Medicolegal considerations

This Statement is not intended as a clinical practice directive or legal standard of care and should not be interpreted as such. The information conveyed is provided in good faith and without warranties of any kind, either expressed or implied. It does not constitute medical, legal or other professional advice or services. This document is only a guide and is of a general nature, consistent with the reasonable practice of an HCP. Individual assessment, treatment, management and advice will depend on the facts and circumstances specific to each individual case. Given the many different cultures, resources, healthcare systems and other factors to be considered when managing athletes at risk of or who have sustained a concussion, the summary of evidence and recommendations from this Statement can be used and adapted to inform local and regional processes. It is intended that this Statement will be formally reviewed and updated before the end of 2027.

Sport-related concussion

The Consensus Statement from the Berlin 2016 International Conference on Concussion in Sport9 refers to the ‘11 Rs’ of SRC (RECOGNISE, REDUCE, REMOVE, REFER, RE-EVALUATE, REST, REHABILITATE, RECOVER, RETURN-TO-LEARN/RETURN-TO-SPORT, RECONSIDER and RESIDUAL EFFECTS) to provide a logical flow of clinical concussion management and considerations. A similar format has been followed for the Amsterdam 2022 Statement with additional ‘Rs’ including RETIRE, to address issues related to potential career-ending decisions, and REFINE, to highlight the need to embrace ongoing strategies to advance the field.

New recommendations determined at the Amsterdam 2022 meeting that were anonymously e-voted on by the expert panel ( figure 2 ) are italicized.

RECOGNISE: definition of sport-related concussion

The CISG proposed a conceptual definition of SRC in 2001.10 This definition has undergone updates and modifications at subsequent CISG meetings, with the most recent being in Berlin in 2016.9 In preparation for the Amsterdam International Consensus Conference on Concussion in Sport, the Scientific Committee considered that the Berlin definition required modification to align with more recent scientific evidence relating to advances in our understanding of SRC pathophysiology. The conceptual definition, accepted as a majority decision (78.6%) but not reaching an 80% consensus, is:

Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain. Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged.

No abnormality is seen on standard structural neuroimaging studies (computed tomography or magnetic resonance imaging T1- and T2-weighted images), but in the research setting, abnormalities may be present on functional, blood flow or metabolic imaging studies. Sport-related concussion results in a range of clinical symptoms and signs that may or may not involve loss of consciousness. The clinical symptoms and signs of concussion cannot be explained solely by (but may occur concomitantly with) drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction) or other comorbidities (such as psychological factors or coexisting medical conditions).

The conceptual definition above does not provide specific diagnostic criteria. Diagnostic criteria using an operational definition for mild traumatic brain injury have recently been published.11 They were developed by the Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine (ACRM) Brain Injury Special Interest Group through rapid evidence reviews and a Delphi expert consensus process. A unified conceptual and operational definition remains a desirable aim of both the CISG and ACRM.

REDUCE: prevention of concussion

A focus on primary concussion prevention will mitigate the burden of injury, risk of recurrent injury and potential for persisting symptoms. Sport policy-makers and HCPs are encouraged to identify and optimise SRC prevention strategies in their environment. Implementing primary prevention of SRC across all levels of sport is a priority that can have a significant public health impact. In the past 5 years, there has been a threefold increase in studies examining the effectiveness of SRC prevention that have assessed policy and rule changes, personal protective equipment, training strategies and management. Studies including children and adolescents represented over 60% of studies evaluating SRC prevention strategies.12

