 2) and individual sport-specific exercise (Step 3) as part of the treatment of SRC from the remainder of the RTS progression (Steps 4–6) can be useful for the athlete and their support network (eg, parents, coaches, administrators and agents). Athletes may be moved into the later stages that involve risk of head impact (typically Steps 4–6 and Step 3 if there is any inadvertent risk of head impact with sport-specific activity) of the RTS strategy following authorisation by an HCP and after full resolution of concussion-related symptoms, abnormalities in cognitive function and clinical findings related to the current concussion, including the absence of symptoms with and after physical exertion. Each step typically takes at least 24 hours. Clinicians and athletes can expect a minimum of 1 week to complete the full rehabilitation strategy, but typical unrestricted RTS can take up to 1 month post-SRC. The time frame for RTS may vary based on individual characteristics, necessitating an individualised approach to clinical management. Athletes having difficulty progressing through the RTS strategy or with symptoms and signs that are not progressively recovering beyond the first 2–4 weeks may benefit from rehabilitation in addition to the RTL and RTS strategies 38 (see Rehabilitation section) and/or involvement of a multidisciplinary team of HCPs experienced in managing SRC (see Refer section).37 Medical determination of readiness to return to at-risk activities should occur prior to returning to any activities at risk of contact, collision or fall (eg, multiplayer training drills), which may be required prior to any of Steps 4–6, depending on the nature of the sport or activity that the athlete is returning to and in keeping with local laws/requirements.
RECONSIDER: potential long-term effects
There is increasing societal concern about possible problems with later-in-life brain health in former athletes, such as mental health problems, cognitive impairment and neurological diseases. The literature was reviewed for published studies using research designs that could estimate future risk to former athletes (ie, cohort studies and case–control studies). These research designs, either prospective or retrospective, require that an exposed and an unexposed group be followed through time to the outcome of interest. 49
Studies that examined mental health as an outcome found that (1) former amateur athletes (primarily American football players) are not at increased risk for depression or suicidality during early adulthood or as older adults, 50–54 (2) former professional soccer players are not at increased risk for psychiatric hospitalisation during their adult life 55 and (3) former professional football and soccer players are not at increased risk for death associated with having a psychiatric disorder 56 57 or as a result of suicide. 55–59
Other studies evaluated cognitive impairment, neurological disorders (eg, dementia) and neurodegenerative diseases (e.g., Alzheimer’s disease, Parkinson’s disease and amyotrophic lateral sclerosis (ALS)) as the outcome. Former male amateur athletes were not at increased risk for cognitive impairment, neurological disorders or neurodegenerative diseases compared with men from the general population. 53 60–62 In contrast, studies of former professional athletes examining causes of death reported greater mortality rates from neurological diseases and dementia in former professional American football players 63–65 and professional soccer players. 66 Former professional football players 64 65 and soccer players 59 66 67 have greater mortality rates from ALS. ALS is a rare disease with a possible genetic cause in some cases of men who develop the disease before age 50, 68 and it involves a highly selective population of neurons, about half of which are in the spinal cord, which makes identifying specific trauma-related aetiological mechanisms challenging.
The studies, to date, are methodologically limited because most were not able to examine, or adjust for, many factors that can be associated with the mental health and neurological outcomes of interest. The studies examining cognitive impairment and neurological outcomes did not examine genetic factors and usually did not consider or control for factors known to be important for brain health in the general population, such as educational attainment, socioeconomic status, smoking, hypertension and cardiovascular disease, diabetes, sleep apnea, white matter hyperintensities, social isolation, diet, PA or exercise. 69–79 To establish a clear causal association between sports participation early in life and cognitive impairment or dementia late in life or to quantify that association, future well-designed case–control and cohort studies, that include as many individual risk-modifying and confounding factors as possible, are needed.
Chronic traumatic encephalopathy-neuropathological change and traumatic encephalopathy syndrome 49
Historically, a clinical condition associated with chronic traumatic brain injury in boxers was described using terms like punch drunk, 80 dementia pugilistica 81 and chronic traumatic encephalopathy (CTE). 82 83 In recent years, CTE has been described as a neuropathological entity. 84–86 To avoid conceptual confusion between the pathology and a possible clinical condition, the postmortem neuropathology is referred to as CTE neuropathologic change (CTE-NC). The literature suggests that CTE-NC is very uncommon in community samples and brain banks, using strict criteria for case identification, and more common in brain bank samples of former professional athletes with high exposure to repetitive head impacts. However, these studies of former athletes are not cohort studies that can examine causation or quantify risk and thus were not included in the systematic review. It is reasonable to consider extensive exposure to repetitive head impacts, such as that experienced by some professional athletes, as potentially associated with the development of the specific neuropathology described as CTE-NC.
