Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008

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1 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om Consensus Statement on Conussion in Sport: the 3rd International Conferene on Conussion in Sport held in Zurih, November 2008 P MCrory, 1 W Meeuwisse, 2 K Johnston, 3 J Dvorak, 4 M Aubry, 5 M Molloy, 6 R Cantu 7 1 Centre for Health, Exerise & Sports Mediine, University of Melbourne, Parkville, Australia; 2 Sport Mediine Centre, Faulty of Kinesiology, and Department of Community Health Sienes, Faulty of Mediine, University of Calgary, Calgary, Alberta, Canada; 3 Sport Conussion Clini, Toronto Rehabilitation Institute, Toronto, Ontario, Canada; 4 FIFA Medial Assessment and Researh Center and Shulthess Clini, Zurih, Switzerland; 5 International Ie Hokey Federation and Hokey Canada, and Ottawa Sport Mediine Centre, Ottawa, Canada; 6 International Rugby Board, Dublin, Ireland; 7 Emerson Hospital, Conord, Massahusetts, USA Correspondene to: Assoiate Professor P MCrory, Centre for Health, Exerise & Sports Mediine, University of Melbourne, Parkville, Australia 3010; paulmr@ bigpond.net.au This paper is a revision and update of the reommendations developed following the 1st (Vienna) and 2nd (Prague) International Symposia on Conussion in Sport. 1 2 The Zurih Consensus statement is designed to build on the priniples outlined in the original Vienna and Prague douments and to develop further oneptual understanding of this problem using a formal onsensus-based approah. A detailed desription of the onsensus proess is outlined at the end of this doument. This doument is developed for use by physiians, therapists, ertified athleti trainers, health professionals, oahes and other people involved in the are of injured athletes, whether at the rereational, elite or professional level. While agreement exists pertaining to prinipal messages onveyed within this doument, the authors aknowledge that the siene of onussion is evolving and therefore management and return to play deisions remain in the realm of linial judgement on an individualised basis. Readers are enouraged to opy and distribute freely the Zurih Consensus doument and/or the Sports Conussion Assessment Tool (SCAT2) ard and neither is subjet to any opyright restrition. The authors request, however that the doument and/or the SCAT2 ard be distributed in their full and omplete format. The following fous questions formed the foundation for the Zurih onussion onsensus statement: Aute simple onussion Whih symptom sale and whih sideline assessment tool is best for diagnosis and/or follow up? How extensive should the ognitive assessment be in elite athletes? How extensive should linial and neuropsyhologial (NP) testing be at non-elite level? Who should do/interpret the ognitive assessment? Is there a gender differene in onussion inidene and outomes? Return to play (RTP) issues Is provoative exerise testing useful in guiding RTP? What is the best RTP strategy for elite athletes? What is the best RTP strategy for nonelite athletes? Is protetive equipment (eg, mouthguards and helmets) useful in reduing onussion inidene and/or severity? Complex onussion and long-term issues Is the simple versus omplex lassifiation a valid and useful differentiation? Are there speifi patient populations at risk of long-term problems? Is there a role for additional tests (eg, strutural and/or funtional MRI, balane testing, biomarkers)? Should athletes with persistent symptoms be sreened for depression/anxiety? Paediatri onussion Whih symptoms sale is appropriate for this age group? Whih tests are useful and how often should baseline testing be performed in this age group? What is the most appropriate RTP guideline for elite and non-elite hild and adolesent athletes? Future diretions What is the best method of knowledge transfer and eduation? Is there evidene that new and novel injury prevention strategies work (eg, hanges to rules of the game, fair play strategies, et)? The Zurih doument additionally examines the management issues raised in the previous Prague and Vienna douments and applies the onsensus questions to these areas. SPECIFIC RESEARCH QUESTIONS AND CONSENSUS DISCUSSION 1. Conussion 1.1 Definition of onussion A panel disussion regarding the definition of onussion and its separation from mild traumati brain injury (mtbi) was held. Although there was aknowledgement that the terms refer to different injury onstruts and should not be used interhangeably, it was not felt that the panel would define mtbi for the purpose of this doument. There was unanimous agreement, however, that onussion is defined as follows: Conussion is defined as a omplex pathophysiologial proess affeting the brain, indued by traumati biomehanial fores. Several ommon features that inorporate linial, pathologi and biomehanial injury onstruts that may be utilised in defining the nature of a onussive head injury inlude: 1. Conussion may be aused either by a diret blow to the head, fae, nek or elsewhere on the body with an impulsive fore transmitted to the head. 2. Conussion typially results in the rapid onset of short-lived impairment of neurologi funtion that resolves spontaneously. 3. Conussion may result in neuropathologial hanges but the aute linial symptoms largely reflet a funtional i76

2 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om disturbane rather than a strutural injury. 4. Conussion results in a graded set of linial symptoms that may or may not involve loss of onsiousness. Resolution of the linial and ognitive symptoms typially follows a sequential ourse; however it is important to note that in a small perentage of ases however, postonussive symptoms may be prolonged. 5. No abnormality on standard strutural neuroimaging studies is seen in onussion. 1.2 Classifiation of onussion There was unanimous agreement to abandon the simple versus omplex terminology that had been proposed in the Prague agreement statement as the panel felt that the terminology itself did not fully desribe the entities. The panel however unanimously retained the onept that the majority (80 90%) of onussions resolve in a short (7 10 day) period, although the reovery time frame may be longer in hildren and adolesents Conussion evaluation 2.1 Symptoms and signs of aute onussion The panel agreed that the diagnosis of aute onussion usually involves the assessment of a range of domains inluding linial symptoms, physial signs, behaviour, balane, sleep and ognition. Furthermore, a detailed onussion history is an important part of the evaluation both in the injured athlete and when onduting a pre-partiipation examination. The detailed linial assessment of onussion is outlined in the SCAT2 form (see p 85). The suspeted diagnosis of onussion an inlude one or more of the following linial domains: a. Symptoms somati (eg, headahe), ognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability). b. Physial signs (eg, loss of onsiousness, amnesia).. Behavioural hanges (eg, irritability). d. Cognitive impairment (eg, slowed reation times). e. Sleep disturbane (eg, drowsiness). If any one or more of these omponents is present, a onussion should be suspeted and the appropriate management strategy instituted. 