Article Text
PDF
Statistics from Altmetric.com
Sports-related concussion (SRC) is one of the most important medical issues in contact and collision sports around the world. The NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocols, published in this edition of the BJSM, represent a comprehensive approach to concussion management in professional sport.1 The protocols highlight how much the approach to SRC has evolved, particularly since the first International Conference on Concussion in Sport held in Vienna in November 2001.2 This evolution has been driven largely by concerns (both medical and public) regarding potential short-term and long-term adverse outcomes following SRC, and have been underpinned by evolving concepts from five international consensus meetings, and an explosion of research on SRC over the past decade.
Berlin October 2016
The fifth International Conference on Concussion in Sport was held in Berlin in October 2016. The meeting involved more than 18 months of active planning, 10 scientific committee members, 23 additional expert panellists and 420 participants representing 24 countries.3 The output included 12 comprehensive systematic reviews (which collectively screened nearly 60 000 articles), 202 additional conference scientific abstracts, a consensus paper4 and revised standardised concussion recognition and assessment tools (SCAT5, ChildSCAT5 and CRT5). The output from the Berlin meeting provides a blueprint of 11 key principles of concussion management (the 11 ‘R’s’).4 Translation and implementation of these principles into clinical practice is now the role of medical professionals and sporting bodies throughout the world. Importantly, the Berlin meeting acknowledged, and indeed encouraged, the need for further meetings and protocols aimed specifically at implementation of the consensus guidelines in sport.
Dublin July 2017
In July 2017, representatives from 10 national and international sports organisations (American football, Australian football, basketball, cricket, equestrian sports, football/soccer, ice hockey, rugby league, rugby union and skiing) met in Dublin to discuss implementation of the Berlin Statement with an emphasis on harmonising the interpretation across the codes.5 Key themes from this meeting centred on detection and diagnosis of SRC, sideline management protocols and criteria for return to play decisions. Impediments to implementation and identification of areas for harnessing collaboration among team collision sports were also considered.5
NFL guidelines 2017/2018
Rather than representing a deviation from current care guidelines, the NFL concussion protocols reflect a pragmatic translation of the Berlin consensus statement and an affirmation of the collaborative approach of the Dublin meeting. The recommendations provide an example of a comprehensive approach to implementing concussion management in professional sport. There are a number of pertinent points of the NFL approach that are worth highlighting.
A focus on concussion awareness and education
Educating players about the importance of identifying and reporting symptoms to team medical staff is a critical component of any SRC management guideline. Education may take many forms including specific audiovisual or reading material provided to the players by the sport’s governing body or Players Association, or informally by team medical staff during the preseason screening process.
An environment that facilitates recognition of concussion
Early signs (eg, tonic posturing following impact or staggers/disequilibrium) are often brief and may be missed from the sidelines. The addition of video review, concussion spotters, unaffiliated neurological consultants, and so on improves the chance that a potential concussion event is identified by team medical staff.
Clear management guidelines at the time of injury
The NFL has a number of ‘NO-GO’ criteria that reflect mandatory visible signs of concussion. The presence of any of these signs guides the immediate course of action and facilitates consistent decision-making across the competition. Equally important, the NFL clinical assessment template is based on Berlin’s SCAT5, reinforcing consistency across codes.
Time and space to assess the player without distraction
The provision of a sideline tent, free substitution of the player and further assessment conducted in the rooms allows any player with a suspected concussion adequate time for evaluation in a distraction and stress-free environment.
Independence in the concussion management process…
SRC is a complex condition that presents with a spectrum of clinical features, which evolve over time. Moreover, there is currently no single objective biomarker of injury and/or recovery. Consequently, decisions regarding diagnosis and clearance for return to play can be challenging. Experienced, independent medical experts provide additional opinion that may complement the decision-making process. Screening for potential concussions (in the NFL’s case the use of a Certified Athletic Trainer (ATC) spotter and video review) and the use of independent clinical assessors (the Unaffiliated Neurotrauma Consultant) add layers of protection to comprehensive care. Auditing of concussion diagnoses and management however should be encouraged for quality assurance and ongoing education purposes.
…but the Team Physician oversees management
Importantly, appropriate management of the return-to-sport process requires clinical input from doctors experienced in concussion management. Understanding and knowing players remains a significant advantage and the NFL document acknowledges that the Team Physician, with support from independent experts, is in the best position to guide care.
Being comprehensive but concise
The NFL Concussion Game Day Checklist1 represents a concise summary of the NFL protocols. Guidelines can be easily followed, consistently implemented and effectively audited. Other sports and, indeed the consensus process, may well learn from how this useful flow chart is presented.
The challenge for all sports
Many international sports have adopted a similar approach to concussion management. Ultimately, it is incumbent on all sporting bodies/codes to provide adequate resources and education, together with guidelines on appropriate concussion management strategies within their respective sports. This should also include sufficient time and space for team medical staff to adequately assess players unencumbered by external pressures (time, space, opinion of non-medical staff, and so on). Sports that currently do not have a substitution or replacement policy (eg, football/soccer) should consider how best to address these challenges. This should be a pressing issue for governing bodies such as FIFA.
In situations (eg, lower levels of competition, sports involving child or adolescent athletes) where experienced personnel and/or resources are limited, a more conservative, but equally thorough, approach to SRC must be adhered to. Sporting codes should have guidelines and education programmes that extend to athletes, parents, coaches and support staff at all levels of competition. The emphasis should be on recognising the injury, removing from play and referring the player for a medical assessment. That certainly does not mean that amateur sports should not offer comprehensive concussion care. Rather, the concept of Advanced Care Settings tabled in Dublin should apply wherever possible.
Conclusion
SRC is an important medical issue in contact and collision sports worldwide. As our understanding continues to evolve, it is imperative that our management guidelines remain dynamic and evolve in line with new information. The sporting codes should continue to collaborate and learn from each other. Overall, the priority remains the acute and long-term welfare of the player.
Footnotes
Contributors MM conceived the outline and themes of the paper. MM and JP both contributed to the content, design and drafting of the paper. MM submitted the paper and acts as guarantor.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.