CTE-NC is not a clinical diagnosis. The first consensus criteria for traumatic encephalopathy syndrome (TES), a new clinical diagnosis, were published in 2021. 87 These diagnostic criteria can be used to determine the extent to which CTE-NC identified after death was associated with this new clinical diagnosis during life. The prevalence of CTE-NC (a neuropathological entity) and TES (a clinical diagnosis) in former athletes, military veterans and people from the general population is not known. It is also not known whether (1) CTE-NC causes specific neurological or psychiatric problems, (2) the extent to which CTE-NC can be clearly identified within the presence of Alzheimer’s disease neuropathology or (3) whether CTE-NC is inevitably progressive.
RETIRE
There is no clear evidence of the factors that, if present, would unequivocally lead to retirement or discontinued participation in contact or collision sports. 88 However, some sports have their own specific medical regulations regarding clearance for participation (e.g., retinal detachment in boxing).
Decisions regarding retirement or discontinuation from contact or collision sports are complex and multifaceted and should involve clinicians with expertise in traumatic brain injury and sport and preferably a multidisciplinary team. The decision-making process should include a comprehensive clinical evaluation that considers important patient-, injury-, sport-specific and other sociocultural factors. 88
The discussion should provide athletes with the scientific evidence and uncertainties of their condition balanced against the benefits of participation in sport. It should incorporate the athlete’s preferences and risk tolerance as well as psychological readiness to make an informed decision. The discussion should be carefully documented and should use language that is appropriate for the health literacy of the individual to reduce the risk that the information is misinterpreted. For children and adolescents, the parent/guardian should be involved in the discussion. HCPs should make the athlete aware of the role(s) they are playing in the athlete’s care, stating clearly if they have any potential or actual conflicts of interest. The shared decision-making process should be individualised and incorporate a comprehensive clinical evaluation that may involve a multidisciplinary team and considers patient-, injury-, sport-specific and other sociocultural factors. These principles also apply to all of those involved in the coaching and management of the athlete. 88
In the child or adolescent athlete, additional concerns are a successful return to school and to maintain healthy levels of PA. This often requires a multidisciplinary process that includes the child/adolescent, parent/caregivers, HCPs, school leadership and teachers in the discussions.
Given the positive benefits of exercise on health, care must be taken to avoid restricting all PA. All athletes who ultimately retire from contact or collision sports should be encouraged to continue non-contact or low-contact PA and have the health benefits of exercise explained.
REFINE
Additional topics of relevance to SRC were included in the Amsterdam consensus. Several considerations that could strengthen the consensus process were identified and are described below.
Para sport
Participation in sport across the lifespan for people with disabilities, estimated at 15%–25% of the global population, is increasing. 89 Modern definitions of disability are broad-ranging and inclusive of impairment types that span the Paralympic movement (eg, physical disability, blind/low vision, intellectual disability), Special Olympics (eg, intellectual disability, developmental disability) and Deaflympics (eg, deaf, hard of hearing). 90 Many people with disabilities also participate, train and compete in mainstream sporting environments.
The concussion experience of the para athlete is unique, due to the interaction of the individual’s primary impairment and the pathophysiology of concussion. Para athletes may experience a concussion in widely played sports like ice hockey and soccer, as well as in para athlete-specific sports such as wheelchair racing and para swimming.91 92 Commonly used SRC tools (eg, SCAT) are not validated in the para athlete population, who require a more individualised approach.
Although the literature describing SRC in people with disabilities is limited, elite Paralympic athletes are known to be at higher risk of injury when compared with athletes with no disability. 93–95 Additionally, athletes with visual impairment may be at even greater risk of concussion, as the mechanisms of injury in this population are primarily through collisions or direct head contact.96 97 Moreover, it is likely that prevention approaches, detection of initial symptoms, diagnosis, recovery (ie, potential for persisting symptoms of concussion) and treatment strategies may be impacted by the characteristics of the individual’s underlying impairment.