2.2 On-field or sideline evaluation of aute onussion When a player shows any features of a onussion: a. The player should be medially evaluated onsite using standard emergeny management priniples and partiular attention should be given to exluding a ervial spine injury. b. The appropriate disposition of the player must be determined by the treating healthare provider in a timely manner. If no healthare provider is available, the player should be safely removed from pratie or play and urgent referral to a physiian arranged.. One the first aid issues are addressed, then an assessment of the onussive injury should be made using the SCAT2 or other similar tool. d. The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury. e. A player with diagnosed onussion should not be allowed to return to play on the day of injury. Oasionally in adult athletes, there may be return to play on the same day as the injury. See Setion 4.2. It was unanimously agreed that suffiient time for assessment and adequate failities should be provided for the appropriate medial assessment both on and off the field for all injured athletes. In some sports this may require rule hange to allow an off-field medial assessment to our without affeting the flow of the game or unduly penalising the injured player s team. Sideline evaluation of ognitive funtion is an essential omponent in the assessment of this injury. Brief neuropsyhologial test batteries that assess attention and memory funtion have been shown to be pratial and effetive. Suh tests inlude the Maddoks questions 3 4 and the Standardized Assessment of Conussion (SAC). 5 7 It is worth noting that standard orientation questions (eg, time, plae, person) have been shown to be unreliable in the sporting situation when ompared with memory assessment. 4 8 It is reognised, however, that abbreviated testing paradigms are designed for rapid onussion sreening on the sidelines and are not meant to replae omprehensive neuropsyhologial testing whih is sensitive to detet subtle defiits that may exist beyond the aute episode; nor should they be used as a stand-alone tool for the ongoing management of sports onussions. It should also be reognised that the appearane of symptoms might be delayed several hours following a onussive episode. 2.3 Evaluation in emergeny room or offie by medial personnel An athlete with onussion may be evaluated in the emergeny room or dotor s offie as a point of first ontat following injury or may have been referred from another are provider. In addition to the points outlined above, the key features of this exam should enompass: a. A medial assessment inluding a omprehensive history, and detailed neurologial examination inluding a thorough assessment of mental status, ognitive funtioning and gait and balane. b. A determination of the linial status of the patient inluding whether there has been improvement or deterioration sine the time of injury. This may involve seeking additional information from parents, oahes, teammates and eyewitnesses to the injury.. A determination of the need for emergent neuroimaging in order to exlude a more severe brain injury involving a strutural abnormality In large part, these points above are inluded in the SCAT2 assessment, whih forms part of the Zurih onsensus statement. 3. Conussion investigations A range of additional investigations may be utilised to assist in the diagnosis and/or exlusion of injury. These inlude the following. 3.1 Neuroimaging It was reognised by the panellists that onventional strutural neuroimaging is normal in onussive injury. Given that aveat, the following suggestions are made: brain CT (or where available, MR brain san) ontributes little to onussion evaluation but should be employed whenever suspiion of an intraerebral strutural lesion exists. Examples of suh situations may inlude prolonged disturbane of onsious state, foal neurologial defiit or worsening symptoms. Newer strutural MRI modalities inluding gradient eho, perfusion and diffusion imaging have greater sensitivity for strutural abnormalities. However, the lak of published studies as well as absent pre-injury neuroimaging data limits the usefulness of this approah in linial management at the present time. In i77

3 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om addition, the preditive value of various MR abnormalities that may be inidentally disovered is not established at the present time. Other imaging modalities suh as funtional MRI (fmri) show ativation patterns that orrelate with symptom severity and reovery in onussion While not part of routine assessment at the present time, they nevertheless provide additional insight to pathophysiologial mehanisms. Alternative imaging tehnologies (eg, positron emission tomography, diffusion tensor imaging, magneti resonane spetrosopy, funtional onnetivity), while demonstrating some ompelling findings, are still at early stages of development and annot be reommended other than in a researh setting. 3.2 Objetive balane assessment Published studies, using both sophistiated fore plate tehnology and less sophistiated linial balane tests (eg, balane error soring system (BESS)), have identified postural stability defiits lasting approximately 72 hours following sportrelated onussion. It appears that postural stability testing provides a useful tool for objetively assessing the motor domain of neurologial funtioning, and should be onsidered a reliable and valid addition to the assessment of athletes suffering from onussion, partiularly where symptoms or signs indiate a balane omponent Neuropsyhologial assessment The appliation of neuropsyhologial (NP) testing in onussion has been shown to be of linial value and ontinues to ontribute signifiant information in onussion evaluation Although in most ase ognitive reovery largely overlaps with the time ourse of symptom reovery, it has been demonstrated that ognitive reovery may oasionally preede or more ommonly follow linial symptom resolution, suggesting that the assessment of ognitive funtion should be an important omponent in any return to play protool It must be emphasised however, that NP assessment should not be the sole basis of management deisions; rather it should be seen as an aid to the linial deisionmaking proess in onjuntion with a range of linial domains and investigational results. Neuropsyhologists are in the best position to interpret NP tests by virtue of their bakground and training. However, there may be situations where neuropsyhologists are not available and other medial professionals may perform or interpret NP sreening tests. The ultimate return to play deision should remain a medial one in whih a multidisiplinary approah, when possible, has been taken. In the absene of NP and other (eg, formal balane assessment) testing, a more onservative return to play approah may be appropriate. In the majority of ases, NP testing will be used to assist return to play deisions and will not be done until patient is symptom free. There may be situations (eg, hild and adolesent athletes) where testing may be performed early while the patient is still symptomati to assist in determining management. This will normally be best determined in onsultation with a trained neuropsyhologist Geneti testing The signifiane of apolipoprotein (Apo) E4, ApoE promotor gene, tau polymerase and other geneti markers in the management of sports onussion risk or injury outome is unlear at this time. Evidene from human and animal studies in more severe traumati brain injury shows indution of a variety of geneti and ytokine fators, suh as: insulin-like growth fator-1 (IGF-1), IGF binding protein-2, fibroblast growth fator, Cu Zn superoxide dismutase, superoxide dismutase-1 (SOD-1), nerve growth fator, glial fibrillary aidi protein (GFAP) and S Whether suh fators are affeted in sporting onussion is not known at this stage Experimental onussion assessment modalities Different eletrophysiologial reording tehniques (eg, evoked response potential (ERP), ortial magneti stimulation and eletroenephalography) have demonstrated reproduible abnormalities in the post-onussive state; however not all studies reliably differentiated onussed athletes from ontrols The linial signifiane of these hanges remains to be established. In addition, biohemial serum and erebral spinal fluid markers of brain injury (inluding S-100, neuron speifi enolase (NSE), myelin basi protein (MBP), GFAP, tau, et) have been proposed as means by whih ellular damage may be deteted if present There is urrently insuffiient evidene however, to justify the routine use of these biomarkers linially. 