Sport-Related Concussion

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Sport-related concussion can occur in any population playing sport. Accurate diagnosis, management, and return-to-sport decisions are essential at all levels of participation (i.e., amateur to professional) and for all types of sport. Concussion can be recognized in the community by all sport stakeholders including athletes, parents, coaches, officials, teachers, trainers, and licensed healthcare providers. However, a formal diagnosis should be made by a physician following a thorough medical assessment. Athletes with a sport-related concussion may require onsite (on-field) medical assessments by emergency medical professionals for a more severe head injury, cervical or spine injury, or loss of consciousness.

Sport-related concussions often present without neurological signs and can cause a variety of symptoms making the injury complex and potentially difficult to assess and manage. Due to rapidly changing clinical signs and symptoms in the acute phase, sport-related concussions are considered to be among the most complex injuries in sports medicine to diagnose, assess and manage.1 A concussion is more likely to occur when the force or impact suffered is not anticipated by the athlete. Concussions are more likely to occur in contact sports, with the highest incidences (excluding combat sports) being in soccer, football, ice hockey, rugby and basketball2,3.

Given that the current guideline is not specific to sport-related injuries, the information and guidance included herein for acute and subacute management is limited. Thus, readers interested in further guidance on the assessment and management of concussion in this specific patient population should consult the latest Consensus Statement on Concussion in Sport: the Fifth International Conference on Concussion in Sport held in Berlin, October 2016, the Concussion Management Guidelines for Certified Athletic Therapists in Quebec, or the Canadian Guideline on Concussion in Sport. Many sports organizations also formally provide specific guidance and recommendations that are unique to their sport and parallel the principles of existing guidelines; this information can provide further clarity and assistance when making decisions about how to proceed with progressive return to an activity/sport.

*This section will be updated soon to reflect the new Consensus Statement on Concussion in Sport: the Sixth International Conference on Concussion in Sport held in Amsterdam, October 2022. 

Introduction-only references:

  1. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med. 2017; 51:838-847
  2. Ianof JN, Freire FR, Calado VTG, et al. Sport-related concussions. Dementia & Neuropsychologia. 2014;8(1):14-19.
  3. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. British Journal of Sports Medicine. 2013;47:15-26.
Assessment and Management of Sport-Related Concussion
3.1

Patients with sport-related concussion may develop symptoms acutely or subacutely. If any one of the following signs/symptoms are observed/reported at any point following a blow to the head, or elsewhere on the body leading to impulsive forces transmitted to the head, concussion should be suspected and appropriate management instituted.

  1. Any period of loss of or decreased level of consciousness less than 30 min
  2. Any lack of memory for events immediately before or after the injury (post-traumatic amnesia) less than 24 hours
  3. Any alteration in mental state at the time of the injury (e.g., confusion, disorientation, slowed thinking, alteration of consciousness/mental state)
  4. Physical symptoms (e.g., vestibular, headache, weakness, loss of balance, change in vision, auditory sensitivity, dizziness) Note: No evidence of intracranial lesion on standard imaging (if present, it is suggestive of more severe brain injury)

Refer to Table A for a comprehensive list of signs for possible concussion.

*Note that this definition was adapted for the purposes of this guideline. For the definition of Concussion as defined by the 2017 Concussion in Sport please visit HERE.

Adapted from McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med 2017;51:838-847

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3.2

When a player shows any symptoms or signs of a Sport-Related Concussion (SRC):

  • The player should be medically evaluated by a physician or other licensed healthcare professional onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury. (A)
  • The appropriate disposition of the player must be determined by the treating healthcare professional in a timely manner. If no healthcare professional is available, the player should be safely removed from practice or play and urgent referral to a physician arranged. (C)
  • Once the first-aid issues are addressed, an assessment of the concussive injury should be made by a healthcare professional using a sideline assessment tool (e.g., SCAT5 - Appendix 3.2). Non-medical professionals should use the Sport Concussion Recognition Tool (Appendix 3.3). (C)
  • The player should not be left alone following the injury, and serial monitoring for increasing symptoms or signs of deterioration is essential over the initial few hours after injury with the aim of detecting an evolving injury. (C)
  • A player with suspected SRC should not be allowed to return-to-play on the day of injury. (C)

Taken from McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med 2017;51:838-847

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3.3

The need for early neuroimaging should be determined according to the Canadian CT Head Rule (Figure 1.1). For patients who fulfill these criteria, CT scanning is the most appropriate investigation for the exclusion of neurosurgically significant lesions, such as hemorrhage. Plain skull x-rays are not recommended.*

*NOT AN ORIGINAL RECOMMENDATION - REPEAT OF 1.3

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3.4

There is currently insufficient evidence that prescribing complete rest may ease discomfort during the acute recovery period by mitigating post-concussion symptoms and/or that rest may promote recovery by minimizing brain energy demands following concussion.

