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Abstract
Objectives This cohort study reported descriptive statistics in athletes engaged in Summer and Winter Olympic sports who sustained a sport-related concussion (SRC) and assessed the impact of access to multidisciplinary care and injury modifiers on recovery.
Methods 133 athletes formed two subgroups treated in a Canadian sport institute medical clinic: earlier (≤7 days) and late (≥8 days) access. Descriptive sample characteristics were reported and unrestricted return to sport (RTS) was evaluated based on access groups as well as injury modifiers. Correlations were assessed between time to RTS, history of concussions, the number of specialist consults and initial symptoms.
Results 160 SRC (median age 19.1 years; female=86 (54%); male=74 (46%)) were observed with a median (IQR) RTS duration of 34.0 (21.0–63.0) days. Median days to care access was different in the early (1; nSRC=77) and late (20; nSRC=83) groups, resulting in median (IQR) RTS duration of 26.0 (17.0–38.5) and 45.0 (27.5–84.5) days, respectively (p<0.001). Initial symptoms displayed a meaningful correlation with prognosis in this study (p<0.05), and female athletes (52 days (95% CI 42 to 101)) had longer recovery trajectories than male athletes (39 days (95% CI 31 to 65)) in the late access group (p<0.05).
Conclusions Olympic athletes in this cohort experienced an RTS time frame of about a month, partly due to limited access to multidisciplinary care and resources. Earlier access to care shortened the RTS delay. Greater initial symptoms and female sex in the late access group were meaningful modifiers of a longer RTS.
- Recovery
- Brain Concussion
- Athletes
- Cohort Studies
- Retrospective Studies
Data availability statement
Data are available on reasonable request. Due to the confidential nature of the dataset, it will be shared through a controlled access repository and made available on specific and reasonable requests.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Most data regarding the impact of sport-related concussion (SRC) guidelines on return to sport (RTS) are derived from collegiate or recreational athletes. In these groups, time to RTS has steadily increased in the literature since 2005, coinciding with the evolution of RTS guidelines. However, current evidence suggests that earlier access to care may accelerate recovery and RTS time frames.
WHAT THIS STUDY ADDS
This study reports epidemiological data on the occurrence of SRC in athletes from several Summer and Winter Olympic sports with either early or late access to multidisciplinary care. We found the median time to RTS for Olympic athletes with an SRC was 34.0 days which is longer than that reported in other athletic groups such as professional or collegiate athletes. Time to RTS was reduced by prompt access to multidisciplinary care following SRC, and sex-influenced recovery in the late access group with female athletes having a longer RTS timeline. Greater initial symptoms, but not prior concussion history, were also associated with a longer time to RTS.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Considerable differences exist in access to care for athletes engaged in Olympic sports, which impact their recovery. In this cohort, several concussions occurred during international competitions where athletes are confronted with poor access to organised healthcare. Pathways for prompt access to multidisciplinary care should be considered by healthcare authorities, especially for athletes who travel internationally and may not have the guidance or financial resources to access recommended care.
Introduction
After two decades of consensus statements, sport-related concussion (SRC) remains a high focus of research, with incidence ranging from 0.1 to 21.5 SRC per 1000 athlete exposures, varying according to age, sex, sport and level of competition.1 2 Evidence-based guidelines have been proposed by experts to improve its identification and management, such as those from the Concussion in Sport Group.3 Notably, they recommend specific strategies to improve SRC detection and monitoring such as immediate removal,4 prompt access to healthcare providers,5 evidence-based interventions6 and multidisciplinary team approaches.7 It is believed that these guidelines contribute to improving the early identification and management of athletes with an SRC, thereby potentially mitigating its long-term consequences.