REMOVE: sideline evaluation

The recognition of concussion is the first step to initiating the management of SRC. Removal of a player from the field of play should be done if there is suspicion of a possible concussion to avoid further potential injury. This may be based on a player’s symptoms or signs observed by other players, medical staff or officials (on the field or video). Signs that warrant immediate removal from the field include actual or suspected loss of consciousness, seizure, tonic posturing, ataxia, poor balance, confusion, behavioural changes and amnesia.21 Players exhibiting these signs should not return to a match or training that day, unless evaluated acutely by an experienced HCP with a multimodal assessment (as noted below) who determines that the sign was not related to a concussion (eg, the player has sustained a musculoskeletal injury and thus unable to balance). Maddocks’ questions remain part of a useful and brief on-field screen for athletes >12 years of age without clear on-field signs of a concussion; incorrect answers warrant a more comprehensive off-field evaluation as does any clinical suspicion of concussion. Symptoms and signs of a concussion may evolve over minutes, hours or days. Whether acute concussion is suspected or confirmed, the player should be serially re-evaluated in the coming hours and days.21 22

Designed to assist in the multimodal evaluation of athletes, previous versions of the SCAT have been shown to be most effective in discriminating between concussed and non-concussed athletes within 72 hours of injury and up to 5–7 days postinjury, although their clinical utility appears to diminish after 72 hours. Ceiling effects were apparent on the 5-word list learning and concentration subtests.21 Use of more challenging tests, including the 10-word list, was recommended. Differences were found among the 3 forms of the list learning task,23 suggesting that the forms are not equivalent in difficulty. Test–retest data revealed limitations in temporal stability across subtests.21 Except for the symptom scale, these tools may not be appropriate for use in the return-to-sport (RTS) decision-making process beyond 7 days postinjury. Empirical data are limited in some sports and for preadolescent, female and para athletes, suggesting a need for more globally diverse research including athletes from under-represented groups.

The bullet points below present the recommendations and considerations for modifying the previous iteration of the SCAT22 to develop the SCAT6 and Child SCAT6.21 The Child SCAT6 should be used in patients aged 8–12 years. The final determinations of content included in the SCAT6 and Child SCAT6 were based on findings from the systematic review as well as expert panel discussions highlighting the importance of the scientific evidence while balancing pragmatic considerations for the development and utility of the tools. For example, some expert panel members were hesitant to make changes that would invalidate existing normative data. Factors such as applicability and time constraints that exist during the acute/sideline evaluation guided considerations. The initially proposed changes to the SCAT5 that were voted on did not reach a consensus in the first round of voting. Following further discussions, subsequent voting on individual subcomponent tests to add/remove from the SCAT5 occurred to incorporate a specific test as ‘recommended’ or ‘optional’. Each proposed change, except for the Vestibular-Ocular Motor Screen (VOMS), had >80% agreement to include as either recommended or optional (see figure 2 for details). As a result, the VOMS was not included in the SCAT6. Further, detailed deliberations regarding the development of the SCAT6 occurred during a dedicated Tools Meeting on day 4 of the Amsterdam Conference. As with previous versions, the SCAT6 and Child SCAT6 require validation.

The following recommendations were made based on the systematic review and subsequent expert panel discussions:

• Create both paper and electronic formats of SCAT6/Child SCAT6/CRT6.

• Explore the development of alternate tools for serial evaluation in the office setting.

• Improve psychometric properties: longer word list (eg, 12- or 15-word list) and remove the 5-word list.

• Further examine form differences on existing 10-word lists and consider the use of regression-based norms.

• Create a cognitive composite score to improve test–retest reliability and reduce false positives.

• Add digits (ie, increase the longest string by two digits) to the digit span backward subtest to reduce ceiling effects.

• Revise months backward to include a component of timed information processing.

• Add timed dual gait tasks.

• Implement tests and/or procedures to assess the performance validity of baseline testing.

• Add a more robust set of visible signs to the SCAT6/Child SCAT6/CRT6, including: Falling with no protective action, tonic posturing, impact seizure, ataxia/motor incoordination, altered mental status and blank/vacant/dazed look.

• Support serial SCAT6/Child SCAT6 assessments after an athlete is removed from play, for example, half-time after the game and 24–48 hours after injury.