4. Conussion management The ornerstone of onussion management is physial and ognitive rest until symptoms resolve and then a graded programme of exertion prior to medial learane and return to play. The reovery and outome of this injury may be modified by a number of fators that may require more sophistiated management strategies. These are outlined in the setion on modifiers below. As desribed above, the majority of injuries will reover spontaneously over several days. In these situations, it is expeted that an athlete will proeed progressively through a stepwise return to play strategy. 57 During this period of reovery while symptomati, following an injury, it is important to emphasise to the athlete that physial and ognitive rest is required. Ativities that require onentration and attention (eg, sholasti work, videogames, text messaging, et) may exaerbate symptoms and possibly delay reovery. In suh ases, apart from limiting relevant physial and ognitive ativities (and other risk-taking opportunities for re-injury) while symptomati, no further intervention is required during the period of reovery and the athlete typially resumes sport without further problem. 4.1 Graduated return to play protool Return to play protool following a onussion follows a stepwise proess as outlined in table 1. With this stepwise progression, the athlete should ontinue to proeed to the next level if asymptomati at the urrent level. Generally eah step should take 24 hours so that an athlete would take approximately one week to proeed through the full rehabilitation protool one they are asymptomati at rest and with provoative exerise. If any postonussion symptoms our while in the stepwise programme, the patient should drop bak to the previous asymptomati level and try to progress again after a further 24-hour period of rest has passed. 4.2 Same day RTP With adult athletes, in some settings, where there are team physiians experiened in onussion management and suffiient resoures (eg, aess to neuropsyhologists, onsultants, neuroimaging, et) as well as aess to immediate (ie, sideline) neuroognitive assessment, return to play management may be more rapid. The RTP strategy must still follow the same basi management priniples, i78

4 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om Table 1 Graduated return to play protool Rehabilitation stage Funtional exerise at eah stage of rehabilitation Objetive of eah stage 1. No ativity Complete physial and ognitive rest Reovery 2. Light aerobi exerise Walking, swimming or stationary yling keeping intensity Inrease heart rate,70% maximum predited heart rate No resistane training 3. Sport-speifi exerise Skating drills in ie hokey, running drills in soer. No head impat ativities Add movement 4. Non-ontat training drills Progression to more omplex training drills, eg passing drills in football and ie hokey May start progressive resistane training) 5. Full ontat pratie Following medial learane partiipate in normal training ativities 6. Return to play Normal game play namely full linial and ognitive reovery before onsideration of return to play. This approah is supported by published guidelines, suh as the Amerian Aademy of Neurology, US Team Physiian Consensus Statement, and US National Athleti Trainers Assoiation Position Statement This issue was extensively disussed by the onsensus panellists and it was aknowledged that there is evidene that some professional Amerian football players are able to RTP more quikly, with even same day RTP supported by National Football League studies without a risk of reurrene or sequelae. 61 There are data however, demonstrating that at the ollegiate and high shool level, athletes allowed to RTP on the same day may demonstrate NP defiits post-injury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms It should be emphasised however, that the young (,18) elite athlete should be treated more onservatively even though the resoures may be the same as for an older professional athlete (see Setion 6.1). 4.3 Psyhologial management and mental health issues In addition, psyhologial approahes may have potential appliation in this injury, partiularly with the modifiers listed below Caregivers are also enouraged to evaluate the onussed athlete for affetive symptoms suh as depression, as these symptoms may be ommon in onussed athletes The role of pharmaologial therapy Pharmaologial therapy in sports onussion may be applied in two distint situations. The first of these situations is the management of speifi prolonged symptoms (eg, sleep disturbane, anxiety, et). The seond situation is where drug Exerise, oordination, and ognitive load Restore onfidene and assess funtional skills by oahing staff therapy is used to modify the underlying pathophysiology of the ondition with the aim of shortening the duration of the onussion symptoms. 71 In broad terms, this approah to management should only be onsidered by liniians experiened in onussion management. An important onsideration in RTP is that onussed athletes should not only be symptom-free but also should not be taking any pharmaologial agents/mediations that may mask or modify the symptoms of onussion. Where antidepressant therapy may be ommened during the management of a onussion, the deision to return to play while still on suh mediation must be onsidered arefully by the treating liniian. 4.5 The role of pre-partiipation onussion evaluation Reognising the importane of a onussion history, and appreiating the fat that many athletes will not reognise all the onussions they may have suffered in the past, a detailed onussion history is of value Suh a history may preidentify athletes that fit into a high risk ategory and provides an opportunity for the healthare provider to eduate the athlete in regard to the signifiane of onussive injury. A strutured onussion history should inlude speifi questions as to previous symptoms of a onussion; not just the pereived number of past onussions. It is also worth noting that dependene on the reall of onussive injuries by teammates or oahes has been shown to be unreliable. 72 The linial history should also inlude information about all previous head, fae or ervial spine injuries as these may also have linial relevane. It is worth emphasising that in the setting of maxillofaial and ervial spine injuries, oexistent onussive injuries may be missed unless speifially assessed. Questions pertaining to disproportionate impat versus symptom severity mathing may alert the liniian to a progressively inreasing vulnerability to injury. As part of the linial history it is advised that details regarding protetive equipment employed at time of injury be sought, for both reent and remote injuries. A omprehensive pre-partiipation onussion evaluation allows for modifiation and optimisation of protetive behaviour and an opportunity for eduation. 