Nevertheless, evidence regarding the impact of SRC guidelines implementation remains remarkably limited, especially within high-performance sport domains. In fact, most reported SRC data focus on adolescent student-athletes, collegiate and sometimes professional athletes in the USA but often neglect Olympians.1 2 8–11 Athletes engaged in Olympic sports, often referred to as elite amateurs, are typically classified among the highest performers in elite sport, alongside professional athletes.12 13 They train year-round and uniquely compete regularly on the international stage in sports that often lack professional leagues and rely on highly variable resources and facilities, mostly dependent on winning medals.14 Unlike professional athletes, Olympians do not have access to large financial rewards. Although some Olympians work or study in addition to their intensive sports practice, they can devote more time to full-time sports practice compared with collegiate athletes. Competition calendars in Olympians differ from collegiate athletes, with periodic international competitions (eg, World Cups, World Championships) throughout the whole year rather than regular domestic competitions within a shorter season (eg, semester). Olympians outclass most collegiate athletes, and only the best collegiate athletes will have the chance to become Olympians and/or professionals.12 13 15 In Canada, a primary reason for limited SRC data in Olympic sports is that the Canadian Olympic and Paralympic Sports Institute (COPSI) network only adopted official guidelines in 2018 to standardise care for athletes’ SRC nationwide.16 17 The second reason could be the absence of a centralised medical structure and surveillance systems, identified as key factors contributing to the under-reporting and underdiagnosis of athletes with an SRC.18
Among the available evidence on the evolution of SRC management, a 2023 systematic review and meta-analysis in athletic populations including children, adolescents and adults indicated that a full return to sport (RTS) could take up to a month but is estimated to require 19.8 days on average (15.4 days in adults), as opposed to the initial expectation of approximately 10.0 days based on studies published prior to 2005.19 In comparison, studies focusing strictly on American collegiate athletes report median times to RTS of 16 days.9 20 21 Notably, a recent study of military cadets reported an even longer return to duty times of 29.4 days on average, attributed to poorer access to care and fewer incentives to return to play compared with elite sports.22 In addition, several modifiers have also been identified as influencing the time to RTS, such as the history of concussions, type of sport, sex, past medical problems (eg, preinjury modifiers), as well as the initial number of symptoms and their severity (eg, postinjury modifiers).20 22 The evidence regarding the potential influence of sex on the time to RTS has yielded mixed findings in this area.23–25 In fact, females are typically under-represented in SRC research, highlighting the need for additional studies that incorporate more balanced sample representation across sexes and control for known sources of bias.26 Interestingly, a recent Concussion Assessment, Research and Education Consortium study, which included a high representation of concussed female athletes (615 out of 1071 patients), revealed no meaningful differences in RTS between females and males (13.5 and 11.8 days, respectively).27 Importantly, findings in the sporting population suggested that earlier initiation of clinical care is linked to shorter recovery after concussion.5 28 However, these factors affecting the time to RTS require a more thorough investigation, especially among athletes engaged in Olympic sports who may or may not have equal access to prompt, high-quality care.
Therefore, the primary objective of this study was to provide descriptive statistics among athletes with SRC engaged in both Summer and Winter Olympic sport programmes over a quadrennial, and to assess the influence of recommended guidelines of the COPSI network and the fifth International Consensus Conference on Concussion in Sport on the duration of RTS performance.16 17 Building on available evidence, the international schedule constraints, variability in resources14 and high-performance expectation among this elite population,22 prolonged durations for RTS, compared with what is typically reported (eg, 16.0 or 15.4 days), were hypothesised in Olympians.3 19 The secondary objective was to more specifically evaluate the impact of access to multidisciplinary care and injury modifiers on the time to RTS. Based on current evidence,5 7 29 30 the hypothesis was formulated that athletes with earlier multidisciplinary access would experience a faster RTS. Regarding injury modifiers, it was expected that female and male athletes would show similar time to RTS despite presenting sex-specific characteristics of SRC.31 The history of concussions, the severity of initial symptoms and the number of specialist consults were expected to be positively correlated to the time to RTS.20 32
Methods
Participants
A total of 133 athletes (F=72; M=61; mean age±SD: 20.7±4.9 years old) who received medical care at the Institut national du sport du Québec, a COPSI training centre set up with a medical clinic, were included in this cohort study with retrospective analysis. They participated in 23 different Summer and Winter Olympic sports which were classified into six categories: team (soccer, water polo), middle distance/power (rowing, swimming), speed/strength (alpine skiing, para alpine skiing, short and long track speed skating), precision/skill-dependent (artistic swimming, diving, equestrian, figure skating, gymnastics, skateboard, synchronised skating, trampoline) and combat/weight-making (boxing, fencing, judo, para judo, karate, para taekwondo, wrestling) sports.13 This sample consists of two distinct groups: (1) early access group in which athletes had access to a medical integrated support team of multidisciplinary experts within 7 days following their SRC and (2) late access group composed of athletes who had access to a medical integrated support team of multidisciplinary experts eight or more days following their SRC.5 30 Inclusion criteria for the study were participation in a national or international-level sports programme13 and having sustained at least one SRC diagnosed by an authorised healthcare practitioner (eg, physician and/or physiotherapist).