  • An initial period of rest in the acute symptomatic period following injury (24-48 hours) may be of benefit.
  • After a brief period of rest, a sensible approach involves the gradual return to school and social activities (prior to contact sports) as tolerated (i.e., in a manner that does not result in a significant or prolonged exacerbation of symptoms. See Table 12.2).

Adapted from McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med 2017;51:838-847

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3.5

Schools, teachers, family members, coaches and athletes should be educated on concussion risk factors/ risks.

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3.6

A range of "modifying" factors may influence the investigation and management of concussion and, in some cases, may predict the potential for prolonged or persistent symptoms. These modifiers would be important to consider in a detailed concussion history and should be managed in an interdisciplinary manner by healthcare professionals with experience in sport-related concussion (see Table 3.1).

Taken from McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med 2017;51:838-847

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3.7

Primary care providers should perform a clinical neurological assessment (including evaluation of mood, mental status/cognition, oculomotor function, gross sensorimotor, coordination, gait, vestibular function and balance) on all concussed athletes as part of their overall management (see Appendix 3.4).

Adapted from McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med 2017;51:838-847

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Return-to-Play
3.8

Return-to-play (RTP) protocol following a concussion follows a stepwise process as outlined in Table 3.2. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 hours so that an athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24- hour period of rest has passed.

Adapted from McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sport Medicine. 2013;47(5):250-8.

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3.9

If pharmacotherapy is used, then an important consideration in return-to-sport is that concussed athletes should not only be free from concussion-related symptoms, but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of SRC. When pharmacological therapy is begun during the management of an SRC, the decision to return-to-play while still on such medication must be considered carefully by the primary care provider.

Adapted from McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med 2017;51:838-847

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Appendix 3.1
Sport Concussion Assessment Tool (SCAT6)
 

EVALUATION

Title of Resource: SCAT6: Sport Concussion Assessment Tool – 6th Edition

Reference: Echemendia RJ, Burma JS, Bruce JM, et al. Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review. Br J Sports Med. 2023;57(11):722-735.

Description: SCAT6 is a standardized tool used to assess injured athletes for concussion and is suitable for athletes ages 13 and older. It is designed for use by medical professionals. 

The below information will be updated soon to reflect the SCAT6.

Resource Criteria:

Population
Athletes suspected for concussion, ages 13 and older

Reliability/ Validity

The utility and sensitivity of a 100-point scoring system for the SCAT2 has been questioned.1 

The SCAT2 items were obtained from published sources and agreed upon by a panel of experts, thus establishing the face validity of the instrument.2 The instrument has since been adopted by a number of organizations.

The reliability/validity of the new SCAT 5 cannot be found for adults. 

Proprietary?
No

Time to Administer

15 - 20 minutes

Method to Administer

Patient is evaluated by a medical professional using the tool. 

Formal Instructions (Mention if special environment/ equipment is needed)

See page 7 in the SCAT5 tool.
NB. The diagnosis of a concussion is a clinical judgment, ideally made by a medical professional. The SCAT5 should not be used solely to make, or exclude, the diagnosis of concussion in the absence of clinical judgment. An athlete may have a concussion even if their SCAT5 is “normal”.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5  Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

1 Guskiewicz KM, Register-Mihalik J, McCrory P, McCrea M, Johnston K, Makdissi M, et al. Evidence-based approach to revising the SCAT2: introducing the SCAT3. Br J Sports Med 2013;47:5 289-293. doi:10.1136/bjsports-2013-092225.

2 Alla S, Sullivan SJ, Hale L, McCrory P. Self-report scales/checklists for the measurement of concussion symptoms: a systematic review. Br J Sports Med 2009;43(Suppl I):i3–i12. doi:10.1136/bjsm.2009.058339.

Appendix 3.2
Concussion Recognition Tool 6
 

EVALUATION

Title of Resource: Pocket Concussion Recognition Tool (CRT)

Reference: Echemendia RJ, Ahmed OH, Bailey CM, et al. The Concussion Recognition Tool 6 (CRT6). Br J Sports Med. 2023;57(11):692-694.

The below information will be updated soon to reflect the CRT6.