5. Modifying fators in onussion management The onsensus panel agreed that a range of modifying fators may influene the investigation and management of onussion and in some ases, may predit the potential for prolonged or persistent symptoms. These modifiers would also be important to onsider in a detailed onussion history and are outlined in Table 2. In this setting, there may be additional management onsiderations beyond simple RTP advie. There may be a more important role for additional investigations, inluding formal NP testing, balane assessment and neuroimaging. It is envisioned that athletes with suh modifying features would be managed in a multidisiplinary manner oordinated by a physiian with speifi expertise in the management of onussive injury. The role of female gender as a possible modifier in the management of onussion was disussed at length by the panel. There was not unanimous agreement that the urrent published researh evidene is onlusive that this should be inluded as a modifying fator, although it was aepted that gender may be a risk fator for injury and/or influene injury severity The signifiane of loss of onsiousness (LOC) In the overall management of moderate to severe traumati brain injury, duration of LOC is an aknowledged preditor of outome. 79 While published findings in onussion desribe LOC assoiated with speifi early ognitive defiits it has not been noted as a measure of injury severity. Consensus disussion determined that prolonged (.1 minute duration) LOC would be onsidered as a fator that may modify management. 5.2 The signifiane of amnesia and other symptoms There is renewed interest in the role of post-traumati amnesia and its role as a i79

5 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om Table 2 Fators Symptoms Signs Sequelae Temporal Threshold Age Co- and pre-morbidities Mediation Behaviour Sport Conussion modifiers Modifier Number Duration (.10 days) Severity Prolonged loss of onsiousness (.1 min), amnesia Conussive onvulsions Frequeny repeated onussions over time Timing injuries lose together in time Reeny reent onussion or traumati brain injury Repeated onussions ourring with progressively less impat fore or slower reovery after eah suessive onussion Child and adolesent (,18 years old) Migraine, depression or other mental health disorders, attention defiit hyperativity disorder, learning disabilities, sleep disorders Psyhoative drugs, antioagulants Dangerous style of play High risk ativity, ontat and ollision sport, high sporting level surrogate measure of injury severity. Published evidene suggests that the nature, burden and duration of the linial post-onussive symptoms may be more important than the presene or duration of amnesia alone Further it must be noted that retrograde amnesia varies with the time of measurement post-injury and hene is poorly refletive of injury severity Motor and onvulsive phenomena A variety of immediate motor phenomena (eg, toni posturing) or onvulsive movements may aompany a onussion. Although dramati, these linial features are generally benign and require no speifi management beyond the standard treatment of the underlying onussive injury. 5.4 Depression Mental health issues (suh as depression) have been reported as a long-term onsequene of traumati brain injury, inluding sports related onussion. Neuroimaging studies using fmri suggest that a depressed mood following onussion may reflet an underlying pathophysiologial abnormality onsistent with a limbi-frontal model of depression. 6. Speial populations 6.1 The hild and adolesent athlete There was unanimous agreement by the panel that the evaluation and management reommendations ontained herein ould be applied to hildren and adolesents down to the age of 10 years. Below that age hildren report different onussion symptoms from adults and would require age appropriate symptom heklists as a omponent of assessment. An additional onsideration in assessing the hild or adolesent athlete with a onussion is that in the linial evaluation by the healthare professional there may be the need to inlude both patient and parent input as well as teaher and shool input when appropriate The deision to use NP testing is broadly the same as the adult assessment paradigm. However, timing of testing may differ in order to assist planning in shool and home management (and may be performed while the patient is still symptomati). If ognitive testing is performed, it must be developmentally sensitive until the late teen years due to the ongoing ognitive maturation that ours during this period whih, in turn, makes the utility of omparison to either the person s own baseline performane or to population norms limited. 20 In this age group it is more important to onsider the use of trained neuropsyhologists to interpret assessment data, partiularly in hildren with learning disorders and/or attention defiit hyperativity disorder (ADHD) who may need more sophistiated assessment strategies The panel strongly endorsed the view that hildren should not be returned to pratie or play until linially ompletely symptom-free, whih may require a longer time frame than for adults. In addition, the onept of ognitive rest was highlighted with speial referene to a hild s need to limit exertion with ativities of daily living and to limit sholasti and other ognitive stressors (eg, text messaging, videogames, et) while symptomati. Shool attendane and ativities may also need to be modified to avoid provoation of symptoms. Beause of the different physiologial response and longer reovery after onussion and speifi risks (eg, diffuse erebral swelling) related to head impat during hildhood and adolesene, a more onservative return to play approah is reommended. It is appropriate to extend the amount of time of asymptomati rest and/or the length of the graded exertion in hildren and adolesents. It is not appropriate for a hild or adolesent athlete with onussion to RTP on the same day as the injury regardless of the level of athleti performane. Conussion modifiers apply even more to this population than adults and may mandate more autious RTP advie. 6.2 Elite versus non-elite athletes The panel unanimously agreed that all athletes regardless of level of partiipation should be managed using the same treatment and return to play paradigm. A more useful onstrut was agreed whereby the available resoures and expertise in onussion evaluation were of more importane in determining management than a separation between elite and non-elite athlete management. Although formal baseline NP sreening may be beyond the resoures of many sports or individuals, it is reommended that in all organised high risk sports onsideration be given to having this ognitive evaluation regardless of the age or level of performane. 6.3 Chroni traumati brain injury Epidemiologial studies have suggested an assoiation between repeated sports onussions during a areer and late life ognitive impairment. Similarly, ase reports have noted anedotal ases where neuropathologial evidene of hroni traumati enephalopathy was observed in retired football players Panel disussion was held and no onsensus was reahed on the signifiane of suh observations at this stage. Cliniians need to be mindful of the potential for longterm problems in the management of all athletes. 7. Injury prevention 7.1 Protetive equipment: mouthguards and helmets There is no good linial evidene that urrently available protetive equipment will prevent onussion although mouthguards have a definite role in preventing dental and orofaial injury. Biomehanial studies have shown a redution in impat fores to the brain with the use of head gear and helmets, but these findings have not been translated to show a redution i80