Clinical context
The institute clinic provides multidisciplinary services for care of patients with SRC including a broad range of recommended tests for concussion monitoring (table 1). The typical pathway for the athletes consisted of an initial visit to either a sports medicine physician or their team sports therapist. A clinical diagnosis of SRC was then confirmed by a sports medicine physician, and referral for the required multidisciplinary assessments ensued based on the patient’s signs and symptoms. Rehabilitation progression was based on the evaluation of exercise tolerance,33 priority to return to cognitive tasks and additional targeted support based on clinical findings of a cervical, visual or vestibular nature.17 The expert team worked in an integrated manner with the athlete and their coaching staff for the rehabilitation phase, including regular round tables and ongoing communication.34 For some athletes, access to recommended care was fee based, without a priori agreements with a third party payer (eg, National Sports Federation).
Main evaluations performed to guide the return to sport following sport-related concussion
Data collection
Data were collected at the medical clinic using a standardised injury surveillance form based on International Olympic Committee guidelines.35 All injury characteristics were extracted from the central injury database between 1 July 2018 and 31 July 2022. This period corresponds to a Winter Olympic sports quadrennial but also covers 3 years for Summer Olympic sports due to the postponing of the Tokyo 2020 Olympic Games. Therefore, the observation period includes a typical volume of competitions across sports and minimises differences in exposure based on major sports competition schedules. The information extracted from the database included: participant ID, sex, date of birth, sport, date of injury, type of injury, date of their visit at the clinic, clearance date of unrestricted RTS (eg, defined as step 6 of the RTS strategy with a return to normal gameplay including competitions), the number and type of specialist consults, mechanism of injury (eg, fall, hit), environment where the injury took place (eg, training, competition), history of concussions, history of modifiers (eg, previous head injury, migraines, learning disability, attention deficit disorder or attention deficit/hyperactivity disorder, depression, anxiety, psychotic disorder), as well as the number of symptoms and the total severity score from the first Sport Concussion Assessment Tool 5 (SCAT5) assessment following SRC.17
Analysis
Following a Shapiro-Wilk test, medians, IQR and non-parametric tests were used for the analyses because of the absence of normal distributions for all the variables in the dataset (all p<0.001). The skewness was introduced by the presence of individuals that required lengthy recovery periods. One participant was removed from the analysis because their time to consult with the multidisciplinary team was extremely delayed (>1 year).
Descriptive statistics were used to describe the participant’s demographics, SRC characteristics and risk factors in the total sample. Estimated incidences of SRC were also reported for seven resident sports at the institute for which it was possible to quantify a detailed estimate of training volume based on the annual number of training and competition hours as well as the number of athletes in each sport.
To assess if access to multidisciplinary care modified the time to RTS, we compared time to RTS between early and late access groups using a method based on median differences described elsewhere.36 Wilcoxon rank sum tests were also performed to make between-group comparisons on single variables of age, time to first consult, the number of specialists consulted and medical visits. Fisher’s exact tests were used to compare count data between groups on variables of sex, history of concussion, time since the previous concussion, presence of injury modifiers, environment and mechanism of injury. Bonferroni corrections were applied for multiple comparisons in case of meaningful differences.