Typically, the process of conducting a multimodal screen to evaluate a potential concussion takes at least 10–15 min. Sport organisations are strongly advised to allow for at least that amount of time for an adequate evaluation and to accommodate such an assessment off-field, preferably in a quiet area away from the pressures and scrutiny of match play. For athletes with potential signs of a concussion, any screening assessment short of a multimodal evaluation of symptoms, signs, balance, gait, neurological and cognitive changes associated with a potential concussion may be inadequate to allow continued sports participation. Sports whose rules currently do not facilitate such evaluations should strongly consider enacting rule changes in the interest of player welfare.

Based on the research on previous iterations, the SCAT has optimum utility in the first 72 hours and up to a week after injury.22 24 The SCOAT6 or Child SCOAT6 tools are intended for multimodal and serial evaluations conducted in the office after 72 hours.

RE-EVALUATE: the office assessment

The purpose of developing a Sport Concussion Office Assessment Tool (SCOAT6/Child SCOAT6) was to give HCPs a standardised, expansive and age-appropriate clinical guide to a multidomain evaluation in the subacute phase (72 hours to weeks postinjury), with a view to guide individualised management. 25

In some cases, a SCAT/Child SCAT may have been performed close to the time of acute injury, in which case the comparison of recorded symptoms and signs will be of value. In other scenarios, the SCOAT6/Child SCOAT6 may be the initial assessment used to inform SRC diagnosis and management.

The SCOAT6/Child SCOAT6 is designed to assist clinicians in assessing important clinical manifestations influencing the presentation of concussion, identifying areas for potential individualised therapeutic interventions, directing the need for specialist referral(s) and monitoring recovery.

The SCOAT6/Child SCOAT6 does not replace the HCP’s clinical acumen; rather, it provides a standardised framework that can be adapted to help inform the clinical evaluation in an office setting. The Child SCOAT6 should be used in patients aged 8–12 years, while the SCOAT6 should be used in patients 13 years and older. These tools are meant to be used within the expertise and areas of competency of the clinician. We recognise that consultation time, available resources and practitioner experience will vary. As with earlier versions of the SCAT, the SCOAT6 requires evaluation, including an appraisal of its psychometric properties, validation (including at different time points postinjury, in different populations, cultures and languages) and modification with time and evolving evidence.25

The athlete’s history of concussions, how each concussion was managed and recovery time should be noted. Medical and psychological diagnoses that may modify the presentation or recovery such as migraine, other headache disorder, anxiety and depression should be documented. The SCOAT6/Child SCOAT6 symptom scale mirrors that of the SCAT6/Child SCAT6. Preinjury (baseline), sideline or acute symptom scores, if available, should be used for comparison. 25

The following were recommended to be included in an official evaluation of SRC (details included in the SCOAT6):

• Word recall and Digit Backwards tests: The 10-word immediate recall and digit string backwards tests should be used. If the athlete finds the word recall task too easy (eg, exhibits a ceiling effect), a 15-word list may be used.

• Measurement of systolic and diastolic blood pressure as well as heart rate taken in two positions:

  • Supine position, rest for 2 min and take measurements.

  • Follow with the standing position, measure again after 1 min.

  Symptoms brought on by a change in postural position (eg, lightheaded, dizzy or motion sensation) should be noted in the patient’s record.

• Evaluation of cervical spine range of motion, muscle spasm and palpation for segmental or midline tenderness.

• A neurological examination includes the assessment of cranial and spinal nerves, motor function, sensation and deep tendon reflexes.

• Timed tandem gait as a single task and a more complex dual task with the addition of a cognitive task (such as serial 7’s, months backwards or word recall backwards).

• The modified Vestibular-Ocular Motor Screen (VOMS).

• Delayed word recall a minimum of 5 min after completion of the immediate word recall test.

New content discussed at the dedicated Tools workshop (Day 4 of the Amsterdam Conference) led to additional recommended items for the Child SCOAT6 including:

• Additional symptoms for child and parent reports that capture multiple subacute domains.

• An age-appropriate measure of cognitive reaction time such as the Symbol Digit Modalities Test.

