Gavin A. Davis

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012

This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3 The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or converted to a digital format. The authors request that the document and/or the accompanying tools be distributed in their full and complete format. This consensus paper is broken into a number of sections 1. A summary of concussion and its management, with updates from the previous meetings; 2. Background information about the consensus meeting process; 3. A summary of the specific consensus questions discussed at this meeting; 4. The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT …

Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements1–4 and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement. This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps. A series of specific clinical questions were developed as part of the consensus process for the Berlin 2016 meeting. Each consensus question was the subject of a specific formal systematic review, which is published concurrently with this summary statement. Readers are directed to these background papers in conjunction with this summary statement as they provide the context for the issues and include the scope of published research, search strategy and citations reviewed for each question. This 2017 consensus statement also summarises each topic and recommendations in the context of all five CISG meetings (that is, 2001, 2004, 2008, 2012 as well as 2016). Approximately 60 000 published articles were screened by the expert panels for the Berlin …

Consensus statement on concussion in sport: the 4th international conference on concussion in sport, Zurich, november 2012

Paul McCrory, MBBS, PhD*; Willem H. Meeuwisse, MD, PhD†; Mark Aubry, MD‡; Robert C. Cantu, MD§; Jiři Dvořak, MD||; Ruben J. Echemendia, PhD¶; Lars Engebretsen, MD, PhD#; Karen Johnston, MD, PhD**; Jeffrey S. Kutcher, MD††; Martin Raftery, MBBS‡‡; Allen Sills, MD§§; Brian W. Benson, MD, PhD||||; Gavin A. Davis, MBBS¶¶; Richard Ellenbogen, MD##; Kevin M. Guskiewicz, PhD***; Stanley A. Herring, MD†††; Grant L. Iverson, PhD‡‡‡; Barry D. Jordan, MD§§§; James Kissick, MD||||||; Michael McCrea, PhD¶¶¶; Andrew S. McIntosh, PhD###; David Maddocks, LLB, PhD****; Michael Makdissi, MBBS, PhD††††; Laura Purcell, MD‡‡‡‡; Margot Putukian, MD§§§§; Kathryn Schneider, PhD||||||||; Charles H. Tator, MD, PhD¶¶¶¶; Michael Turner, MD####

Can we manage sport related concussion in children the same as in adults

Evidence based guidelines are required for the management of concussive injury in children Consensus guidelines for managing sport related concussion in adults have been increasingly widely implemented.1 So far, there are no guidelines that enable clinicians to manage similar sporting concussive injuries in children. Furthermore, there are a number of important anatomical, physiological, and behavioural differences between adults and children that suggest that adult guidelines will need to be either modified or rewritten to manage injuries in this age group. The annual incidence of traumatic brain injury (TBI) in adults is remarkably constant worldwide and has been estimated at between 180 and 300 cases per 100 000 population.2–5 This is believed to be an underestimate of the true incidence as an equivalent number of mild injuries are treated by general practitioners and do not result in hospital admission.6 Direct sport participation accounts for approximately 15–20% of all such TBI3,7 and in children a further smaller percentage of TBI is associated with play activities.8 In children aged 15 years and under, the estimated incidence rate of TBI is 180 per 100 000 children per year of which approximately 85% are categorised as mild injuries.7 In the US, it has been estimated that more than 1 million children sustain a TBI annually and that TBI accounts for more than 250 000 paediatric hospital admissions as well as more than 10% of all visits to emergency service settings.9 In child and adolescent populations, few well controlled studies exist to identify the age specific frequency and outcome of sport related concussive injuries. The most common cognitive sequelae of concussive injuries in children are the same as for adults, namely reduced speed of information processing, poor attention, and impaired executive function.10–14 Concussion may also have a significant …

Evidence-based approach to revising the SCAT2: introducing the SCAT3

The Sport Concussion Assessment Tool 2 (SCAT2), which evolved from the 2008 Concussion in Sport Group (CISG) Consensus meeting, has been widely used internationally for the past 4 years. Although the instrument is considered very practical and moderately effective for use by clinicians who manage concussion, the utility and sensitivity of a 100-point scoring system for the SCAT2 has been questioned. The 2012 CISG Consensus Meeting provided an opportunity for several of the worlds leading concussion researchers and clinicians to present data and to share experiences using the SCAT2. The purpose of this report is to consider recommendations by the CISG, and to review the current literature to identify the most sensitive and reliable concussion assessment components for inclusion in a revised version—the SCAT3. Through this process, it was determined that important clinical information can be ascertained in a streamlined manner through the use of a multimodal instrument such as the SCAT3. This test battery should include an initial assessment of injury severity using the Glasgow Coma Scale, immediately followed by observing and documenting concussion signs. Once this is complete, symptom endorsement and symptom severity, neurocognitive function and balance function should be assessed in any athlete suspected of sustaining a concussion. There is no evidence to support the use of a composite/total score; however, there is good evidence to support the use of each component (scored independently) in a revised assessment tool.

Second impact syndrome or cerebral swelling after sporting head injury.