To assess if injury modifiers modified time to RTS in the total sample, we compared time to RTS between sexes, history of concussions, time since previous concussion or other injury modifiers using a method based on median differences described elsewhere.36 Kaplan-Meier curves were drawn to illustrate time to RTS differences between sexes (origin and start time: date of injury; end time: clearance date of unrestricted RTS). Trajectories were then assessed for statistical differences using Cox proportional hazards model. Wilcoxon rank sum tests were employed for comparing the total number of symptoms and severity scores on the SCAT5. The association of multilevel variables on return to play duration was evaluated in the total sample with Kruskal-Wallis rank tests for environment, mechanism of injury, history of concussions and time since previous concussion. For all subsequent analyses of correlations between SCAT5 results and secondary variables, only data obtained from SCAT5 assessments within the acute phase of injury (≤72 hours) were considered (n=65 SRC episodes in the early access group).37 Spearman rank correlations were estimated between RTS duration, history of concussions, number of specialist consults and total number of SCAT5 symptoms or total symptom severity. All statistical tests were performed using RStudio (R V.4.1.0, The R Foundation for Statistical Computing). The significance level was set to p<0.05.
Equity, diversity and inclusion statement
The study population is representative of the Canadian athletic population in terms of age, gender, demographics and includes a balanced representation of female and male athletes. The study team consists of investigators from different disciplines and countries, but with a predominantly white composition and under-representation of other ethnic groups. Our study population encompasses data from the Institut national du sport du Québec, covering individuals of all genders, ethnicities and geographical regions across Canada.
Patient and public involvement
The patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.
Results
Sample characteristics
During the 4-year period covered by this retrospective chart review, a total of 160 SRC episodes were recorded in 132 athletes with a median (IQR) age of 19.1 (17.8–22.2) years old (table 2). 13 female and 10 male athletes had multiple SRC episodes during this time. The sample had a relatively balanced number of females (53.8%) and males (46.2%) with SRC included. 60% of the sample reported a history of concussion, with 35.0% reporting having experienced more than two episodes. However, most of these concussions had occurred more than 1 year before the SRC for which they were being treated. Within this sample, 33.1% of participants reported a history of injury modifiers. Importantly, the median (IQR) time to first clinic consult was 10.0 (1.0–20.0) days and the median (IQR) time to RTS was 34.0 (21.0–63.0) days in this sample (table 3). The majority of SRCs occurred during training (56.3%) rather than competition (33.1%) and were mainly due to a fall (63.7%) or a hit (31.3%). The median (IQR) number of follow-up consultations and specialists consulted after the SRC were, respectively, 9 (5.0–14.3) and 3 (2.0–4.0).
Participants demographics
Sport-related concussion characteristics
Among seven sports of the total sample (n=89 SRC), the estimated incidence of athletes with SRC was highest in short-track speed skating (0.47/1000 hours; 95% CI 0.3 to 0.6), and lower in boxing, trampoline, water polo, judo, artistic swimming, and diving (0.24 (95% CI 0.0 to 0.5), 0.16 (95% CI 0.0 to 0.5), 0.13 (95% CI 0.1 to 0.2), 0.11 (95% CI 0.1 to 0.2), 0.09 (95% CI 0.0 to 0.2) and 0.06 (95% CI 0.0 to 0.1)/1000, respectively (online supplemental material). Furthermore, most athletes sustained an SRC in training (66.5%; 95% CI 41.0 to 92.0) rather than competition (26.0%; 95% CI 0.0 to 55.0) except for judo athletes (20.0% (95% CI 4.1 to 62.0) and 80.0% (95% CI 38.0 to 96.0), respectively). Falls were the most common injury mechanism in speed skating, trampoline and judo while hits were the most common injury mechanism in boxing, water polo, artistic swimming and diving.
Supplemental material
Access to care
The median difference in time to RTS was 19 days (95% CI 9.3 to 28.7; p<0.001) between the early (26 (IQR 17.0–38.5) days) and late (45 (IQR 27.5–84.5) days) access groups (table 3; figure 1). Importantly, the distribution of SRC environments was different between both groups (p=0.008). The post hoc analysis demonstrated a meaningful difference in the distribution of SRC in training and competition environments between groups (p=0.029) but not for the other comparisons. There was a meaningful difference between the groups in time to first consult (p<0.001; 95% CI −23.0 to −15.0), but no meaningful differences between groups in median age (p=0.176; 95% CI −0.3 to 1.6), sex distribution (p=0.341; 95% CI 0.7 to 2.8), concussion history (p=0.210), time since last concussion (p=0.866), mechanisms of SRC (p=0.412), the presence of modifiers (p=0.313; 95% CI 0.3 to 1.4) and the number of consulted specialists (p=0.368; 95% CI −5.4 to 1.0) or medical visits (p=0.162; 95% CI −1.0 to 3.0).