• Validated paediatric measures of (1) orthostatic tachycardia, (2) orthostatic intolerance, (3) vestibular and oculomotor function and (4) child mental health and sleep questionnaires.

It is not unusual to have athletes experience fear, anxiety or depression associated with concussion or as preinjury conditions exacerbated by concussion injury. Where deemed appropriate, HCPs are encouraged to screen for these symptoms using validated mental health screening instruments 26–28 such as those included in the Sport Mental Health Assessment Tool (SMHAT). 29

Neurocognitive test batteries, where accessible, may add value to assessing SRC and its sequelae. Computer-based test batteries, especially in comparison of reaction times against patient baseline and community norms, may be useful. The results of these tests should be interpreted in the context of broader clinical findings and are not to be used in isolation to inform management or diagnostic decisions. 25

The components of the SCOAT6/Child SCOAT6, many of which have been previously validated on their own and are typically used in clinical practice as individual tests, form a multimodal assessment that is designed to better inform the HCP’s assessment and management of concussion and may be augmented by additional clinical measures and investigations. Where available, HCPs are further encouraged to make use of a multidisciplinary network to provide additional specialised diagnostic input, particularly in cases of persisting symptoms. In reviewing studies informing the SCOAT6, the period defined for the included papers was 3-30 days. HCPs may choose to use the SCOAT6 beyond this time frame but should be aware of the parameters of the review.

REST and exercise

The best available evidence shows that recommending strict rest until the complete resolution of concussion-related symptoms is not beneficial following SRC. Relative (not strict) rest, which includes activities of daily living and reduced screen time, is indicated immediately and for up to the first 2 days after injury.30 Individuals can return to light-intensity physical activity (PA), such as walking that does not more than mildly exacerbate symptoms, during the initial 24–48 hours following a concussion.30

• Clinicians are encouraged to recommend early (after 24–48 hours) return to PA as tolerated (eg, walking or stationary cycling while avoiding the risk of contact, collision or fall).30

• The best data on cognitive exertion show that reduced screen use in the first 48 hours after injury is warranted but may not be effective beyond that.31 32

• Individuals can systematically advance their exercise intensity based on the degree of symptom exacerbation experienced during the prior bout of aerobic exercise.

• HCPs with access to exercise testing can safely prescribe subsymptom threshold aerobic exercise treatment within 2–10 days after SRC, based on the individual’s heart rate threshold (HRt) that does not elicit more than mild symptom exacerbation during the exercise test (eg, ‘mild’=testing stops with an increase of more than two points on a 0–10 point scale when compared with the pre-exercise resting value). Subsymptom threshold aerobic exercise treatment can be progressed systematically based on the determination of the new HRt on repeat exercise testing (every few days to every week).33 34

Athletes may continue/advance the duration and intensity of PA or prescribed aerobic exercise provided there is no more than mild (increase of no more than 2 points vs the pre-exercise value) and brief (<1 hour) exacerbation of their concussion-related symptoms. 30

PA/exercise and cognitive exertion should be stopped if concussion symptom exacerbation is more than mild and brief and may be resumed once symptoms have returned to the prior level. Clinicians should inform their patients that mild symptom exacerbation during PA, prescribed aerobic exercise treatment or during cognitive activity is typically brief (under an hour) and does not delay recovery. Prescribed subsymptom threshold aerobic exercise within 2–10 days of SRC is effective for reducing the incidence of persisting symptoms after concussion (symptoms >1 month) and is also effective for facilitating recovery in athletes suffering from symptoms lasting longer than 1 month. 34 Importantly, individuals should be advised to avoid the risk of reinjury (ie, contact, collision or fall) until determined by a qualified HCP to be safe for higher risk activities. 30

Sleep disturbance in the 10 days after SRC is associated with an increased risk of persisting symptoms and may warrant evaluation and treatment. 35 36

REFER

Where the clinical environment allows, referral to clinicians with specialised knowledge and skills in concussion management should be considered for the targeted treatment of persisting symptoms.37 This may include the management of cervicogenic symptoms, migraine and headache, cognitive and psychological difficulties, balance disturbances, vestibular signs and oculomotor manifestations.