Second impact syndrome is believed to be the catastrophic consequence of repeated head injury in sport. The scientific evidence to support this concept is nonexistent, and belief in the syndrome is based upon the interpretation of anecdotal cases more often than not, lacking sufficient clinical detail to make definitive statements. The fear of this condition has driven many of the current return-to-play guidelines following concussion. Diffuse cerebral swelling (DCS) following a head injury is a well-recognized condition, more common in children than in adults, and usually has a poor outcome.

Contributions of neuroimaging, balance testing, electrophysiology and blood markers to the assessment of sport-related concussion

Objective: To review the diagnostic tests and investigations used in the management of sports concussion, in the adult and paediatric populations, to (a) monitor the severity of symptoms and deficits, (b) track recovery and (c) advance knowledge relating to the natural history and neurobiology of the injury. Design: Qualitative literature review of the neuroimaging, balance testing, electrophysiology, blood marker and concussion literature. Intervention: PubMed and Medline databases were reviewed for investigations used in the management of adult and paediatric concussion, including structural imaging (computerised tomography, magnetic resonance imaging, diffusion tensor imaging), functional imaging (single photon emission computerised tomography, positron emission tomography, functional magnetic resonance imaging), spectroscopy (magnetic resonance spectroscopy, near infrared spectroscopy), balance testing (Balance Error Scoring System, Sensory Organization Test, gait testing, virtual reality), electrophysiological tests (electroencephalography, evoked potentials, event related potentials, magnetoencephalography, heart rate variability), genetics (apolipoprotein E4, channelopathies) and blood markers (S100, neuron-specific enolase, cleaved Tau protein, glutamate). Results: For the adult and paediatric populations, each test has been classified as being: (1) clinically useful, (2) a research tool only or (3) not useful in sports-related concussion. Conclusions: The current status of the diagnostic tests and investigations is analysed, and potential directions for future research are provided. Currently, all tests and investigations, with the exception of clinical balance testing, remain experimental. There is accumulating research, however, that shows promise for the future clinical application of functional magnetic resonance imaging in sport concussion assessment and management.

Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups?

Background One of the key difficulties while managing concussion in sport is that there are few prognostic factors to reliably predict clinical outcome. The aims of the current paper are to review the evidence for concussion modifiers and to consider how the evaluation and management of concussion may differ in specific groups. Methods A qualitative review of the literature on concussion was conducted with a focus on prognostic factors and specific groups including children, female athletes and elite versus non-elite players. PubMed, MEDLINE and SportsDiscus databases were reviewed. Results The literature demonstrates that number and severity of symptoms and previous concussions are associated with prolonged recovery and/or increased risk of complications. Brief loss of consciousness (LOC) and/or impact seizures do not reliably predict outcomes following a concussion, although a cautious approach should be adopted in an athlete with prolonged LOC or impact seizures (ie, >1 min). Children generally take longer to recover from concussions and assessment batteries have yet to be validated in the younger age group. Currently, there are insufficient data on the influence of genetics and gender on outcomes following a concussion. Conclusions Several modifiers are associated with prolonged recovery or increased risk of complications following a concussion and have important implications for management. Children with concussion should be managed conservatively, with an emphasis on return to learn as well as return to sport. In cases of concussions managed with limited resources (eg, non-elite players), a conservative approach should also be taken. There should be an emphasis on concussion education in all sports and at all levels, particularly in junior and community-based competitions.

Consensus statement on Concussion in Sport - The 4th International Conference on Concussion in Sport held in Zurich, November 2012.

the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Paul McCrory, Willem H Meeuwisse, Mark Aubry, Bob Cantu, Jiří Dvořák, Ruben J Echemendia, Lars Engebretsen, Karen Johnston, Jeffrey S Kutcher, Martin Raftery, Allen Sills, Brian W Benson, Gavin A Davis, Richard G Ellenbogen, Kevin Guskiewicz, Stanley A Herring, Grant L Iverson, Barry D Jordan, James Kissick, Michael McCrea, Andrew S McIntosh, David Maddocks, Michael Makdissi, Laura Purcell, Margot Putukian, Kathryn Schneider, Charles H Tator, Michael Turner

The evaluation and management of acute concussion differs in young children

Background There are many reasons why concussion in children needs to be considered different from adults. The Zurich (2008) recommendations on the management of concussion in children are restricted to children less than to 10 years of age. It does not include recommendations for children aged 5–10 years. The aim of this study is to review the current literature on (1) concussion assessment at the sideline and during recovery stages, especially in the age group 5–15 years, and (2) the management of concussion in children and adolescents. Methods A literature review using the MEDLINE database was undertaken. Articles were selected that included evaluation and/or management in children aged 5–15 years. Results There are no sideline assessment tools validated for use in this age group. There are a number of different symptom scales that have been validated during different stages of the follow-up assessment in children. No single paediatric concussion assessment tool has been validated for use from sideline through to all stages of recovery. Reliability studies have been published on Balance Error Scoring System in children, but validity studies in this age group have not been published. The management of concussion includes withdrawal from play on the day and cognitive and physical rest. The priority of concussion management in children is to return to learn; while this is usually rapid, there are some children in whom a graduated return to school is required, which should include a number of accommodations. Conclusions A young child is physically, cognitively and emotionally very different from adults, and requires the use of a different set of tools for the diagnosis, recovery-assessment and management of concussion. Age-specific, validated diagnostic tools are required, and management of concussion in children should focus attention on return to learn before considering return to play.