Time to return to sport following sport-related concussion as a function of group’s access to care and sex. Outliers: below=Q1−1.5×IQR; above=Q3+1.5×IQR.
Modifiers
Sex
The median difference in time to RTS was 6.5 days (95% CI −19.3 to 5.3; p=0.263; figure 1) between female (37.5 (IQR 22.0–65.3) days) and male (31.0 (IQR 20.0–48.0) days) athletes. Survival analyses highlighted an increased hazard of longer recovery trajectory in female compared with male athletes (HR 1.4; 95% CI 1.4 to 0.7; p=0.052; figure 2A), which was mainly driven by the late (HR 1.8; 95% CI 1.8 to 0.6; p=0.019; figure 2C) rather than the early (HR 1.1; 95% CI 1.1 to 0.9; p=0.700; figure 2B) access group. Interestingly, a greater number of female athletes (n=15) required longer than 100 days for RTS as opposed to the male athletes (n=6). There were no meaningful differences between sexes for the total number of symptoms recorded on the SCAT5 (p=0.539; 95% CI −1.0 to 2.0) nor the total symptoms total severity score (p=0.989; 95% CI −5.0 to 5.0).
Time analysis of sex differences in the time to return to sport following sport-related concussion in the (A) total sample, as well as (B) early, and (C) late groups using survival curves with 95% confidence bands and tables of time-specific number of patients at risk (censoring proportion: 0%).
History of modifiers
SRC modifiers are presented in table 2, and their influence on RTP is shown in table 4. The median difference in time to RTS was 1.5 days (95% CI −10.6 to 13.6; p=0.807) between athletes with none and one episode of previous concussion, was 3.5 days (95% CI −13.9 to 19.9; p=0.728) between athletes with none and two or more episodes of previous concussion, and was 2 days (95% CI −12.4 to 15.4; p=0.832) between athletes with one and two or more episodes of previous concussion. The history of concussions (none, one, two or more) had no meaningful impact on the time to RTS (p=0.471). The median difference in time to RTS was 4.5 days (95% CI −21.0 to 30.0; p=0.729) between athletes with none and one episode of concussion in the previous year, was 2 days (95% CI −10.0 to 14.0; p=0.744) between athletes with none and one episode of concussion more than 1 year ago, and was 2.5 days (95% CI −27.7 to 22.7; p=0.846) between athletes with an episode of concussion in the previous year and more than 1 year ago. Time since the most recent concussion did not change the time to RTS (p=0.740). The longest time to RTS was observed in the late access group in which athletes had a concussion in the previous year, with a very large spread of durations (65.0 (IQR 33.0–116.5) days). The median difference in time to RTS was 3 days (95% CI −13.1 to 7.1; p=0.561) between athletes with and without other injury modifiers. The history of other injury modifiers had no meaningful influence on the time to RTS (95% CI −6.0 to 11.0; p=0.579).
Preinjury modifiers of time to return to sport following SRC
SCAT5 symptoms and severity scores
Positive associations were observed between the time to RTS and the number of initial symptoms (r=0.3; p=0.010; 95% CI 0.1 to 0.5) or initial severity score (r=0.3; p=0.008; 95% CI 0.1 to 0.5) from the SCAT5. The associations were not meaningful between the number of specialist consultations and the initial number of symptoms (r=−0.1; p=0.633; 95% CI −0.3 to 0.2) or initial severity score (r=−0.1; p=0.432; 95% CI −0.3 to 0.2). Anecdotally, most reported symptoms following SRC were ‘headache’ (86.2%) and ‘pressure in the head’ (80.0%), followed by ‘fatigue’ (72.3%), ‘neck pain’ (70.8%) and ‘not feeling right’ (67.7%; online supplemental material).