Persisting symptoms (>4 weeks across all age groups) may be pre-existing, concussion-related or both. Serial multimodal evaluation using a tool such as the SCOAT6/Child SCOAT6, and additional detailed clinical evaluations for specific symptoms (eg, headaches, dizziness, cognition) can help guide referrals. Specialist clinicians whose diagnostic assessments, clinical evaluations and treatment interventions for SRC may be of use as part of a clinician network may vary depending on the region, practice culture and local healthcare environment, and available areas of competency and expertise.25 This SRC clinician network may include sports medicine physicians, athletic trainers/therapists, physiotherapists, occupational therapists, sports chiropractors, neurologists, neurosurgeons, neuropsychologists, ophthalmologists, optometrists, physiatrists, psychologists and psychiatrists.

Specific recommendations include:

• The term ‘persisting symptoms’ is used for symptoms that persist >4 weeks across children, adolescents and adults.

• Persisting symptoms can be assessed using standardised and validated symptom rating scales. However, evidence-based recommendations regarding the use of other specific tests or measures in the clinical diagnosis of persisting symptoms in any age group are not possible based on existing research.37

• A multimodal clinical assessment, ideally by a multidisciplinary team, is indicated to characterise individuals with persisting symptoms, including the types, pattern and severity of symptoms, and any associated conditions or other factors that may be causing or contributing to the symptoms.

Symptoms attributed to concussion are non-specific, commonly also reported by healthy individuals and those with conditions other than concussion, and can be exacerbated by a variety of biopsychosocial factors aside from concussion, which should be assessed in the context of persisting symptoms. Other problems may exist prior to injury (but can be exacerbated by a concussion), co-occur with persisting symptoms or mimic persisting symptoms but do not arise from concussion. Common considerations in the context of persisting symptoms include mental health issues; learning or attention difficulties; visual, oculomotor, cervical and vestibular problems; headache disorders and migraine; sleep disturbance; dysautonomia, including orthostatic intolerance and postural orthostatic tachycardia syndrome; and pain.

REHABILITATION

If dizziness, neck pain and/or headaches persist for more than 10 days, cervicovestibular rehabilitation is recommended. 38 If symptoms persist beyond 4 weeks in children and adolescents, active rehabilitation and collaborative care may be of benefit. For children, adolescents and adults with dizziness/balance problems, either vestibular rehabilitation or cervicovestibular rehabilitation may be of benefit. The inclusion of subsymptom threshold aerobic exercise (as outlined above) in combination with other treatments should be considered. In the case of a recurrence of symptoms when progressing through the return-to-learn (RTL) or return-to-sport (RTS) strategies, re-evaluation and referral for rehabilitation may be of benefit to facilitate recovery. 38

Rehabilitation may be targeted to individual symptoms or maybe more general and focus on overall recovery. The effects of combinations of rehabilitation, optimal timing for initiation of rehabilitation and modifying factors (such as age and sex) are not yet well established and require further evaluation.

RECOVERY

RETURN-TO-LEARN and RETURN-TO-SPORT

Since the introduction of the RTL and RTS strategies, there has been a fivefold increase in the time to unrestricted RTS.40 Many questions remain about how to optimise RTL and RTS. Importantly, measures used to assess recovery have moved beyond symptoms, cognitive function and balance, to include measures of oculomotor and vestibular function, as well as biobehavioural and physical examination findings (as per SCOAT6/Child SCOAT6).25 While immediate and early postinjury symptoms remain the most robust predictor of recovery, the emergence of new assessment tools and variability in recovery endpoints underscores the importance of consistent definitions and measurement approaches. The systematic review of RTL and RTS found that continuing to play and delayed access to HCPs after SRC are associated with longer recovery.41 In addition, similar RTL and RTS management strategies can be implemented in different cohorts (eg, age, sex) with minimal differences in the time for recovery.41

The systematic review revealed wide variability in clinical time points for recovery from SRC, making the integration and interpretation of results from multiple studies challenging, and limiting our ability to develop recommendations applicable to the individual athlete. 41 To improve our clinical recommendations, the following definitions have been adopted by the Amsterdam consensus panel:

• Symptom resolution at rest : resolution of symptoms associated with the current concussion at rest.