Description: The Pocket CRT is an assessment tool designed for immediate use by either a responsible adult or a medical professional to determine if a concussion could potentially be present in an individual following impact. It allows for initial recognition of symptoms to better identify the need for further medical attention by qualified professionals. (Also, see SCAT5)

Resource Criteria:

Population
Athletes suspected for concussion, ages 13 and older

Reliability/ Validity

The utility and sensitivity of a 100-point scoring system for the SCAT2 has been questioned.1 

The SCAT2 items were obtained from published sources and agreed upon by a panel of experts, thus establishing the face validity of the instrument.2 The instrument has since been adopted by a number of organizations.

The reliability/validity of the new SCAT 5/Pocket CRT cannot be found for adults.

Proprietary?
No

Time to Administer

5 minutes

Method to Administer

Patient is evaluated by a responsible adult or a medical professional (if present) using the tool in order to determine whether a concussion could potentially be present. This is to be done immediately following impact. 

Formal Instructions (Mention if special environment/ equipment is needed)

If there is a possibility of concussion, the patient should receive further medical attention from a qualified health professional.

Abbreviated testing paradigms are designed for rapid concussion evaluation on the sidelines and are not meant to replace comprehensive neuropsychological testing which is sensitive to detect subtle deficits that may exist beyond the acute episode; nor should they be used as a stand alone tool for the ongoing management of sports concussions.

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5  Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

1 Guskiewicz KM, Register-Mihalik J, McCrory P, McCrea M, Johnston K, Makdissi M, et al. Evidence-based approach to revising the SCAT2: introducing the SCAT3. Br J Sports Med 2013;47:5 289-293. doi:10.1136/bjsports-2013-092225. 

2 Alla S, Sullivan SJ, Hale L, McCrory P. Self-report scales/checklists for the measurement of concussion symptoms: a systematic review. Br J Sports Med 2009;43(Suppl I):i3–i12. doi:10.1136/bjsm.2009.058339.

Appendix 3.3
Buffalo Concussion Treadmill Testing
appendix-3-3.pdf
Appendix 3.4
Important Components of a Neurological Exam
appendix-3-4.pdf
Figure 1.1
Canadian CT Head Rule
Table A
Common Symptoms of mTBI
Table 3.1
Concussion Modifiers
Table 3.2
Graduated Return-to-Sport Strategy
Table 12.2
Stepwise Approach to Return-to-Work Planning for Patients with Concussion/mTBI
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Sharp AL, Nagaraj G, Rippberger EJ, et al. Computed Tomography Use for Adults With Head Injury: Describing Likely Avoidable Emergency Department Imaging Based on the Canadian CT Head Rule. Acad Emerg Med. 2017;24(1):22-30.
Country: USA
Design: Observational Study
Quality Rating: DOWNS & BLACK: 15/32 *7 of the sections were not applicable

Nygren-de Boussard C, Holm LW, Cancelliere C, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S257-264.
Country: Sweden
Design: Systematic Review
Quality Rating: PRISMA: 17/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, Bauer RM. "Playing Through It": Delayed Reporting and Removal From Athletic Activity After Concussion Predicts Prolonged Recovery. J Athl Train. 2016;51(4):329-335.
Country: USA
Design: Cross-Sectional
Quality Rating: DOWNS & BLACK: 12/32 *7 of the sections were not applicable

Thesleff T, Kataja A, A-hman J, Luoto TM. Head injuries and the risk of concurrent cervical spine fractures. Acta Neurochir (Wien). 2017;159(5):907-914.
Country: Finland
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 16/32 *6 of the sections were not applicable

Kennedy E, Quinn D, Tumilty S, Chapple CM. Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis. Musculoskelet Sci Pract. 2017;29:91-98.
Country: New Zealand
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 16/32 *5 of the sections were not applicable

Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. J Head Trauma Rehabil. 2016;31(4):233-241.
Country: USA
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 15/32 *6 of the sections were not applicable

Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930-934.
Country: Canada
Design: Systematic Review
Quality Rating: PRISMA: 18/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable

Silverberg ND, Iverson GL. Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259.
Country: Canada
Design: Discussion/Review Article
Quality Rating: N/A *No checklists were appropriate to score this article design

Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions. Acad Emerg Med. 2017;24(1):75-82.
Country: Canada
Design: Randomized Control Trial
Quality Rating: PEDro: 8/11

Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed Physical Exertion in Recovery From Sports-Related Concussion: A Randomized Pilot Study. Dev Neuropsychol. 2015;40(5):273-278.
Country: USA
Design: Pilot Randomized Control Trial
Quality Rating: PEDro: 6/11

Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307.
Country: Canada
Design: Systematic Review
Quality Rating: PRISMA: 10/27 *Additional analyses were not undertaken (i.e., meta-analyses), so 5 of the items were not applicable