Discussion
This study is the first to report descriptive data on athletes with SRC collected across several sports during an Olympic quadrennial, including athletes who received the most recent evidence-based care at the time of data collection. Primarily, results indicate that the time to RTS in athletes engaged in Summer and Winter Olympic sports may require a median (IQR) of 34.0 (21.0–63.0) days. Importantly, findings demonstrated that athletes with earlier (≤7 days) access to multidisciplinary concussion care showed faster RTS compared with those with late access. Time to RTS exhibited large variability where sex had a meaningful influence on the recovery pathway in the late access group. Initial symptoms, but not history of concussion, were correlated with prognosis in this sample. The main reported symptoms were consistent with previous studies.38 39
Time to RTS in Olympic sports
This study provides descriptive data on the impact of SRC monitoring programmes on recovery in elite athletes engaged in Olympic sports. As hypothesised, the median time to RTS found in this study (eg, 34.0 days) was about three times longer than those found in reports from before 2005, and 2 weeks longer than the typical median values (eg, 19.8 days) recently reported in athletic levels including youth (high heterogeneity, I2=99.3%).19 These durations were also twice as long as the median unrestricted time to RTS observed among American collegiate athletes, which averages around 16 days.9 20 21 However, they were more closely aligned with findings from collegiate athletes with slow recovery (eg, 34.7 days) and evidence from military cadets with poor access where return to duty duration was 29.4 days.8 22 Several reasons could explain such extended time to RTS, but the most likely seems to be related to the diversity in access among these sports to multidisciplinary services (eg, 10.0 median days (1–20)), well beyond the delays experienced by collegiate athletes, for example (eg, 0.0 median days (0–2)).40 In the total sample, the delays to first consult with the multidisciplinary clinic were notably mediated by the group with late access, whose athletes had more SRC during international competition. One of the issues for athletes engaged in Olympic sports is that they travel abroad year-round for competitions, in contrast with collegiate athletes who compete domestically. These circumstances likely make access to quality care very variable and make the follow-up of care less centralised. Also, access to resources among these sports is highly variable (eg, medal-dependant),14 and at the discretion of the sport’s leadership (eg, sport federation), who may decide to prioritise more or fewer resources to concussion management considering the relatively low incidence of this injury. Another explanation for the longer recovery times in these athletes could be the lack of financial incentives to return to play faster, which are less prevalent among Olympic sports compared with professionals. However, the stakes of performance and return to play are still very high among these athletes.
Additionally, it is plausible that studies vary their outcome with shifting operational definitions such as resolution of symptoms, return to activities, graduated return to play or unrestricted RTS.19 40 It is understood that resolution of symptoms may occur much earlier than return to preinjury performance levels. Finally, an aspect that has been little studied to date is the influence of the sport’s demands on the RTS. For example, acrobatic sports requiring precision/technical skills such as figure skating, trampoline and diving, which involve high visuospatial and vestibular demands,41 might require more time to recover or elicit symptoms for longer times. Anecdotally, athletes who experienced a long time to RTS (>100 days) were mostly from precision/skill-dependent sports in this sample. The sports demand should be further considered as an injury modifier. More epidemiological reports that consider the latest guidelines are therefore necessary to gain a better understanding of the true time to RTS and impact following SRC in Olympians.
Supporting early multidisciplinary access to care
In this study, athletes who obtained early access to multidisciplinary care after SRC recovered faster than those with late access to multidisciplinary care. This result aligns with findings showing that delayed access to a healthcare practitioner delays recovery,19 including previous evidence in a sample of patients from a sports medicine clinic (ages 12–22), indicating that the group with a delayed first clinical visit (eg, 8–20 days) was associated with a 5.8 times increased likelihood of a recovery longer than 30 days.5 Prompt multidisciplinary approach for patients with SRC is suggested to yield greater effectiveness over usual care,3 6 17 which is currently evaluated under randomised controlled trial.42 Notably, early physical exercise and prescribed exercise (eg, 48 hours postinjury) are effective in improving recovery compared with strict rest or stretching.43 44 In fact, preclinical and clinical studies have shown that exercise has the potential to improve neurotransmission, neuroplasticity and cerebral blood flow which supports that the physically trained brain enhanced recovery.45 46 Prompt access to specialised healthcare professionals can be challenging in some contexts (eg, during international travel), and the cost of accessing medical care privately may prove further prohibitive. This barrier to recovery should be a priority for stakeholders in Olympic sports and given more consideration by health authorities.