6 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om in onussion inidene. For skiing and snowboarding there are a number of studies to suggest that helmets provide protetion against head and faial injury and hene should be reommended for partiipants in alpine sports In speifi sports suh as yling, motor and equestrian sports, protetive helmets may prevent other forms of head injury (eg, skull frature) that are related to falling on hard road surfaes; these may be an important injury prevention issue for those sports Rule hange Consideration of rule hanges to redue the head injury inidene or severity may be appropriate where a lear-ut mehanism is impliated in a partiular sport. An example of this is in football (soer) where researh studies demonstrated that upper limb to head ontat in heading ontests aounted for approximately 50% of onussions. 129 As noted earlier, rule hanges may also be needed in some sports to allow an effetive off-field medial assessment to our without ompromising the athlete s welfare, affeting the flow of the game or unduly penalising the player s team. It is important to note that rule enforement may be a ritial aspet of modifying injury risk in these settings; referees play an important role in this regard. 7.3 Risk ompensation An important onsideration in the use of protetive equipment is the onept of risk ompensation. 130 This is where the use of protetive equipment results in behavioural hange, suh as the adoption of more dangerous playing tehniques, whih an result in a paradoxial inrease in injury rates. This may be a partiular onern in hild and adolesent athletes where head injury rates are often higher than in adult athletes Aggression versus violene in sport The ompetitive/aggressive nature of sport whih makes it fun to play and wath should not be disouraged. However, sporting organisations should be enouraged to address violene that may inrease onussion risk. Fair play and respet should be supported as key elements of sport. 8. Knowledge transfer As the ability to treat or redue the effets of onussive injury after the event is minimal, eduation of athletes, olleagues and the general publi is a mainstay of progress in this field. Athletes, referees, administrators, parents, oahes and healthare providers must be eduated regarding the detetion of onussion, its linial features, assessment tehniques and priniples of safe return to play. Methods to improve eduation, inluding web-based resoures, eduational videos and international outreah programmes are important in delivering the message. In addition, onussion working groups plus the support and endorsement of enlightened sport groups, suh as Fédération Internationale de Football Assoiation (FIFA), International Olympi Commission (IOC), International Rugby Board (IRB) and International Ie Hokey Federation (IIHF), who initiated this endeavour have enormous value and must be pursued vigorously. Fair play and respet for opponents are ethial values that should be enouraged in all sports and sporting assoiations. Similarly oahes, parents and managers play an important part in ensuring these values are implemented on the field of play. 9. Future diretions The onsensus panellists reognise that researh is needed aross a range of areas in order to answer some ritial researh questions. The key areas for researh identified inlude: Validation of the SCAT2. Gender effets on injury risk, severity and outome. Paediatri injury and management paradigms. Virtual reality tools in the assessment of injury. Rehabilitation strategies (eg, exerise therapy). Novel imaging modalities and their role in linial assessment. Conussion surveillane using onsistent definitions and outome measures. Clinial assessment where no baseline assessment has been performed. Best-pratie neuropsyhologial testing. Long-term outomes. On-field injury severity preditors. 10. Medio-legal onsiderations This onsensus doument reflets the urrent state of knowledge and will need to be modified aording to the development of new knowledge. It provides an overview of issues that may be of importane to healthare providers involved in the management of sports related onussion. It is not intended as a standard of are, and should not be interpreted as suh. This doument is only a guide, and is of a general nature, onsistent with the reasonable pratie of a healthare professional. Individual treatment will depend on the fats and irumstanes speifi to eah individual ase. It is intended that this doument will be formally reviewed and updated prior to 1 Deember Statement on bakground to onsensus proess In November 2001, the 1st International Conferene on Conussion in Sport was held in Vienna, Austria. This meeting was organised by the IIHF in partnership with FIFA and the Medial Commission of the IOC. As part of the resulting mandate for the future, the need for leadership and future updates was identified. The 2nd International Conferene on Conussion in Sport was organised by the same group with the additional involvement of the IRB and was held in Prague, Czeh Republi in November The original aims of the symposia were to provide reommendations for the improvement of safety and health of athletes who suffer onussive injuries in ie hokey, rugby, football (soer) and other sports. To this end, a range of experts were invited to both meetings to address speifi issues of epidemiology, basi and linial siene, injury grading systems, ognitive assessment, new researh methods, protetive equipment, management, prevention and long-term outome. 1 2 The 3rd International Conferene on Conussion in Sport was held in Zurih, Switzerland on Otober 2008 and was designed as a formal onsensus meeting following the organisational guidelines set forth by the US National Institutes of Health. (Details of the onsensus methodology an be obtained at: htm) The basi priniples governing the ondut of a onsensus development onferene are summarised below: 1. A broad based non-government, nonadvoay panel was assembled to give balaned, objetive and knowledgeable attention to the topi. Panel members exluded anyone with sientifi or ommerial onflits of interest and inluded researhers in linial mediine, sports mediine, neurosiene, neuroimaging, athleti training and sports siene. i81

