Jonathan Speridon Patricios

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 …

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.

BokSmart - implementing a National Rugby Safety Programme.

The BokSmart National Rugby Safety Programme is a joint initiative between the South African Rugby Union and the Chris Burger/Petro Jackson Players Fund aimed at implementing evidence-based sports medicine and exercise research to prevent injury and enhance performance at all levels of rugby union in South Africa. The BokSmart programme has four main elements: Head and neck trauma form a large part of the injuries associated with contact and collision sport.6 Rugby Union is a collision sport that exposes players to cervical spinal injuries, with permanent disabling injuries being the most serious and highly publicised complication.7 Part of BokSmart s mandate is to record serious and catastrophic head, neck and spine rugby injuries in South Africa (SA), and to formulate appropriate initiatives aimed at prevention of these injuries.4 Even though spinal cord injuries in rugby union are few, there are inherent risks associated primarily with the tackle and scrum6 that are the main contributors to spinal injuries, with scrum injuries consistently being more severe.3,–,5 7 10 Over the last 4 years in SA, these phases contributed to 78% of all serious and catastrophic head, neck and spine injuries in …

The FIFA medical emergency bag and FIFA 11 steps to prevent sudden cardiac death: setting a global standard and promoting consistent football field emergency care

Life-threatening medical emergencies are an infrequent but regular occurrence on the football field. Proper prevention strategies, emergency medical planning and timely access to emergency equipment are required to prevent catastrophic outcomes. In a continuing commitment to player safety during football, this paper presents the FIFA Medical Emergency Bag and FIFA 11 Steps to prevent sudden cardiac death. These recommendations are intended to create a global standard for emergency preparedness and the medical response to serious or catastrophic on-field injuries in football.

Association of type XI collagen genes with chronic Achilles tendinopathy in independent populations from South Africa and Australia

Background Type XI collagen, which is expressed in developing tendons and is encoded by the COL11A1, COL11A2 and COL2A1 genes, shares structural and functional homology with type V collagen, which plays an important role in collagen fibril assembly. We investigated the association of these three polymorphisms with Achilles tendinopathy (AT) and whether these polymorphisms interact with COL5A1 to modulate the risk of AT. Methods 184 participants diagnosed with chronic AT (TEN) and 338 appropriately matched asymptomatic controls (CON) were genotyped for the three polymorphisms. Results Although there were no independent associations with AT, the TCT pseudohaplotype constructed from rs3753841 (T/C), rs1676486 (C/T) and rs1799907 (T/A) was significantly over-represented (p=0.006) in the TEN (25.9%) compared with the CON (17.1%) group. The TCT(AGGG) pseudohaplotypes constructed using these type XI collagen polymorphisms and the functional COL5A1 rs71746744 (-/AGGG) polymorphism were also significantly over-represented (p<0.001) in the TEN (25.2%) compared with the CON (9.1%) group. Discussion The genes encoding structural and functionally related type XI (COL11A1 and COL11A2) and type V (COL5A1) collagens interact with one another to collectively modulate the risk for AT. Although there are no immediate clinical applications, the results of this study provide additional evidence that interindividual variations in collagen fibril assembly might be an important molecular mechanism in the aetiology of chronic AT.

The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5)

This article presents the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). The Sport Concussion Assessment Tool was introduced in 2004, following the 2nd International Conference on Concussion in Sport in Prague, Czech Republic. Following the 4th International Consensus Conference, held in Zurich, Switzerland, in 2012, the SCAT 3rd edition (Child SCAT3) was developed for children aged between 5 and12 years. Research to date was reviewed and synthesised for the 5th International Consensus Conference on Concussion in Sport in Berlin, Germany, leading to the current revision of the test, the Child SCAT5. This article describes the development of the Child SCAT5.