• Complete symptom resolution : resolution of symptoms associated with the current concussion at rest with no return of symptoms during or after maximal physical and cognitive exertion.

• Return-to-learn (RTL) : return to preinjury learning activities with no new academic support, including school accommodations or learning adjustments.

• Return-to-sport (RTS) : completion of the RTS strategy with no symptoms and no clinical findings associated with the current concussion at rest and with maximal physical exertion.41

RECONSIDER: potential long-term effects

There is increasing societal concern about possible problems with later-in-life brain health in former athletes, such as mental health problems, cognitive impairment and neurological diseases. The literature was reviewed for published studies using research designs that could estimate future risk to former athletes (ie, cohort studies and case–control studies). These research designs, either prospective or retrospective, require that an exposed and an unexposed group be followed through time to the outcome of interest. 49

Studies that examined mental health as an outcome found that (1) former amateur athletes (primarily American football players) are not at increased risk for depression or suicidality during early adulthood or as older adults, 50–54 (2) former professional soccer players are not at increased risk for psychiatric hospitalisation during their adult life 55 and (3) former professional football and soccer players are not at increased risk for death associated with having a psychiatric disorder 56 57 or as a result of suicide. 55–59

Other studies evaluated cognitive impairment, neurological disorders (eg, dementia) and neurodegenerative diseases (e.g., Alzheimer’s disease, Parkinson’s disease and amyotrophic lateral sclerosis (ALS)) as the outcome. Former male amateur athletes were not at increased risk for cognitive impairment, neurological disorders or neurodegenerative diseases compared with men from the general population. 53 60–62 In contrast, studies of former professional athletes examining causes of death reported greater mortality rates from neurological diseases and dementia in former professional American football players 63–65 and professional soccer players. 66 Former professional football players 64 65 and soccer players 59 66 67 have greater mortality rates from ALS. ALS is a rare disease with a possible genetic cause in some cases of men who develop the disease before age 50, 68 and it involves a highly selective population of neurons, about half of which are in the spinal cord, which makes identifying specific trauma-related aetiological mechanisms challenging.

The studies, to date, are methodologically limited because most were not able to examine, or adjust for, many factors that can be associated with the mental health and neurological outcomes of interest. The studies examining cognitive impairment and neurological outcomes did not examine genetic factors and usually did not consider or control for factors known to be important for brain health in the general population, such as educational attainment, socioeconomic status, smoking, hypertension and cardiovascular disease, diabetes, sleep apnea, white matter hyperintensities, social isolation, diet, PA or exercise. 69–79 To establish a clear causal association between sports participation early in life and cognitive impairment or dementia late in life or to quantify that association, future well-designed case–control and cohort studies, that include as many individual risk-modifying and confounding factors as possible, are needed.

Chronic traumatic encephalopathy-neuropathological change and traumatic encephalopathy syndrome 49

Historically, a clinical condition associated with chronic traumatic brain injury in boxers was described using terms like punch drunk, 80 dementia pugilistica 81 and chronic traumatic encephalopathy (CTE). 82 83 In recent years, CTE has been described as a neuropathological entity. 84–86 To avoid conceptual confusion between the pathology and a possible clinical condition, the postmortem neuropathology is referred to as CTE neuropathologic change (CTE-NC). The literature suggests that CTE-NC is very uncommon in community samples and brain banks, using strict criteria for case identification, and more common in brain bank samples of former professional athletes with high exposure to repetitive head impacts. However, these studies of former athletes are not cohort studies that can examine causation or quantify risk and thus were not included in the systematic review. It is reasonable to consider extensive exposure to repetitive head impacts, such as that experienced by some professional athletes, as potentially associated with the development of the specific neuropathology described as CTE-NC.

