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Background and rationale
The Concussion In Sport Group (CISG) first developed the Sport Concussion Assessment Tool (SCAT)1 during its 2004 meeting in Prague to serve as an educational tool for the public and to assist healthcare professionals (HCPs) in evaluating sport-related concussion (SRC). The SCAT has been revised several times, including the most recent SCAT6.2 The SCAT6 and its predecessors were designed for use by HCPs. However, HCPs are rarely present at many, if not most, sporting and recreational activities, particularly at the community level involving children and adolescents. Understanding this void in concussion care, the CISG designed the Pocket SCAT2 in 2009 following the 3rd International Consensus Conference in Zurich3 as a tool to assist the layperson recognise the signs and symptoms of suspected SRC at all ages. The tool was also designed to provide guidance for removing an athlete from activity and seeking further medical assessment. The Pocket SCAT2 was revised by the CISG in 20124 and renamed the Pocket Concussion Recognition Tool (CRT) and subsequently the CRT 5 (CRT5).5 This paper introduces the most recent version, the CRT6.
Development process
The Sixth International Conference on Concussion in Sport was convened in Amsterdam in October 2022. The consensus approach followed the process used by the CISG in prior consensus meetings1: develop questions to explore the most up-to-date scientific literature2; perform systematic reviews of the literature3; present the results of the 10 reviews and selected abstracts in open forums, including discussion by participants in attendance and the inclusion of the athlete voice; conduct an expert panel consensus meeting to evaluate and vote on recommendations arising from the open meetings and reviews; and identify a subset of co-authors from the ‘tools’ systematic reviews who met separately to discuss and implement recommendations for modifying the tools, including the CRT6.6
Although there was no CRT6 specific systematic review, the contents of the CRT6 follow that of the SCAT62 7 and Child SCAT6.8
Content of the CRT6
The CRT6 co-authors emphasised the importance of continuing to provide a ‘recognise and remove’ tool for the layperson, which could be used to identify suspected SRC at all ages and levels of activity (organised and recreational), across a broad range of athletes from different sports, including para athletes, and those from differing cultural, linguistic and educational backgrounds. The CRT6 was designed to be easy to use and was written in a style intended for a general audience with no clinical training.
The CRT6 contains four key sections1: a Red Flags section that alerts individuals to key signs that require urgent medical attention (eg, transport to hospital or medical facility)2; visible or observable clues that a concussion may have occurred3; symptoms of concussion grouped by type of symptom⇓ and athlete awareness.
What’s new?
Continuity across the Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6 and the Concussion Recognition Tool 6 (CRT6).
Emphasis that the CRT6 is NOT a tool for diagnosing concussion.
Enhanced emphasis on Recognise and Remove, including para athletes.
Further expansion of the Red Flags section, including instruction that the presence of any red flag demands removal from activity and urgent medical attention.
Warning not to remove helmets unless trained to do so.
Emphasis on assuming the possibility of spinal injury with any head injury.
List of visible clues/signs of suspected concussion and symptoms consistent with the SCAT6/Child SCAT6.
Symptom list is divided into three symptom categories (physical symptoms, changes in emotions and changes in thinking) for easier recognition of sport-related concussion.
Example of ‘awareness’ questions expanded for use across a greater number of sports.
Emphasis added on explicit instructions that any athlete suspected of concussion should be immediately removed from activity and not returned to activity until assessed and managed medically.
Cautions regarding acute management and restrictions on behaviours for any athlete with a suspected concussion (eg, not being alone, drinking alcohol, driving or using recreational drugs).
How to use the CRT6
The CRT6 is modelled after its predecessors and serves as a tool for non-medically trained individuals to recognise suspected SRC and to take appropriate next steps when a concussion is suspected. Although the SCAT6, Child SCAT6 and the CRT6 are designed to work in tandem, they serve different purposes. The CRT6 is not to be used in the diagnosis of concussion; it is a tool to help recognise injury and remove the athlete from activity. Although used widely, there has been little systematic research regarding the utility or efficacy of the CRT tools in improving the recognition and management of SRC. Early recognition and removal of the acutely injured athlete is crucial and can improve the health and well-being of athletes. We encourage community and research groups to assess the utility of this tool and to provide feedback for continuous improvement.
We are committed to the free and broad distribution of the CRT6. The CRT6 may be freely copied and distributed in its current form. However, modifications, including translations and other alterations of the CRT6, are not permitted unless approved by the CISG Tools Committee.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors gratefully acknowledge the work of the co-authors of the systematic review that served as a foundation for the Sport Concussion Assessment Tool 6 and Concussion Recognition Tool 6: RJE, JSB, JMB, GAD, Christopher C Giza, Kevin M Guskiewicz, Dhiren J, Naidu, Amanda M Black, Steven P Broglio, Simon Kemp, JPatricios, Margot Putukian, RZ, Juan Carlos Arango-Lasprilla, CMB, Benjamin L Brett, Nyaz Didehbani, Gerard A Gioia, Stanley A Herring, DH, Christina Master, Tamara C Valovich McLeod, William P Meehan III, Zahra Premji, Danielle Salmon, JvI, Neil Bhathela, Michael Makdissi, SRW, James Kissick, JPardini and KJS. The authors also gratefully recognise the assistance of librarians Alix Hayden and Heather Ganshorn, and Corson Johnson, Candice Goerger, Shauna Rutherford, Kenzie Vaandering, Stacy Sick and Kirsten Holte.