The recent position statement of the Concussion in Para Sport Group summarised expert opinion regarding concussion prevention, assessment and management in para sport participants. 96 Most significantly, (1) individuals may benefit from baseline testing given the variable nature of their disability and the potential for atypical presenting signs/symptoms of concussion, (2) individuals with a history of central nervous system injury (eg, cerebral palsy, stroke) may require an extended period of initial rest, (3) testing for symptoms of concussion through recovery may require modification such as the use of arm ergometry as opposed to a treadmill/stationary bike and (4) RTS protocols must be tailored and include the use of the individual’s personal adaptive equipment and, for applicable participants with visual impairment, partnership with their guide.
Future research is needed to enhance our knowledge of concussion assessment and management in para sport participants. This should include longitudinal injury surveillance to examine modifiable risk factors and prevention strategies, establishing reference data for commonly used assessment tools, evaluating outcomes of concussion and the intersection of the individual’s primary impairment type and understanding the unique challenges of under-researched subpopulations such as the female and child/adolescent with a disability.
Paediatrics
Brain development in the child (5–12 years) and adolescent (13–18 years) and the requirement for return to school guidance necessitate modified paradigms in paediatric SRC. Prevention efforts are important, and rule changes and contact practice limitations for children and adolescents participating in ice hockey and American football have demonstrated reduced SRC incidence rates.12 13 15 16 The application of such rules in other sports requires more research. The benefits of mouthguards in children and adolescent ice hockey are clear and should be evaluated across all collision sports.12 NMT warm-up programmes are recommended in rugby with more research needed in female athletes and other team sports.19 Further research evaluating headgear in non-helmeted sports is required to inform recommendations.
Paediatric athletes are less likely to have trained medical personnel available on the sideline, and it is strongly recommended that the CRT6 be used by all adults supervising child and adolescent sport. The Child SCAT6 (8–12 years) and SCAT6 (adolescents) should be used by HCPs; however, baseline testing is of limited use in younger athletes because of neurocognitive development. Evaluation with the Child SCAT6/SCOAT6 provides a framework for multiple domain assessments and informs the clinician on implementing appropriate exercise, RTL and RTS, and rehabilitation. Such a multifaceted clinical evaluation is recommended to guide both management and the possible need for referral to practitioners from multiple disciplines experienced in paediatric SRC.
Return-to-school is a priority in children and adolescents, and while full RTL is recommended before unrestricted RTS, the two strategies can occur in parallel. The use of advanced neuroimaging, fluid biomarkers and other technologies is under investigation for SRC diagnosis, prognosis and recovery39; however, age-specific data are required to accommodate physiological and neurocognitive development in the child athlete.
Children and adolescents with repeat concussions wishing to continue to play or to progress to the next age-level group or elite pathway programmes require individualised assessment. Considering the health benefits of a physically active lifestyle, any child/adolescent advised against participating in contact sport should be encouraged to participate in other non-contact sporting or exercise activities.
The athlete’s voice
The Scientific Committee deemed it important to include the athlete’s perspective in this consensus process. There was athlete representation (both in-person and via prerecorded videos) at the conference but not on the subsequent scientific expert panel. Although none of these athletes had direct input into the consensus statement itself, the experience that they shared at the conference around the topics of concussion diagnosis, retirement due to concussion, concussion in youth sport, readiness to RTS following concussion, concussion in para athletes and prevention of concussion provided valuable first-person perspectives for the expert panel.
Ethical considerations, limitations and improvements
While many advances have been made, we recognise that future consensus processes should evolve and strive to improve areas that integrate principles of modern ethics, process, methodology and healthcare practice.98 These include the five topics discussed below.
Equity, diversity and inclusion (EDI)
Historically, the expert panel of researchers and clinicians was selected on the basis of specific expertise but had limited demographic (eg, gender, race/ethnicity) and geographical (eg, country and continent of origin, low- and middle-income countries) diversity. The benefits of gender and ethnic diversity in advancing science and innovation are well described.99 100 Although the Amsterdam Scientific Committee and expert panel were the most diverse to date in the concussion in sport consensus process, significant deficiencies and challenges remain in achieving greater inclusivity regarding demographic and geographical diversity. Addressing this will add diverse perspectives to broaden research, knowledge translation and clinical practice into the assessment and management of SRC globally.