CTE-NC is not a clinical diagnosis. The first consensus criteria for traumatic encephalopathy syndrome (TES), a new clinical diagnosis, were published in 2021. 87 These diagnostic criteria can be used to determine the extent to which CTE-NC identified after death was associated with this new clinical diagnosis during life. The prevalence of CTE-NC (a neuropathological entity) and TES (a clinical diagnosis) in former athletes, military veterans and people from the general population is not known. It is also not known whether (1) CTE-NC causes specific neurological or psychiatric problems, (2) the extent to which CTE-NC can be clearly identified within the presence of Alzheimer’s disease neuropathology or (3) whether CTE-NC is inevitably progressive.

RETIRE

There is no clear evidence of the factors that, if present, would unequivocally lead to retirement or discontinued participation in contact or collision sports. 88 However, some sports have their own specific medical regulations regarding clearance for participation (e.g., retinal detachment in boxing).

Decisions regarding retirement or discontinuation from contact or collision sports are complex and multifaceted and should involve clinicians with expertise in traumatic brain injury and sport and preferably a multidisciplinary team. The decision-making process should include a comprehensive clinical evaluation that considers important patient-, injury-, sport-specific and other sociocultural factors. 88

The discussion should provide athletes with the scientific evidence and uncertainties of their condition balanced against the benefits of participation in sport. It should incorporate the athlete’s preferences and risk tolerance as well as psychological readiness to make an informed decision. The discussion should be carefully documented and should use language that is appropriate for the health literacy of the individual to reduce the risk that the information is misinterpreted. For children and adolescents, the parent/guardian should be involved in the discussion. HCPs should make the athlete aware of the role(s) they are playing in the athlete’s care, stating clearly if they have any potential or actual conflicts of interest. The shared decision-making process should be individualised and incorporate a comprehensive clinical evaluation that may involve a multidisciplinary team and considers patient-, injury-, sport-specific and other sociocultural factors. These principles also apply to all of those involved in the coaching and management of the athlete. 88

In the child or adolescent athlete, additional concerns are a successful return to school and to maintain healthy levels of PA. This often requires a multidisciplinary process that includes the child/adolescent, parent/caregivers, HCPs, school leadership and teachers in the discussions.

Given the positive benefits of exercise on health, care must be taken to avoid restricting all PA. All athletes who ultimately retire from contact or collision sports should be encouraged to continue non-contact or low-contact PA and have the health benefits of exercise explained.

REFINE

Additional topics of relevance to SRC were included in the Amsterdam consensus. Several considerations that could strengthen the consensus process were identified and are described below.

Future research

As part of their task, each author group identified gaps in the research. These gaps included additional topic areas of research, other geographical locations (ie, outside of North America), cultural contexts and ages, sexes and genders, which are described in each systematic review. The audience was also invited to share priorities for future research. A total of 342 participants responded to prioritise their top five topics for research, with potential long-term effects ranking first and prevention ranking second (figure 3).

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Figure 3

Percentage of conference attendees who voted for each topic as a top five priority for future research.

Potential long-term sequelae

The potential long-term mental health and neurodegenerative effects of concussion and repetitive head impacts are of increasing interest in the field and have dominated the public discourse on the possible long-lasting effects of collision/contact sports participation. This consensus process has revealed a spectrum of perspectives and the complexities of answering these important questions to which they give rise. Defining the methodology for adequate study designs to better understand if there is a link between neuropathological findings and in vivo processes should be prioritised. The ethical and scientific challenges related to the issue of potential long-term effects of concussion require an ongoing and collaborative process. The Scientific Committee proposes the formation of an interdisciplinary working group, including members of CISG, as well as other clinicians, scholars and scientists, to continue deliberations on these topics in the interest of athlete care. As part of their charge, we recommend this group seek dedicated funding for research into long-term athlete health and consider a separate conference to afford greater time and attention to this topic.