Footnotes
Twitter @osmanhahmed, @HowellDR, @drtinamaster, @Kat_Schneider7, @SammoWalton, @jonpatricios
Contributors RJE served as the primary author and responsible for all aspects of the project, including initial preparation, coordination, review, editing and final preparation of the manuscript and the Concussion Recognition Tool 6 (CRT6) tool. All co-authors contributed to the development and critical review of the manuscript and CRT6 tool, and approved the final version of the manuscript and tool.
Funding Education grant from the Concussion in Sport International Consensus Conference Organizing Committee through Publi Creations for partial administrative and operational costs associated with the writing of the systematic reviews and tool design.
Competing interests OHA reports employment from University Hospitals Dorset NHS Foundation Trust (England) as a Senior Physiotherapist, and paid employment from the Football Association (England) as Para Football Physiotherapy Lead, Para Football Classification Lead, and Physiotherapist to the England Cerebral Palsy Football squad. Unpaid roles/voluntary roles: University of Portsmouth (England) as Visiting Senior Lecturer; Para Football Foundation as Medical Unit Co-Lead; the International Federation of Cerebral Palsy Football as Medical and Sports Science Director; the International Blind Sports Association as a Medical Committee member; British Journal of Sports Medicine Medicine as Associate Editor; BMJ Open Sports & Exercise Medicine as Associate Editor; World Rugby as Institutional Ethics Committee external member; the Concussion in Para Sport Group as co-chair; and the Concussion in Sport Group as board member. CMB reports affiliations with the Cleveland Browns (National Football League) and Cleveland Monsters (American Hockey League), a board position in the Sports Neuropsychology Society, and occasional expert consulting fees. JMB reports being a part-time employee of the NHL. JMB’s institution has received funding from Genzyme, and EyeGuide supporting his work, and he has served as a paid consultant to Med-IQ and Sporting KC. JSB reports receiving methods author funding for this review and Alexander Graham Bell Canada Graduate Scholarships-Doctoral Program. GAD is a member of the Scientific Committee of the 6th International Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee; Section Editor, Sport and Rehabilitation, NEUROSURGERY; and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF, IOC and FIFA; however, has not received any payment, research funding or other monies from these groups other than for travel costs. RJE is a paid consultant for the National Hockey League and co-chair of the National Hockey League /National Hockey League Players Association Concussion Subcommittee, Major League Soccer’s Concussion Committee and the US Soccer Federation, provides testimony in matters related to mTBI and reports a grant from Boston Children’s Hospital (sub-award from the National Football League) and travel support for the CIS conference and other professional conferences, an unpaid board member of CISG and leadership roles (unpaid) in professional organizations. GG reports grant funding from CDC TEAM and OnTRACK grants, NIMH APNA grant, royalties from PAR, consulting fees from NFL Baltimore Ravens, Zogenix International, and Global Pharma Consultancy, and travel support for professional meetings. He is a member of USA Football Medical Advisory Panel. DH reports research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the National Institute of Neurological Disorders And Stroke, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 59th Medical Wing Department of the Air Force, MINDSOURCE Brain Injury Network, the Tai Foundation, and the Colorado Clinical and Translational Sciences Institute (UL1 TR002535‐05) and he serves on the Scientific/Medical Advisory Board of Synaptek, LLC. GWF and CLM reports no financial COI. She holds leadership positions with several organizations American College of Sports Medicine, American Medical Society for Sports Medicine, Pediatric Research in Sports Medicine, Council on Sports Medicine and Fitness, American Academy of Pediatrics, Untold Foundation, Pink Concussions, Headway Foundation, and the editorial boards of Journal of Adolescent Health, Frontiers in Neuroergonomics, Exercise, Sport, and Movement. JPatricios reports travel support for the CIS conference and other professional meetings, consulting fees and grant funding from World Rugby, and an unpaid board member of CISG and EyeGuide. KJS reported receiving an educational grant for assisting with the administrative and operational costs associated with the writing of the reviews and a travel grant from Public Creations, grant funding from Canadian Institutes of Health Research, Public Health Agency of Canada (through Parachute Canada), National Football League Scientific Advisory Board, International Olympic Committee Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary; leadership roles in AFL, Federal Provincial Territorial Work Group on Concussion, Canada. JvI reports CIHR Postdoctoral Fellowship Award, UOMBRI Grant, travel stipend from CTRC and Founder of R2P™ Concussion Management. JPardini reports no disclosures. SRW reports honoraria and travel support for professional meetings and leadership positions in World Federation of Athletic Training and Therapy and Outcomes, International Traumatic Brain Injury Research Initiative. RZ reports competitively funded research grants from Canadian Institutes of Health Research, Ontario Neurotrauma Foundation, Physician Services Incorporated Foundation, CHEO Foundation, Ontario Brain Institute, Health Canada, Public Health Agency of Canada, Ontario SPOR Support Unit, Ontario Ministry of Health, and the National Football League's Scientific Advisory Board. He is clinical research chair in Pediatric Concussion from University of Ottawa, and a volunteer board member the North American Brain Injury Society, co-founder, scientific director and a minority shareholder in 360 Concussion Care, an interdisciplinary concussion clinic.
Provenance and peer review Not commissioned; internally peer reviewed.