Stakeholder voices
Beside including the athlete’s voice, future consideration could be given to a more integrated codesign with stakeholder participation including parents, teachers, officials, coaches and sports administrators. Comments from the conference participants were also scribed, many of which included stakeholder voices expressing their perspectives and insights as youth athletes, para athletes, professional athletes, family members, sport policy-makers and others.
Observer input
The expert panel session benefited from the presence of several observers experienced in the field of SRC. Many of these observers shared their input as co-authors on the systematic reviews, while others were able to provide comment during the public open forums at the conference. Consideration could be given to more formally documenting their appointment, allowing further expert input and including their input into the consensus process.
Sustainability of the consensus process
The exponential increase in SRC scientific publications has greatly amplified the workload on the authors involved in the preparation of the systematic reviews. Consideration could be given to the creation of teams of dedicated clinicians and scientists assigned to narrower topics and questions, or perhaps the development of ‘living’ or regularly updated systematic reviews where new data productions and scientific advancements are rapid.
Potential conflicts of interest and transparency
Considerable efforts were made to record potential conflicts of interest among the members of the leadership group, contributors to the systematic reviews, expert panels and commentators from the floor at the consensus meeting. All speakers declared their interests at the beginning of their presentations (which were recorded on a digital repository), and all contributors from the floor of the consensus meeting were required to do the same verbally. This greater transparency enabled a critical appreciation of the context from which questions, challenges and criticisms were made.
Timing of the consensus meeting and expert panel consensus meeting
All 10 systematic reviews (SRs) were read by the expert panel in advance of the meeting but were then not yet in their final published form. To ensure that the outputs of the consensus were aligned with the final SRs accepted for publication, the lead authors of the SRs as well as of the Consensus Statement cross-checked the recommendations. The final consensus statement was not submitted in its final revised form until the completion of this additional step of the process to ensure that the Consensus Statement aligned with the final SR recommendations.
Future research
As part of their task, each author group identified gaps in the research. These gaps included additional topic areas of research, other geographical locations (ie, outside of North America), cultural contexts and ages, sexes and genders, which are described in each systematic review. The audience was also invited to share priorities for future research. A total of 342 participants responded to prioritise their top five topics for research, with potential long-term effects ranking first and prevention ranking second (figure 3).
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Percentage of conference attendees who voted for each topic as a top five priority for future research.
Potential long-term sequelae
The potential long-term mental health and neurodegenerative effects of concussion and repetitive head impacts are of increasing interest in the field and have dominated the public discourse on the possible long-lasting effects of collision/contact sports participation. This consensus process has revealed a spectrum of perspectives and the complexities of answering these important questions to which they give rise. Defining the methodology for adequate study designs to better understand if there is a link between neuropathological findings and in vivo processes should be prioritised. The ethical and scientific challenges related to the issue of potential long-term effects of concussion require an ongoing and collaborative process. The Scientific Committee proposes the formation of an interdisciplinary working group, including members of CISG, as well as other clinicians, scholars and scientists, to continue deliberations on these topics in the interest of athlete care. As part of their charge, we recommend this group seek dedicated funding for research into long-term athlete health and consider a separate conference to afford greater time and attention to this topic.
Conclusions
The 6th International Conference on Concussion in Sport (Amsterdam 2022) was the culmination of a 5-year process resulting in the development of this Statement and the accompanying sports concussion assessment tools. This consensus process took 2 years longer than initially planned due to pandemic-related postponements and aimed to be more extensive than previous versions. This Statement summarises the state of the science, incorporates several novel aspects and has identified priorities for research. The conference outcomes are intended to serve as summaries of the evidence at the time of the Amsterdam Conference to inform HCPs and sports organisations in the interests of improving athlete care at all levels of sport.
Acknowledgments
The authors would like to acknowledge their colleagues who acted as scribes at the 6th International Conference on Concussion in Sport: Paul Eliason, Christy Fehr, Colm Fuller, Emily Heming, Kirsten Holte, Benjamin Leggett, Linden Penner, Heather A Shepherd, Isla J Shill, Stacy Sick and Stephen W West. In addition, we thank the librarians who assisted with the searches for the systematic reviews, K Alix Hayden and Zahra Premji.
