New recommendations were issued for athletes at all levels of participation who have had concussion or who are at risk of head trauma.
The recommendations were part of the latest Concussion in Sport Group (CISG) consensus statement and were based on outcomes from the sixth International Conference on Concussion in Sport, held in Amsterdam last October.
The statement was published in the British Journal of Sports Medicine, along with 10 systematic reviews, and builds on previous CISG statements, taking more than 5 years to complete.
The 2023 statement addressed updated concussion assessment tools, said co-author Jon Patricios, MD, of Wits University in Johannesburg, South Africa, in a press briefing.
“The new generation of concussion assessment tools … include the Concussion Recognition tool [CRT6], which is aimed at non-healthcare professionals — parents, coaches, etc. — on the side of the field, the SCAT6 or Sport Concussion Assessment Tool-6, and the child version of the SCAT6, which is specifically for [kids] ages 8 to 12,” Patricios said.
The statement also featured updated evidence-based strategies for returning to sports and school after concussion, early exercise and treatment recommendations, and approaches to prevention and targeted rehabilitation.
Prevention recommendations included rule changes to minimize collisions (such as disallowing body-checking in ice hockey), neuromuscular training for balance and strength, and mouth guards for ice hockey players of all ages. Mandatory removal from play after actual or suspected concussion and other protocols was also recommended.
Strict rest was not recommended after concussion, said co-author Kathryn Schneider, MD, of the University of Calgary in Canada. Evidence has shown that light-intensity physical activity — routine activities of daily living and aerobic exercise like walking — can help recovery, as can limiting screen time during the first 48 hours after injury, she added.
In addition, the new statement advised multidisciplinary team assessments for athletes whose symptoms last more than 4 weeks.
The statement examined later-in-life risks for former athletes, including mental health problems, cognitive impairment, and neurologic diseases. “Former amateur athletes do not appear to be at increased risk of cognitive impairment, neurological disorders, or neurodegenerative diseases compared to men from the general population,” noted co-author Grant Iverson, PhD, of Massachusetts General Hospital in Boston.
In contrast, studies “have found an association between being a professional athlete and increased risk for having a neurological or neurodegenerative disease listed on your death certificate,” Iverson pointed out. “This applies to both former American football players and former professional soccer players.”
The CISG statement did not establish whether head impacts and chronic traumatic encephalopathy (CTE) were linked. This was largely because there was not enough evidence, said co-author Robert Cantu, MD, of Boston University.
Many CTE studies are case series, which did not meet inclusion criteria for systematic review, Cantu observed. “We need well-designed, or at least much better designed, case-control and cohort studies that include, importantly, careful control of confounding variables,” he said.
The statement also did not address sex-based differences in concussion prevention and management. “In our systematic review that evaluated prevention strategies, only six out of 220 studies were focused on female athletes,” Schneider pointed out. “In most cases, the results did not evaluate differences between the sexes.”
This is an important consideration for the future, she noted.
Other evidence gaps included a lack of data about sports-related concussions in children ages 5 to 12 and concussion management in para sport athletes, the authors acknowledged.