7 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om 2. These experts presented data in a publi session, followed by inquiry and disussion. The panel then met in an exeutive session to prepare the onsensus statement. 3. A number of speifi questions were prepared and posed in advane to define the sope and guide the diretion of the onferene. The priniple task of the panel was to eluidate responses to these questions. These questions are outlined above. 4. A systemati literature review was prepared and irulated in advane for use by the panel in addressing the onferene questions. 5. The onsensus statement is intended to serve as the sientifi reord of the onferene. 6. The onsensus statement will be widely disseminated to ahieve maximum impat on both urrent healthare pratie and future medial researh. The panel hairperson (WM) did not identify with any advoay position. The hairperson was responsible for direting the onsensus session and guiding the panel s deliberations. Panellists were drawn from linial pratie, aademi and researh in the field of sports related onussion. They do not represent organisations per se but were seleted for their expertise, experiene and understanding of this field. Competing interests: None. Consensus panellists (listed in alphabetial order): In addition to the authors above, the onsensus panellists were S Broglio, G Davis, R Dik, J Dvorak, R Ehemendia, G Gioia, K Guskiewiz, S Herring, G Iverson, J Kelly, J Kissik, M Makdissi, M MCrea, A Ptito, L Purell, M Putukian. Also invited but not in attendane: R Bahr, L Engebretsen, P Hamlyn, B Jordan, P Shamash. This artile has been o-published in the following journals: Clinial Journal of Sport Mediine, Physiian and Sportsmediine, Neurosurgery, Physial Mediine and Rehabilitation, Journal of Athleti Training, Sandinavian Journal of Mediine & Siene in Sport, Journal of Clinial Neurosiene, Journal of Siene & Mediine in Sport. Aepted 2 February 2009 Br J Sports Med 2009;43:i76 i84. doi: /bjsm REFERENCES 1. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Conferene on Conussion in Sport, Vienna Reommendations for the improvement of safety and health of athletes who may suffer onussive injuries. Br J Sports Med 2002;36: MCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conferene on Conussion in Sport, Prague Br J Sports Med 2005;39: Maddoks D, Diker G. An objetive measure of reovery from onussion in Australian rules footballers. Sport Health 1989;7(Suppl): Maddoks DL, Diker GD, Saling MM. The assessment of orientation following onussion in athletes. Clin J Sport Med 1995;5: MCrea M. Standardized mental status assessment of sports onussion. Clin J Sport Med 2001;11: MCrea M, Kelly J, Randolph C, et al. Standardised assessment of onussion (SAC): on site mental status evaluation of the athlete. J Head Trauma Rehab 1998;13: MCrea M, Randolph C, Kelly J. The Standardized Assessment of Conussion (SAC): manual for administration, soring and interpretation, 2nd edn. Waukesha, WI: MCrea M, Kelly JP, Kluge J, et al. Standardized assessment of onussion in football players. Neurology 1997;48: Chen J, Johnston K, Collie A, et al. A validation of the Post Conussion Symptom Sale in the assessment of omplex onussion using ognitive testing and funtional MRI. J Neurol Neurosurg Psyhiatry 2007;78: Chen J, Johnston K, Frey S, et al. Funtional abnormalities in symptomati onussed athletes: an fmri study. Neuroimage 2004;22: Chen JK, Johnston KM, Collie A, et al. Assoiation between symptom severity, ogsport tests results, and funtional MRI ativation in symptomati onussed athletes. Clin J Sport Med 2004;14: Chen JK, Johnston KM, Collie A, et al. Behavioural and funtional imaging outomes in symptomati onussed athletes measured with ogsport and funtional MRI. Br J Sports Med 2004;38: Ptito A, Chen JK, Johnston KM. Contributions of funtional magneti resonane imaging (fmri) to sport onussion evaluation. NeuroRehabilitation 2007;22: Guskiewiz K. Postural stability assessment following onussion. Clin J Sport Med 2001;11: Guskiewiz KM. Assessment of postural stability following sport-related onussion. Curr Sports Med Rep 2003;2: Guskiewiz KM, Ross SE, Marshall SW. Postural stability and neuropsyhologial defiits after onussion in ollegiate athletes. J Athl Train 2001;36: Cavanaugh JT, Guskiewiz KM, Giuliani C, et al. Deteting altered postural ontrol after erebral onussion in athletes with normal postural stability. Br J Sports Med 2005;39: Cavanaugh JT, Guskiewiz KM, Giuliani C, et al. Reovery of postural ontrol after erebral onussion: new insights using approximate entropy. J Athl Train 2006;41: Cavanaugh JT, Guskiewiz KM, Stergiou N. A nonlinear dynami approah for evaluating postural ontrol: new diretions for the management of sport-related erebral onussion. Sports Med 2005;35: Fox ZG, Mihalik JP, Blakburn JT, et al. Return of postural ontrol to baseline after anaerobi and aerobi exerise protools. J Athl Train 2008;43: Collie A, Darby D, Maruff P. Computerised ognitive assessment of athletes with sports related head injury. Br J Sports Med 2001;35: Collie A, Maruff P. Computerised neuropsyhologial testing. Br J Sports Med 2003;37: Collie A, Maruff P, MStephen M, et al. Psyhometri issues assoiated with omputerised neuropsyhologial assessment of onussed athletes. Br J Sports Med 2003;37: Collins MW, Grindel SH, Lovell MR, et al. Relationship between onussion and neuropsyhologial performane in ollege football players. JAMA 1999;282: Lovell MR. The relevane of neuropsyhologi testing for sports-related head injuries. Curr Sports Med Rep 2002;1: Lovell MR, Collins MW. Neuropsyhologial assessment of the ollege football player. J Head Trauma Rehabil 1998;13(2): Bleiberg J, Cernih AN, Cameron K, et al. Duration of ognitive impairment after sports onussion. Neurosurgery 2004;54: Bleiberg J, Warden D. Duration of ognitive impairment after sports onussion. Neurosurgery 2005;56:E Broglio SP, Maiohi SN, Ferrara MS. Neuroognitive performane of onussed athletes when symptom free. J Athl Train 2007;42: Broglio SP, Maiohi SN, Ferrara MS. Sensitivity of the onussion assessment battery. Neurosurgery 2007;60: Gioia G, Janusz J, Gilstein K, et al. Neueopsyhologial management of onussion in hildren and adolesents: effets of age and gender on ImPat (abstrat). Br J Sports Med 2004;38: MCrory P, Collie A, Anderson V, et al. Can we manage sport related onussion in hildren the same as in adults? Br J Sports Med 2004;38: Kristman VL, Tator CH, Kreiger N, et al. Does the apolipoprotein epsilon 4 allele predispose varsity athletes to onussion? A prospetive ohort study. Clin J Sport Med 2008;18: Terrell TR, Bostik RM, Abramson R, et al. APOE, APOE promoter, and tau genotypes and risk for onussion in ollege athletes. Clin J Sport Med 2008;18: Vagnozzi R, Tavazzi B, Signoretti S, et al. Temporal window of metaboli brain vulnerability to onussions: mitohondrial-related impairment part I. Neurosurgery 2007;61: Hang CH, Chen G, Shi JX, et al. Cortial expression of nulear fator kappab after human brain ontusion. Brain Res 2006;1109: Peng RY, Gao YB, Xiao XY, et al. [Study on the expressions of basi fibroblast growth fator and nervous growth fator genes in rat erebral onussion]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2003;15: Yunoki M, Kawauhi M, Ukita N, et al. Effets of leithinized SOD on sequential hange in SOD ativity after erebral ontusion in rats. Ata Neurohir Suppl 1998;71: Hinkle DA, Baldwin SA, Sheff SW, et al. GFAP and S100beta expression in the ortex and hippoampus in response to mild ortial ontusion. J Neurotrauma 1997;14: Holmin S, Shalling M, Hojeberg B, et al. Delayed ytokine expression in rat brain following experimental ontusion. J Neurosurg 1997;86: Sandberg Nordqvist AC, von Holst H, Holmin S, et al. Inrease of insulin-like growth fator (IGF)-1, IGF binding protein-2 and -4 mrnas following erebral ontusion. Brain Res Mol Brain Res 1996;38: Fukuhara T, Nishio S, Ono Y, et al. Indution of Cu, Zn-superoxide dismutase after ortial ontusion injury during hypothermia. Brain Res 1994;657: Boutin D, Lassonde M, Robert M, et al. Neurophysiologial assessment prior to and following sports-related onussion during hildhood: a ase study. Neuroase 2008;14: De Beaumont L, Brisson B, Lassonde M, et al. Long-term eletrophysiologial hanges in athletes with a history of multiple onussions. Brain Inj 2007;21: De Beaumont L, Lassonde M, Leler S, et al. Long-term and umulative effets of sports onussion on motor ortex inhibition. Neurosurgery 2007;61: Gaetz M, Weinberg H. Eletrophysiologial indies of persistent post-onussion symptoms. Brain Inj 2000;14: Gosselin N, Theriault M, Leler S, et al. Neurophysiologial anomalies in symptomati and asymptomati onussed athletes. Neurosurgery 2006;58: i82

