Highly Anticipated Concussion Consensus Statement Released

Types : Alerts

By: Dylan F. Henry, Esq., Kimberly L. Sachs, Esq., and Tara Hessenthaler, J.D. Candidate

The Game Plan

• Review the Amsterdam 2022 Statement and updated assessment tools;
• Update existing concussion management policies accordingly;
• Conduct training on the revised concussion management policies across the board (not just for medical professionals, but everyone involved with the athletes);
• Monitor advancements in the science and research on concussion;
• Rinse; repeat.

Background

On June 15, 2023, the Concussion in Sport Group (“CISG” or the “Group”)—an international group of scientists and medical professionals devoted to creating the preeminent authority on sport-related concussion through research on concussion and brain health—published the latest consensus statement on sport-related concussion (“SRC”). This consensus statement stems from the sixth International Conference on Concussion in Sport, held in Amsterdam in October 2022 (the “Amsterdam 2022 Statement”) and updates the fifth consensus statement from Berlin 2016. Each consensus statement summarizes the most recent evidence informed principles of concussion prevention, assessment, and management to set forth a gold standard of care for concussion in athletics. The Amsterdam 2022 Statement focuses on new scientific evidence that offers enhanced guidance for best treatment practices of SRCs while introducing new concussion assessment tools for athletes spanning all age groups.

This alert addresses some of the more significant changes and updates from the Berlin 2016 Statement.

Retire and Refine

Previous consensus statements referred to the “11 Rs’ of SRC” to provide a logical flow of clinical concussion management and considerations: recognize, reduce, remove, refer, re-evaluate, rest, rehabilitate, recover, return-to-learn/return-to-sport, reconsider, and residual effects. The Amsterdam 2022 Statement added two additional “Rs” to its analysis: retire and refine. Retire addresses issues related to the discontinued participation in contact or collision sports. The Group suggests an individualized approach to a retirement decision that involves a multidisciplinary team that considers patient-, injury-, sport-specific and other sociocultural factors in reaching an athlete’s decision to retire from contact sports due to concussion. Refine highlights the need to embrace ongoing research strategies to advance and strengthen consensus in the SRC field. The Group requests refined studies that include para sport and pediatric SRCs to strengthen the consensus process as a whole.

Updated And New Assessment Tools (SCAT6; CRT6; SCOAT6)

The most notable change for athletic trainers, sideline healthcare professionals, clinicians, and even lay persons involved in contact sports (e.g., coaches and staff) is the introduction of the updated pocket concussion assessment tools: the Sport Concussion Assessment Tool for medical professionals (SCAT6, Child SCAT6); and the Concussion Recognition Tool for non-medical professionals (CRT6).

The Group also released a new Sport Concussion Office Assessment Tool (SCOAT6 and Child SCOTA6) to be used by clinicians in an office setting after the acute period of an injury (e.g., after seven days).

These standardized assessment tools were designed to help lay persons identify and immediately manage a suspected concussion, and to help practitioners further identify, evaluate, and manage concussions.

The Group identified limitations in some of the specific tests in the SCAT5, such as the word lists and unequal difficulty levels across different forms of the assessment. While the SCAT6 and Child SCAT6 still require validation, the Group recommends utilizing longer word lists to assess factors in the brain that cannot be directly measure or observed, creating an average cognitive score to improve test-retest reliability and reduce false positives, adding timed cognitive tasks that involve executive functions to measure cognitive impairment, and implementing procedures to assess the performance validity of baseline testing. For sideline healthcare professionals to remain compliant with the duty of care that they owe to athletes, they will need to move towards implementation of the SCAT6 assessment and ensure they are conducting adequate evaluations. For example, the SCAT6 clearly states that it cannot be conducted in less than 10 to 15 minutes.

Active Rest

The advice that most directly contradicts prevailing guidance with SRCs is in the realm of rest. Previous consensus reports suggested that athletes who suffer a mild concussion should completely rest for one to two days, or until they become symptom free. The Berlin 2016 statement suggested a brief period of relative physical and cognitive rest for the initial twenty-four to forty-eight hours after injury. However, the Group in Berlin admitted that the exact amount and duration of rest was not well-defined and required further research.

The Amsterdam 2022 Statement capitalized on this requested research and stated that the most recent evidence shows that recommending strict rest until the complete resolution of concussion-related symptoms is not beneficial following SRCs. Clinicians are recommended to encourage early return to light-intensity physical activity, such as walking and activities of daily living, within the first two days after injury. Such physical activity can be continued and advanced so long as there is no more than a mild increase and brief (< 1 hour) exacerbation of the athlete’s concussion-related symptoms. Prescribed aerobic exercise, at an intensity level that does not increase an athlete’s symptoms, within two to ten days of SRC, is shown to be effective in reducing the incidence of persisting symptoms after concussion and for facilitating recovery in athletes suffering from symptoms lasting longer than a month.

Return-to-Sport

The six-step “graduated return to sport” (“RTS”) model is familiar to any athlete or clinician that has experience with SRC. However, the Amsterdam 2022 Statement advances an individualized, sport specific model, which was absent from the Berlin 2016 Statement. The Group notes that the nature of the sport or activity to which an athlete is returning should play a lead role in the RTS process, and thus Step Three calls for “individual sport-specific exercise.” While this does not include activities that put an athlete at risk of head impact, CISG suggests that athletes should engage in sport-specific training, such as running, change of direction, or training drills, away from a team environment. The Group emphasizes that the time frame for RTS may vary based on the individual characteristics of an athlete and the risk of head impact in the sport, necessitating an individualized approach to clinical management.

CTE

While chronic traumatic encephalopathy (“CTE”) has been at the forefront of discussions in professional sport leagues from football to soccer to rugby to hockey, the Group for the first time briefly addresses what we know, and more importantly, what we do not know about CTE. The prevalence of CTE in former athletes is not yet known. CISG warns that the studies conducted into CTE prevalence in former athletes are not cohort studies that examine causation or quantify risk. Questions remain as to whether CTE causes specific neurological or psychiatric problems, the extent to which CTE can be clearly identified within the presence of Alzheimer’s neuropathology, and whether CTE is inevitably progressive. In short, the consensus of the international community is that we still do not know what causes CTE or what CTE causes.

Prevention

The Amsterdam 2022 Statement also discusses the research on concussion prevention, including limiting the frequency of full-contact practices, the use and effectiveness of certain personal protective equipment, and training strategies and exercises to potentially lower the rate of concussion.

Legal Standard of Care and Takeaways

Like all consensus statements before it, the Amsterdam 2022 Statement states that it is not intended to set a standard of care from a legal perspective. From a lawyer’s perspective, it can and does. Moving forward, this is the gold standard for concussion identification, treatment, management, and prevention.

In the wake of the Amsterdam 2022 Statement, healthcare professionals, coaches and staff, risk managers, athletic departments, and any individual or entity that deals with SRCs (and even non-sport related concussions to some extent) should update their concussion management policies and practices. This will provide greater individualized care that is specific to the sport and athlete.

Failing to implement this new gold standard of care not only deprives a patient from the most up-to-date treatment, but also exposes those in the field to liability.

Stay tuned for follow-up articles and alerts that address the nuanced changes in the Amsterdam 2022 Statement.