It is time to give concussion an operational definition: a 3-step process to diagnose (or rule out) concussion within 48 h of injury: World Rugby guideline

Concussion is the number one injury risk in contact and collision sports. Identification of concussive events is critical to optimise injury management and, as identified by Quarrie and Murphy,1 to undertake accurate injury surveillance studies. The Zurich Consensus Statement on Concussion2 provides an expanded theoretical or conceptual definition of concussion but there is not yet an operational definition of concussion. In 2012 World Rugby introduced a new pitch side process for assessment of head injuries, called the head injury assessment (HIA).3 During the evolution of this process an operational definition of concussion has been developed and successfully implemented. This World Rugby operational definition of concussion was developed with the intent of increasing recognition and sensitivity of diagnosis within the sport and subsequently to improve player welfare and safety. Confirmed cases of concussion must follow the recommended rest and graduated return to play programme that serves as a final part of the serial evaluation process. During the development of this operational definition of concussion it was agreed that this definition should address the timing of concussion assessment(s), how the diagnosis of concussion is confirmed or excluded and the …

What is the relationship between groin pain in athletes and femoroacetabular impingement

Groin symptoms in athletes have been likened to the Bermuda Triangle as sports physicians, orthopaedists, surgeons and therapists alike are easily sucked into a sea of confusing suppositions and assumptions.1 Possibly the greatest advance in the understanding and appreciation of ‘sports hernia’ has been the recent acknowledgment by a multidisciplinary panel of experts that there is in fact no hernia associated with the condition and they have coined the term ‘inguinal disruption’.2 Unfortunately, although the authors describe a constellation of symptoms, the label again suggests a localised pathology rather than a syndrome. As much as we concentrate our collective efforts on repairing a defect in an anatomical area or treating what we consider to be the primary area of injury, perhaps we should explore and investigate the concept that symptoms are a result of a structural failure of tissue to compensate for abnormal loads created by an imbalance of forces across the groin area. Single or multiple areas of groin injury may represent a failure of the same functional unit. The proposal of a ‘pubic joint’, distinct from the symphysis pubis, which involves numerous anatomical structures and their resultant forces at different contact sites can explain the multiple pathologies that exist in this condition. …

Zurich 2012: our cohort of ‘concussionologists‘ – conveying consensus

Dr Mike Evans’ YouTube video ‘Concussions 101’1 plays on many desktops partly as a superb audiovisual aid to patients but mostly as a humbling reminder to us as to how efficiently Evans has conveyed to 50 363 people (so far!) the mantra of concussion care. Similarly, every time we watch a South African rugby match, we are astounded by the efficiency of the Wayne Viljoen managed BokSmart2 initiative that has put a field side concussion card in the pocket of 45 432 coaches and referees at all levels of South African rugby countrywide. For those of us who deal frequently with concussed patients, the series of international conferences,3–5 and the consensus documents and team physician guidelines6 ,7 that have emerged since Vienna 2001, have reassuringly guided us from the somewhat dogmatic neurological grading systems of the past to an evolving framework of consensus protocols that facilitate a more personalised approach to the concussed player based on both subjective feedback and objective clinical and cognitive evaluations. We have become comfortable with the on-field screening questions, field side SCAT2, serial office assessments, balance testing and return-to-play protocols. The Fourth International Conference on Concussion in Sport in Zurich from 1 to 2 November 2012 represents the latest gathering of sports neurologys most distinguished minds to further enhance our ability to more objectively and effectively manage this enigmatic neuropathological process. The concussion-in-sport leadership group continues to engage increasingly widely and harness the resources of key international sports bodies. Challenges posed have been taken up internationally and effectively addressed at …

Is the content and duration of the graduated return to play protocol after concussion demanding enough? A challenge for Berlin 2016

Determining the appropriate starting point and duration of the return-to-play (RTP) process after injury is fundamental to clinical sports medicine. The most commonly cited RTP framework after concussion is outlined as part of all international concussion consensus statements. This framework is a key element of concussion management across all levels of sport and provides a ‘cornerstone’ of current education initiatives. In Rugby Union, RTP guidelines last underwent a major update by World Rugby, the International Federation, in 2011, and are consistent with international concussion consensus. There is a limited evidence base informing the content and duration of the graduated return to play (GRTP). Specifically, the evidence evaluating the effect, optimal amount and type of rest is sparse. Moreover, current RTP guidelines for children and adolescents are based on those of adults. While research concerning a range of clinical outcomes following concussive injury in sport continues to develop, until recently, little has been known about the consequences …