8 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om 48. Lavoie ME, Dupuis F, Johnston KM, et al. Visual p300 effets beyond symptoms in onussed ollege athletes. J Clin Exp Neuropsyhol 2004;26: Rousseff RT, Tzvetanov P, Atanassova PA, et al. Correlation between ognitive P300 hanges and the grade of losed head injury. Eletromyogr Clin Neurophysiol 2006;46: Begaz T, Kyriaou DN, Segal J, et al. Serum biohemial markers for post-onussion syndrome in patients with mild traumati brain injury. J Neurotrauma 2006;23: de Boussard CN, Lundin A, Karlstedt D, et al. S100 and ognitive impairment after mild traumati brain injury. J Rehabil Med 2005;37: Lima DP, Simao Filho C, Abib Sde C, et al. Quality of life and neuropsyhologial hanges in mild head trauma. Late analysis and orrelation with S100B protein and ranial CT san performed at hospital admission. Injury 2008;39: Ma M, Lindsell CJ, Rosenberry CM, et al. Serum leaved tau does not predit postonussion syndrome after mild traumati brain injury. Am J Emerg Med 2008;26: Stalnake BM, Tegner Y, Sojka P. Playing ie hokey and basketball inreases serum levels of S- 100B in elite players: a pilot study. Clin J Sport Med 2003;13: Stalnake BM, Tegner Y, Sojka P. Playing soer inreases serum onentrations of the biohemial markers of brain damage S-100B and neuronspeifi enolase in elite players: a pilot study. Brain Inj 2004;18: Townend W, Ingebrigtsen T. Head injury outome predition: a role for protein S-100B? Injury 2006;37: Johnston K, Bloom G, Ramsay J, et al. Current onepts in onussion rehabilitation. Curr Sports Med Rep 2004;3: Guskiewiz KM, Brue SL, Cantu RC, et al. National Athleti Trainers Assoiation position statement: management of sport-related onussion. J Athl Train 2004;39: Herring S, Bergfeld J, Boland A, et al. Conussion (mild traumati brain injury) and the team physiian: a onsensus statement. Mediine Si Sports Exer 2006;38: Kelly JP, Rosenberg JH. The development of guidelines for the management of onussion in sports. Journal Head Trauma Rehabil 1998;13: Pellman EJ, Viano DC, Casson IR, et al. Conussion in professional football: players returning to the same game part 7. Neurosurgery 2005;56: Guskiewiz KM, MCrea M, Marshall SW, et al. Cumulative effets assoiated with reurrent onussion in ollegiate football players. JAMA 2003;290: Lovell M, Collins M, Bradley J. Return to play following sports-related onussion. Clin Sports Med 2004;23: Collins M, Field M, Lovell M, et al. Relationship between postonussion headahe and neuropsyhologial test performane in high shool athletes. Amerian J Sports Med 2003;31: Collins M, Grindel S, Lovell M, et al. Relationship between onussion and neuropsyhologial performane in ollege football players. JAMA 1999;282: Collins MW, Lovell MR, Iverson GL, et al. Cumulative effets of onussion in high shool athletes. Neurosurgery 2002;51: MCrea M, Guskiewiz KM, Marshall SW, et al. Aute effets and reovery time following onussion in ollegiate football players. JAMA 2003;290: MCrea M, Hammeke T, Olsen G, et al. Unreported onussion in high shool football players: impliations for prevention. Clin J Sport Med 2004;14: Bloom G, Horton A, MCrory P, et al. Sport psyhology and onussion: new impats to explore. Br J Sports Med 2004;38: Weiss MR, Gill DL. What goes around omes around: re-emerging themes in sport and exerise psyhology. Res Q Exer Sport 2005; 76(2 Suppl):S MCrory P. Should we treat onussion pharmaologially? The need for evidene based pharmaologial treatment for the onussed athlete. Br J Sports Med 2002;36: MCrory P. Prepartiipation assessment for head injury. Clin J Sport Med 2004;14: Johnston KM, Lassonde M, Ptito A. A ontemporary neurosurgial approah to sportrelated head injury: the MGill onussion protool. J Am Coll Surg 2001;192: Delaney J, Laroix V, Leler S, et al. Conussions during the 1997 Canadian Football League season. Clin J Sport Med 2000;10: Delaney J, Laroix V, Leler S, et al. Conussions among university football and soer players. Clin J Sport Med 2002;12: Gessel LM, Fields SK, Collins CL, et al. Conussions among United States high shool and ollegiate athletes. J Athl Train 2007;42: Dvorak J, Junge A, Fuller C, et al. Medial issues in women s football. Br J Sports Med 2007;41(Suppl 1):i Dvorak J, MCrory P, Kirkendall DT. Head injuries in the female football player: inidene, mehanisms, risk fators and management. Br J Sports Med 2007;41(Suppl 1):i Jennett B, Bond M. Assessment of outome after severe brain damage: a pratial sale. Lanet 1975;1: Leninger B, Gramling S, Farrell A, et al. Neuropsyhologial defiits in symptomati minor head injury patients after onussion and mild onussion. J Neurol Neurosurg Psyhiatry 1990;53: Lovell M, Iverson G, Collins M, et al. Does loss of onsiousness predit neuropsyhologial derements after onussion. Clin J Sport Med 1999;9: MCrea M, Kelly J, Randolph C, et al. Immediate neuroognitive effets of onussion. Neurosurgery 2002;50: Cantu RC. Posttraumati retrograde and anterograde amnesia: pathophysiology and impliations in grading and safe return to play. J Athl Train 2001;36: Lovell MR, Collins MW, Iverson GL, et al. Reovery from mild onussion in high shool athletes. J Neurosurg 2003;98: MCrory PR, Ariens T, Berkovi SF. The nature and duration of aute onussive symptoms in Australian football. Clin J Sport Med 2000;10: Yarnell P, Lynh S. The ding : amnesti state in football trauma. Neurology 1973;23: Yarnell PR, Lynh S. Retrograde memory immediately after onussion. Lanet 1970;1: MCrory PR, Berkovi SF. Video analysis of aute motor and onvulsive manifestations in sport-related onussion. Neurology 2000;54: MCrory PR, Bladin PF, Berkovi SF. Retrospetive study of onussive onvulsions in elite Australian rules and rugby league footballers: phenomenology, aetiology, and outome. BMJ 1997;314: Fleminger S. Long-term psyhiatri disorders after traumati brain injury. Eur J Anaesthesiol Suppl 2008;42: Chen JK, Johnston KM, Petrides M, et al. Neural substrates of symptoms of depression following onussion in male athletes with persisting postonussion symptoms. Arh Gen Psyhiatry 2008;65: Bryant RA. Disentangling mild traumati brain injury and stress reations. N Engl J Med 2008;358: Vanderploeg RD, Curtiss G, Luis CA, et al. Longterm morbidities following self-reported mild traumati brain injury. J Clin Exp Neuropsyhol 2007;29: Guskiewiz KM, Marshall SW, Bailes J, et al. Reurrent onussion and risk of depression in retired professional football players. Med Si Sports Exer 2007;39: Kashluba S, Casey JE, Paniak C. Evaluating the utility of ICD-10 diagnosti riteria for postonussion syndrome following mild traumati brain injury. J Int Neuropsyhol So 2006;12: Iverson GL. Misdiagnosis of the persistent postonussion syndrome in patients with depression. Arh Clin Neuropsyhol 2006;21: Chamelian L, Feinstein A. The effet of major depression on subjetive and objetive ognitive defiits in mild to moderate traumati brain injury. J Neuropsyhiatry Clin Neurosi 2006;18: Mooney G, Speed J, Sheppard S. Fators related to reovery after mild traumati brain injury. Brain