CommunicationConsensus statement on concussion in sport – The 3rd International Conference on concussion in sport, held in Zurich, November 2008☆
Section snippets
PREAMBLE
This paper is a revision and update of the recommendations developed following the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport.1, [2] This Zurich Consensus Statement on Concussion in Sport (the “Zurich Consensus Statement”) is designed to build on the principles outlined in the original Vienna and Prague documents and to further develop conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus
Definition of concussion
Panel discussion regarding the definition of concussion and its separation from mild traumatic brain injury (mTBI) was held. Although there was acknowledgement that the terms refer to different injury constructs and should not be used interchangeably, it was not felt that the panel would define mTBI for the purpose of this document. There was unanimous agreement, however, that concussion is defined as follows:
Concussion is defined as a complex pathophysiological process affecting the brain,
Symptoms and signs of acute concussion
The panel agreed that the diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, behavior, balance, sleep and cognition. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination. The detailed clinical assessment of concussion is outlined in the SCAT2 form (Supplementary Fig. 1).
The suspected diagnosis of concussion can
CONCUSSION INVESTIGATIONS
A range of additional investigations may be utilized to assist in the diagnosis and/or exclusion of other injury. These include the following.
CONCUSSION MANAGEMENT
The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and RTP. The recovery and outcome of this injury may be modified by a number of factors that may require more sophisticated management strategies. These are outlined in the section on modifiers (see Section 5).
As described above, the majority of injuries will recover spontaneously over several days. In these situations, it is expected
MODIFYING FACTORS IN CONCUSSION MANAGEMENT
The consensus panel agreed that a range of “modifying” factors may influence the investigation and management of concussion and, in some cases, may predict the potential for prolonged or persistent symptoms. These modifiers would also be important to consider in a detailed concussion history and are outlined in Table 2.
In this setting, there may be additional management considerations beyond simple RTP advice. There may be a more important role for additional investigations including: formal NP
The child and adolescent athlete
There was unanimous agreement by the panel that the evaluation and management recommendations contained herein could be applied to children and adolescents down to the age of 10 years. Below that age children report concussion symptoms different from adults and would require age-appropriate symptom checklists as a component of assessment. An additional consideration in assessing the child or adolescent athlete with a concussion is that in the clinical evaluation by the healthcare professional
Protective equipment – mouthguards and helmets
There is no good clinical evidence that currently available protective equipment will prevent concussion, although mouthguards have a definite role in preventing dental and orofacial injury. Biomechanical studies have shown a reduction in impact forces to the brain with the use of head gear and helmets, but these findings have not been translated to show a reduction in concussion incidence. For skiing and snowboarding there are studies to suggest that helmets provide protection against head and
KNOWLEDGE TRANSFER
As the ability to treat or reduce the effects of concussive injury after the event is minimal, education of athletes, colleagues and the general public is a mainstay of progress in this field. Athletes, referees, administrators, parents, coaches and healthcare providers must be educated regarding the detection of concussion, its clinical features, assessment techniques and principles of safe RTP. Methods to improve education including web-based resources, educational videos and international
FUTURE DIRECTIONS
The consensus panelists recognize that research is needed across a range of areas in order to answer some critical research questions. The key areas for research identified include:
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validation of the SCAT2 (see Supplementary Figs. 1 and 2)
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gender effects on injury risk, severity and outcome
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pediatric injury and management paradigms
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virtual reality tools in the assessment of injury
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rehabilitation strategies (e.g. exercise therapy)
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novel imaging modalities and their role in clinical assessment
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MEDICAL LEGAL CONSIDERATIONS
This consensus document reflects the current state of knowledge and will need to be modified according to the development of new knowledge. It provides an overview of issues that may be of importance to healthcare providers involved in the management of sports-related concussion. It is not intended as a standard of care, and should not be interpreted as such. This document is only a guide, and is of a general nature, consistent with the reasonable practice of a healthcare professional.
STATEMENT ON BACKGROUND TO THE CONSENSUS PROCESS
In November 2001, the 1st International Conference on Concussion in Sport was held in Vienna, Austria. This meeting was organized by the IIHF in partnership with FIFA and the Medical Commission of the IOC. As part of the resulting mandate for the future, the need for leadership and future updates were identified. The 2nd International Conference on Concussion in Sport was organized by the same group with the additional involvement of the IRB and was held in Prague, Czech Republic, in November
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Cited by (0)
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Consensus panelists in addition to the authors (in alphabetical order): S Broglio, G Davis, R Dick, R Echemendia, G Gioia, K Guskiewicz, S Herring, G Iverson, J Kelly, J Kissick, M Makdissi, M McCrea, A Ptito, L Purcell, M Putukian.
Also invited but not in attendance: R Bahr, L Engebretsen, P Hamlyn, B Jordan, P Schamasch.