Estimated incidences and implications
The estimated incidences of SRC were in the lower range compared with what is reported in other elite sport populations.1 2 However, the burden of injury remained high for these sports, and the financial resources as well as expertise required to facilitate athletes’ rehabilitation was considerable (median number of consultations: 9.0). Notably, the current standard of public healthcare in Canada does not subsidise the level of support recommended following SRC as first-line care, and the financial subsidisation of this recommended care within each federation is highly dependent on the available funding, varying significantly between sports.14 Therefore, the ongoing efforts to improve education, prevention and early recognition, modification of rules to make the environments safer and multidisciplinary care access for athletes remain crucial.7
Strength and limitations
This unique study provides multisport characteristics following the evolution of concussion guidelines in Summer and Winter Olympic sports in North America. Notably, it features a balance between the number of female and male athletes, allowing the analysis of sex differences.23 26 In a previous review of 171 studies informing consensus statements, samples were mostly composed of more than 80% of male participants, and more than 40% of these studies did not include female participants at all.26 This study also included multiple non-traditional sports typically not encompassed in SRC research, feature previously identified as a key requirement of future epidemiological research.47
However, it must be acknowledged that potential confounding factors could influence the results. For example, the number of SRC detected during the study period does not account for potentially unreported concussions. Nevertheless, this figure should be minimal because these athletes are supervised both in training and in competition by medical staff. Next, the sport types were heterogeneous, with inconsistent risk for head impacts or inconsistent sport demand which might have an influence on recovery. Furthermore, the number of participants or sex in each sport was not evenly distributed, with short-track speed skaters representing a large portion of the overall sample (32.5%), for example. Additionally, the number of participants with specific modifiers was too small in the current sample to conclude whether the presence of precise characteristics (eg, history of concussion) impacted the time to RTS. Also, the group with late access was more likely to consist of athletes who sought specialised care for persistent symptoms. These complex cases are often expected to require additional time to recover.48 Furthermore, athletes in the late group may have sought support outside of the institute medical clinic, without a coordinated multidisciplinary approach. Therefore, the estimation of clinical consultations was tentative for this group and may represent a potential confounding factor in this study.
Conclusion
This is the first study to provide evidence of the prevalence of athletes with SRC and modifiers of recovery in both female and male elite-level athletes across a variety of Summer and Winter Olympic sports. There was a high variability in access to care in this group, and the median (IQR) time to RTS following SRC was 34.0 (21.0–63.0) days. Athletes with earlier access to multidisciplinary care took nearly half the time to RTS compared with those with late access. Sex had a meaningful influence on the recovery pathway in the late access group. Initial symptom number and severity score but not history of concussion were meaningful modifiers of recovery. Injury surveillance programmes targeting national sport organisations should be prioritised to help evaluate the efficacy of recommended injury monitoring programmes and to help athletes engaged in Olympic sports who travel a lot internationally have better access to care.35 49
Data availability statement
Data are available on reasonable request. Due to the confidential nature of the dataset, it will be shared through a controlled access repository and made available on specific and reasonable requests.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the ethics board of Université de Montréal (certificate #2023-4052). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank the members of the concussion interdisciplinary clinic of the Institut national du sport du Québec for collecting the data and for their unconditional support to the athletes.
References
Supplementary materials
Supplementary Data
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Footnotes
X @ThomasRomeas
Correction notice This article has been corrected since it published Online First. The ORCID details have been added for Dr Croteau.
Contributors TR, FC and SL were involved in planning, conducting and reporting the work. François Bieuzen and Magdalena Wojtowicz critically reviewed the manuscript. TR is guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.