Inj 2005;19: Broshek DK, Freeman JR. Psyhiatri and neuropsyhologial issues in sport mediine. Clin Sports Med 2005;24: Pellman EJ. Bakground on the National Football League s researh on onussion in professional football. Neurosurgery 2003;53: Purell L, Carson J. Sport-related onussion in pediatri athletes. Clin Pediatr (Phila) 2008;47: Lee LK. Controversies in the sequelae of pediatri mild traumati brain injury. Pediatr Emerg Care 2007;23: Shnadower D, Vazquez H, Lee J, et al. Controversies in the evaluation and management of minor blunt head trauma in hildren. Current Opin Pediatr 2007;19: Wozniak JR, Krah L, Ward E, et al. Neuroognitive and neuroimaging orrelates of pediatri traumati brain injury: a diffusion tensor imaging (DTI) study. Arh Clin Neuropsyhol 2007;22: Hayden MG, Jandial R, Duenas HA, et al. Pediatri onussions in sports; a simple and rapid assessment tool for onussive injury in hildren and adults. Childs Nerv Syst 2007;23: Lee MA. Adolesent onussions management reommendations: a pratial approah. Conn Med 2006;70: Kirkwood MW, Yeates KO, Wilson PE. Pediatri sport-related onussion: a review of the linial management of an oft-negleted population. Pediatris 2006;117: Guskiewiz KM, Marshall SW, Bailes J, et al. Assoiation between reurrent onussion and latelife ognitive impairment in retired professional football players. Neurosurgery 2005;57: Nandoe RD, Sheltens P, Eikelenboom P. Head trauma and Alzheimer s disease. J Alzheimers Dis 2002;4: Stern MB. Head trauma as a risk fator for Parkinson s disease. Mov Disord 1991;6: Omalu BI, DeKosky ST, Hamilton RL, et al. Chroni traumati enephalopathy in a national football league player: part II. Neurosurgery 2006;59: Omalu BI, DeKosky ST, Minster RL, et al. Chroni traumati enephalopathy in a National Football League player. Neurosurgery 2005;57: Hagel BE, Pless IB, Goulet C, et al. Effetiveness of helmets in skiers and snowboarders: ase-ontrol and ase rossover study. BMJ 2005;330: MCrory P. The role of helmets in skiing and snowboarding. Br J Sports Med 2002;36: Mueller BA, Cummings P, Rivara FP, et al. Injuries of the head, fae, and nek in relation to ski helmet use. Epidemiology 2008;19: Sulheim S, Holme I, Ekeland A, et al. Helmet use and risk of head injuries in alpine skiers and snowboarders. JAMA 2006;295: Delaney JS, Al-Kashmiri A, Drummond R, et al. The effet of protetive headgear on head injuries and onussions in adolesent football (soer) players. Br J Sports Med 2008;42: Viano DC, Pellman EJ, Withnall C, et al. Conussion in professional football: performane of newer helmets in reonstruted game impats part 13. Neurosurgery 2006;59: Finh C, Braham R, MIntosh A, et al. Should football players wear ustom fitted mouthguards? i83

9 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om Results from a group randomised ontrolled trial. Inj Prev 2005;11: MIntosh A, MCrory P. The dynamis of onussive head impats in rugby and Australian rules football. Med Si Sports Exer 2000;32: MIntosh A, MCrory P. Impat energy attenuation performane of football headgear. Br J Sports Med 2000;34: MIntosh A, MCrory P. Effetiveness of headgear in a pilot study of under 15 rugby union football. Br J Sports Med 2001;35: MIntosh A, MCrory P, Finh C, et al. Rugby headgear study report. Shool of Safety Siene, The University of New South Wales Sydney, Australia, May Finh C, Newstead S, Cameron M, et al. Head injury redutions in Vitoria two years after the introdution of mandatory biyle helmet use. Report no. 51. Melbourne: Monash University Aident Researh Centre, Curnow WJ. Biyle helmets and publi health in Australia. Health Promot J Austr 2008;19: Hewson PJ. Cyle helmets and road asualties in the UK. Traffi Inj Prev 2005;6: Davidson JA. Epidemiology and outome of biyle injuries presenting to an emergeny department in the United Kingdom. Eur J Emerg Med 2005;12: Hansen KS, Engesaeter LB, Viste A. Protetive effet of different types of biyle helmets. Traffi Inj Prev 2003;4: Andersen T, Arnason A, Engebretsen L, et al. Mehanism of head injuries in elite football. Br J Sports Med 2004;38: Hagel B, Meewisse W. Editorial: Risk ompensation: a side effet of sport injury prevention? Clin J Sport Med 2004;14: Finh C, Mintosh AS, MCrory P, et al. A pilot study of the attitudes of Australian Rules footballers towards protetive headgear. J Si Med Sport 2003;6: Finh CF, MIntosh AS, MCrory P. What do under 15 year old shoolboy rugby union players think about protetive headgear? Br J Sports Med 2001;35: Finh CF, MIntosh AS, MCrory P, et al. A pilot study of the attitudes of Australian Rules footballers towards protetive headgear. J Si Med Sport 2003;6: Reee RM, Sege R. Childhood head injuries: aidental or inflited? Arh Pediatr Adoles Med 2000;154: Shaw NH. Bodyheking in hokey. CMAJ 2004;170: Denke NJ. Brain injury in sports. J Emerg Nurs 2008;34: Gianotti S, Hume PA. Conussion sideline management intervention for rugby union leads to redued onussion laims. NeuroRehabilitation 2007;22: Guilmette TJ, Malia LA, MQuiggan MD. Conussion understanding and management among New England high shool football oahes. Brain Inj 2007;21: Hootman JM, Dik R, Agel J. Epidemiology of ollegiate injuries for 15 sports: summary and reommendations for injury prevention initiatives. J Athl Train 2007;42: Valovih MLeod TC, Shwartz C, Bay RC. Sportrelated onussion misunderstandings among youth oahes. Clin J Sport Med 2007;17: Sye G, Sullivan SJ, MCrory P. High shool rugby players understanding of onussion and return to play guidelines. Br J Sports Med 2006;40: Theye F, Mueller KA. Heads up : onussions in high shool sports. Clin Med Res 2004;2: Kashluba S, Paniak C, Blake T, et al. A longitudinal, ontrolled study of patient omplaints following treated mild traumati brain injury. Arh Clin Neuropsyhol 2004;19: Gabbe B, Finh CF, Wajswelner H, et al. Does ommunity-level Australian football support injury prevention researh? J Si Med Sport 2003;6: Kaut KP, DePompei R, Kerr J, et al. Reports of head injury and symptom knowledge among ollege athletes: impliations for assessment and eduational intervention. Clin J Sport Med 2003;13: Davidhizar R, Cramer C. The best thing about the hospitalization was that the nurses kept me well informed. Issues and strategies of lient eduation. Aid Emerg Nurs 2002;10: MCrory P. What advie should we give to athletes postonussion? Br J Sports Med 2002;36: Bazarian JJ, Veenema T, Brayer AF, et al. Knowledge of onussion guidelines among pratitioners aring for hildren. Clin Pediatr (Phila) 2001;40: APPENDIX 1 Sport Conussion Assessment Tool (SCAT2) form: a linial tool used by pratitioners managing athletes with onussion. APPENDIX 2 Poket SCAT2: a poket ard designed for lay pratitioners to suspet the diagnosis of a onussion. i84

10 Downloaded from bjsm.bmj.om on July 20, Published by group.bmj.om Consensus Statement on Conussion in Sport: the 3rd International Conferene on Conussion in Sport held in Zurih, November 2008 P MCrory, W Meeuwisse, K Johnston, et al. Br J Sports Med : i76-i84 doi: /bjsm Updated information and servies an be found at: Referenes alerting servie These inlude: This artile ites 145 artiles, 43 of whih an be aessed free at: Artile ited in: Reeive free alerts when new artiles ite this artile. Sign up in the box at the top right orner of the online artile. Topi Colletions Artiles on similar topis an be found in the following olletions Editor's hoie (1210 artiles) Notes To request permissions go to: To order reprints go to: To subsribe to BMJ go to: