EVIDENCE BASE FOR SPORT
Sports Concussion and Head Trauma
Sport related concussion can affect athletes participating in many sports and at all levels, from grassroots to elite. In recent years, there has been increasing concern about the long term health impacts of concussion and the potential under-reporting of incidents, which may lead to athletes being undiagnosed, untreated, and potentially suffering greater long-term impacts on their health and wellbeing
This page aims to assist sports medicine professionals, athletes, parents, coaches, administrators and support personnel to understand and maintain awareness of relevant policies, guidelines, insights and emerging research in this area.
Resources, policies and guidelines
Australian policies and guidelines
Position statements/guidelines
- Concussion and Brain Health Position Statement 2023 Concussion in Sport Australia, (updated February 2023).
- Concussion in Sport: Australian Institute of Sport/Australian Medical Association Position Statement [infographic], @YLMSportScience , (5 February 2018).
Resources
- Concussion in Sport Australia [website]. An initiative of the Australian Institute of Sport, Australian Medical Association, Australasian College of Sport and Exercise Physicians, and Sports Medicine Australia. It brings together the most contemporary evidence-based information on concussion for athletes, parents, teachers, coaches and medical practitioners. It provides a valuable and trusted resource for the management of sports-related concussion for all Australians, regardless of the sport, location or level of participation.
Australian Sports Brain Bank, Established in 2018, as collaboration between the University of Sydney and Royal Prince Alfred (RPA) Hospital, the aim of the Sports Brain Bank is to define the spectrum of brain changes found in sportspeople who have had one or more episodes of concussion (mild traumatic brain injury or mTBI), by examination of brain tissue removed at autopsy. More information about the project, and about how to donate or support the organisation is available on the website.
Research
- Chronic traumatic encephalopathy (CTE) in a former Australian rules football player diagnosed with Alzheimer’s disease, Alan J. Pearce, Joanne Sy, Maggie Lee, et.al., Acta Neuropathologica Communications , Volume 8(article 23), (2020)
- Chronic traumatic encephalopathy (CTE) in two former Australian National Rugby League players, Michael E. Buckland, Joanne Sy, Istvan Szentmariay et.al., Acta Neuropathologica Communications, Volume 7(article 97), (2019).
Resources
- Chronic traumatic encephalopathy (CTE) seminar [videos], (December 2019). In December of 2019 the Australian Sports Brain Bank held a public seminar on CTE, featuring the leading international expert Dr Chris Nowinski. Other speakers included ASBB Director Dr Michael Buckland, and author, journalist and former Wallaby Peter FitzSimons.
Position statements/guidelines
Brain Injury Australia Policy Paper: Concussion in Sport, Rushworth N (Executive Officer, Brain Injury Australia), prepared for the Australian Government, Department of Families, Housing, Community Services and Indigenous Affairs, (October 2012). Much of the research into the potential cumulative, long-term effects of concussion derives from gridiron, a sport with greater concussion risk exposures than the three 'collision sports' which are the focus of this report; Australian Rules football, Rugby League and Rugby Union. Brain Injury Australia advocates the development of common “guidelines for the management of concussion…for adoption by all [football] codes”, as was recommended by Australia’s National Health and Medical Research Council in 1994. Brain Injury Australia also holds specific concerns about the increased vulnerability to concussion of the ‘special populations’ of females, children and adolescents, particularly among non-elite athletes. This report contains four major recommendations:
- That the Australian Football League, the Australian Rugby League Commission, and Australian Rugby Union co-fund an independent, large-scale, prospective study – comprising cohorts from all three sports – examining the risk factors for concussion, as well as the incidence, assessment, short and long-term effects, management and potential prevention strategies for child and adolescent players.
- That the three football codes co-fund an independent, large-scale, prospective study – comprising, and comparing, male and female cohorts from all three sports – to investigate whether gender is a “modifying factor” in the risks, incidence, short and long-term effects of, and recovery from, concussion.
- That the three football codes, in collaboration with Australia’s other major participation sports, develop and fund the dissemination of cross-sport concussion assessment and management guidelines.
- That the Australian Government, through the Sport and Recreation Ministers’ Council and the Standing Committee on Recreation and Sport, develop, implement and fund a national cross-sport education campaign in awareness and best practice assessment and management of concussion, suitable for sports administrators, coaches, trainers, players and the broader community.
Position statements/guidelines
- Concussion in Sport Policy, Sports Medicine Australia, (V1.0, January 2018). Developed with the support of the New South Wales Office of Sport these protocols are wide reaching and can be adapted to any type of sport at all levels with the key aim to ensure all players with a suspected concussion – in all sports and at all levels – receive timely and appropriate advice and care to safely return them to everyday activities and sport.
Resources
- Sports Medicine Australia [website], (accessed 3 November 2020). Concussion related information and resources.
- Concussion Webinar w/Andrew Gardner, Sports Medicine Australia, Vimeo, (2020).
International policies & guidelines
Position statements/guidelines
- Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: a consensus statement, Stanley Herring, W Ben Kibler, Margot Putukian, et.al., British Journal of Sports Medicine, (16 June 2021). This document provides an overview of selected medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.
- Concussion in para sport: the first position statement of the Concussion in Para Sport (CIPS) Group, Richard Weiler, Cheri Blauwet, David Clarke, et.al., British Journal of Sports Medicine, (April 2021). The aim of the Concussion in Para Sport (CIPS) group was to develop specific recommendations and guidance related to para athletes and their attending medical professionals in the event that a para athlete sustains a suspected concussion. The Concussion Recognition tool 5 (CRT5), SCAT5 and the CIS 2017 consensus statement lack any specific guidance focusing on the para athlete. Our analysis will focus on the SCAT5, which can be used by physicians and licensed healthcare professionals for athletes aged 13 years or older and encompasses immediate on field assessment and office based off-field assessment of suspected concussion.
- Implementation of the 2017 Berlin Concussion in Sport Group Consensus Statement in contact and collision sports: a joint position statement from 11 national and international sports organisations, Patricios JS, Ardern CL, Hislop MD, et al., British Journal of Sports Medicine, Volume 52(10), pp.635-641, (2018). This document summarises the approaches discussed by medical representatives from the governing bodies of 10 different contact and collision sports in Dublin, Ireland in July 2017. Those sports are: American football, Australian football, basketball, cricket, equestrian sports, football/soccer, ice hockey, rugby league, rugby union and skiing. This document had been endorsed by 11 sport governing bodies/national federations at the time of being published.
- Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016, McCrory P, Meeuwisse W, Dvorak J, et.al., British Journal of Sports Medicine, Volume 51(11), pp.838-847, (2017). The 2017 Concussion in Sport Group consensus statement is designed to build on the principles outlined in the previous statements and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement.
- Consensus Statement on concussion in sport – graduated return to play [infographic], @YLMSportScience/ BJSM (2017).
- Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012, McCrory P, et.al., British Journal of Sports Medicine, Volume 47, Issue 5, Special section, p1, (2013). This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play decisions remain in the realm of clinical judgement on an individualised basis.
Key organisations
- Glasgow Brain Injury Research Group (GBIRG). Our research describes the range of pathologies that occur in people exposed to varying severities of injury from repetitive mild TBI (e.g. after a career in football, rugby, or boxing) to single moderate or severe TBI (such as after an assault or car accident). Many of our current projects are directed towards understanding the link between TBI and increased risk of dementia, and the characteristics of the pathology of survival from TBI, known as chronic traumatic encephalopathy (CTE).
- Football’s InfluencE on Lifelong health and Dementia risk (FIELD). Given growing anxieties over perceived increased risk of dementia in former professional footballers, establishing robust data to inform on late neurodegenerative outcomes of participation in football is a priority to inform public health policy, and the sport. We have brought together a multidisciplinary collaboration of researchers and experts in traumatic brain injury, public health and sport to direct studies to investigate a wide range of physical and mental health outcomes, including neurodegenerative disease, in former footballers.
- VA-BU-CLF Brain Bank. The largest tissue repository in the world focused on traumatic brain injury (TBI) and CTE. The brain bank contains more than 600 brains, including over 325 brains that have been diagnosed with CTE using the recently defined NINDS criteria for the diagnosis of CTE. Dr. McKee and her team of neuropathologists and other investigators have published a large number of studies focused on CTE which are listed on the website along with further information about the purpose of the research.
Research
- Concussion Guidelines in National and International Professional and Elite Sports, Gavin A Davis, Michael Makdissi, Paul Bloomfield, et.al., Neurosurgery, Volume 87(2), pp.418-425, (August 2020). We aimed to examine (1) the implementation of, distribution and education based on the Berlin recommendations, and the development of sport-specific protocols/guidelines among professional and elite sports, (2) the implementation of guidelines at the community level, (3) translation of guidelines into different languages, and (4) research activities. Senior medical advisers and chief medical officers from Australian Football League, All Japan Judo Federation, British Horseracing Authority, Cricket Australia, Fédération Equestre Internationale, Football Association, Gaelic Athletic Association, International Boxing Association, Irish Horseracing Regulatory Board, Major League Baseball, National Football League, National Hockey League, National Rugby League, and World Rugby completed a questionnaire. We conclude that the Berlin recommendations have been included in concussion protocols/guidelines by all the sporting bodies, with consistency in the essential components of the recommendations, whilst also allowing for sport- and regional-specific variations. Education at the elite, community, and junior levels remains an ongoing challenge, and future iterations of guidelines may consider multiple language versions, and community- and junior-level guidelines.
- A review of concussion diagnosis and management in Australian professional sporting codes, Premkumar Gunasekaran, Christopher Hodge, Alan Pearce, et.al., The Physician and Sportsmedicine, Volume 48(1), pp.1-7, (2020). The purpose of this study was to explore the publicly available concussion guidelines of the major Australian sporting codes with an aim to identify potential opportunities to develop a national sporting consensus. Twelve sites were visited. There was consensus between many of the sporting organizations in terms of concussion definition, removal of play and sideline testing protocols. A step-wise return-to-play protocol was prevalent across most sports. A number of sporting sites however did not have readily available information.
- What HIRTS athletes? Establishing a unified public policy understanding of Head Impact-Related Trauma in Sport, Jason Chung and Amanda Zink, Journal of Public Health Policy, Volume 40, pp.393-409, (2019). The authors propose a ‘HIRTS framework’ to advance public policy pertaining to head impacts and their effects. Given the scientific ambiguities regarding the definition, diagnosis, and markers of concussion and resulting complications, we encourage international policymakers, clinicians, and public health officials to adopt the following working definitions and concomitant policy recommendations to safeguard athletes’ health and optimize tracking efforts, public education, funding, and government services.
Position statements/guidelines
- Sport-related concussion guidelines for Canadian national and national development high-performance athletes, Canadian Olympic and Paralympic Sport Institute Network, (2018). This document provides a guideline for National Sport Organizations (NSOs), National Development athletes / teams (i.e., NextGen), and in some provinces Provincial Sport Organizations (PSOs) regarding sport-related concussion in the Canadian Olympic and Paralympic Sport Institute (COPSI) Network.
- Canadian Guideline on Concussion in Sport, Parachute, (July 2017). The Canadian Guideline on Concussion in Sport has been developed to ensure that athletes with a suspected concussion receive timely and appropriate care, and proper management to allow them to return to their sport. Funded by the Public Health Agency of Canada, this Guideline is an important part of the Parachute-led Concussion Protocol Harmonization Project and creates the foundation for a more consistent approach to concussion across the country.
- Sport-related concussion: Evaluation and management, Laura K Purcell, Paediatrics and Child Health, Volume 19(3), pp.153-158, (March 2014). Everyone involved in child and youth sports must recognize the signs and symptoms of concussion, and ensure that any child or adolescent suspected of sustaining a concussion is properly evaluated and managed by qualified medical personnel. The present statement replaces a previous Canadian Paediatric Society position statement published in 2006 and revised in 2012.
Resources
- Canadian Concussion Collaborative (CCC). The Canadian Academy of Sport and Exercise Medicine has joined with health organisations to improve education about concussion and the implementation of best practices for the prevention and management of concussions. The CCC provides a number of concussion resources to help sport organisations and schools.
- Concussion Awareness, (accessed 30 June 2021). Coach Canada website containing information, stories and a quiz relating to concussion.
- Concussion Resources, SIRC, (accessed 30 June 2021). RECOGNIZE the signs and symptoms of concussion; REMOVE the athlete from the game or practice; REFER the athlete to a licensed healthcare professional; RETURN to school and then to sport based on the recommendations of a medical expert. We know which limits to push and which ones to respect. We won’t let a short-term injury become a long-term battle. Video and toolkit as well as FAQs.
- Innovative Strategies Making Concussion Safety the New Normal, Peter Morrow, SIRCuit, (25 March 2020). At the 2020 Canadian Sport for Life Summit, SIRC spoke to these changes and celebrated the success of Canada’s progress to address concussion in sport. Below are some of the presentation highlights.
- Concussion Management: best practices and lessons from the Canadian sport and recreation system, Peter Morrow, SIRC/Canadian Parks and Recreation Association (CPRA), YouTube, (4 March 2020).
Position statements/guidelines
- Sport Concussion in New Zealand: National Guidelines, ACC SportSmart, (accessed 30 June 2021). These guidelines, produced by ACC in consultation with a panel of medical, sport and research experts, is based on the 2016 Berlin Consensus Statement on Concussion in Sport. These guidelines are intended to help people such as medical doctors, health providers, first aiders, coaches, trainers, athletes, parents, sports administrators and school teachers. It is intended to formally review this document prior to February 2019.
Resources
- ACC SportSmart [website], (accessed 30 June 2021]. Developed by an expert panel of academics, clinicians, sports administrators and subject matter experts, ACC SportSmart is an injury prevention framework. It’s based on nine key principles to help you perform well and enjoy an active lifestyle. Specific concussion resources including guidebooks for coaches, concussion awareness posters, and policy templates available.
- Infographic. New Zealand Rugby’s concussion management pathway, Danielle Salmon, Janelle Romanchuk, Ian Murphy, et.al., British Journal of Sports Medicine, Volume 54(5), pp.298-299, (2020).
Research
- What they know and who they are telling: Concussion knowledge and disclosure behaviour in New Zealand adolescent rugby union players, Danielle M. Salmon, Jody Mcgowan, S. John Sullivan, et.al., Journal of Sport Sciences, Volume 38(4), pp.1585-1594, (2020). The purpose of this study was to survey high school rugby players from a range of ethnic, geographic and socioeconomic backgrounds in New Zealand (NZ) to gain an understanding of concussion knowledge, awareness of NZ Rugby’s (NZR) guidelines and attitudes towards reporting behaviours. Male and female high school rugby players (n= 416) from across NZ were surveyed. The findings indicated that 69% of players had sustained a suspected concussion, and 31% had received a medical diagnosis of concussion. 63% of players indicated they were aware of NZR’s guidelines. Māori and Pasifika players were less likely to be aware of the guidelines compared to NZ European. Guideline awareness was significantly higher for those from high decile schools when compared to low; however, when ethnicity and school locations were controlled for this became non-significant. The coach was the key individual for the provision of concussion information and disclosure of symptoms for players.
Resources
- Sports Concussion South Africa [website]. Concussion information, programs, resources, and research.
Position statements/guidelines
- Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement, Herring, Stanley; Kibler, W. Ben; Putukian, Margot, et.al., Sports Medicine Reports, Volume 20(8), pp.420-431, (August 2021). This document provides an overview of select medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC
- CDC Pediatric mTBI Guideline, (accessed 30 June 2021). The CDC Pediatric mTBI Guideline consists of 19 sets of clinical recommendations that cover diagnosis, prognosis, and management and treatment. These recommendations are for healthcare providers working in: inpatient, emergency, primary, and outpatient care settings.
- CDC Guideline on Mild Traumatic Brain Injury in Children: Important Practice Takeaways for Sports Medicine Providers, Kelly Sarmiento, Dana Waltzman, Angela Lumba-Brown, et.al., Clinical Journal of Sport Medicine, Volume 30(6), pp.612-615, (November 2020). The key practice takeaways for sports medicine providers focus on preseason evaluations, neuroimaging, symptom-based assessment, managing recovery, monitoring for persistent symptoms, and return to activity, including sport and school.
- Position Statement on Sports Concussion, American Academy of Neurology, (2020). The American Academy of Neurology (AAN), an association of neurologists and neuroscience professionals, is dedicated to providing the best possible care for patients with neurological disorders. The AAN advocates for policy measures that promote high quality, safe care of individuals participating in contact sports. Neurologists specialize in treating disorders of the brain and nervous system.
- Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines, Noah Silverberg, Mary Alexis Iaccarino, William J. Panenka, et.al., Archives of Physical Medicine and Rehabilitation, Volume 101(2), pp.382-393, (February 2020). This Special Communication synthesizes recent expert consensus statements and evidenced-based clinical practice guidelines for civilians, athletes, military, and pediatric populations for clinicians practicing outside of specialty mTBI clinics, including primary care providers. The article offers guidance on key clinical decisions in mTBI care and highlights priority interventions that can be initiated in primary care to prevent chronicity.
- American Medical Society for Sports Medicine position statement on concussion in sport, Harmon KG, Clugston JR, Dec K, et al., British Journal of Sports Medicine, Volume 53(4), pp. 213-225, (2019). The American Medical Society for Sports Medicine (AMSSM) formed a writing group to review the existing literature on SRC, update its previous position statement, and to address current evidence and knowledge gaps regarding SRC. This statement reviews the definition, pathophysiology and epidemiology of SRC, the diagnosis and management of both acute and persistent concussion symptoms, the short-term and long-term risks of SRC and repetitive head impact exposure, SRC prevention strategies, and potential future directions for SRC research. The AMSSM is committed to best clinical practices, evidence-based research and educational initiatives that positively impact the health and safety of athletes.
- Legal and ethical implications in the evaluation and management of sports-related concussion, Kirschen M, Tsou A, Nelson S, et.al., Neurology, Volume 83(4), (9 July 2014). This position paper of the American Academy of Neurology reviews and compares the components of sports-related concussion laws, including education, removal from play, and clearance for return to play. It highlights the challenges privacy laws present relevant to providing care to concussed athletes and suggests ways to help physicians overcome these obstacles. The report also explores the ethical considerations physicians should bear in mind as they evaluate and manage concussed athletes, addressing them through a framework that includes considerations of professionalism, informed decision-making, patient autonomy, beneficence, non-maleficence, conflicts of interest, and distributive justice.
- National Athletic Trainers’ Association Position Statement: Management of Sport Concussion, Broglio S, Cantu R, Gioia G, Guskiewicz K, Kutcher J, Palm M and McLeod T, Journal of Athletic Training, Volume 49(2), pp.245-265, (2014). This statement is an update to the association’s original 2004 concussion guidelines and addresses education, prevention, documentation and legal aspects, evaluation and return-to-play considerations. In particular, the authors amended the return-to-play guidelines and now recommend no return on the day the athlete is concussed.
- Pediatric sports specific return to play guidelines following concussion, May K, Marshall D, Burns T, Popoli D and Polikandriotis J, International Journal of Sports Physical Therapy, Volume 9(2), pp.242-255, (2014). In 2010 the American Academy of Pediatrics officially adopted the recommended return to play guidelines proposed by the International Conference on Concussion in Sport. Unfortunately, the guidelines fail to take into account the variability that occurs within different sports and the resulting challenges medical professionals face in making sure each athlete is able to withstand the rigors of their specific sport, without return of symptoms. This clinical commentary expands upon the current general consensus guidelines for treatment of concussed pediatric athletes and provides sport specific return to play guidelines.
Resources
- Concussion Legacy Foundation. Concussions can derail a life. The Concussion Legacy Foundation (CLF) believes we all have a responsibility to ensure athletes can reach their full potential on and off the field. We are committed to protecting athletes and families through research, policy, and education. Some key CLF programs are Safer Soccer and advocacy for Flag Football U14 (non-contact version of American Football).
- Flag Football Under 14: An Education Campaign for Parents, Chris Nowinski, and Robert Cantu, Concussion Legacy Foundation White Paper, (1 November 2019). One of the key concerns behind this white paper, and the Flag Football U14 campaign is that existing data suggests CTE risk is determined by a dose-response relationship. If CTE is the response, the dose is number of years played or thousands of hits to the head received. As of 2018, the best evidence suggests a football player’s risk of CTE is primarily determined by the number of years they play football. If an athlete reduces the number of years they participate in tackle football, they should significantly reduce their risk of developing CTE. The authors therefore recommend that until tackle football is proven safe for the developing brain, parents only enroll their children in flag and other non-tackle versions of football before age 14.
- Why Age 14? [infographic], Concussion Legacy Foundation, (2018). The Flag Football Under 14 campaign was launched in 2018 to educate parents that tackle football is an inappropriate activity for children under the age 14. Check out the infographic below to find out why waiting until age 14 matters.
- Heads Up. The Centers for Disease Control and Prevention (CDC) in the United States provides concussion and head trauma information for various user groups and organisations on its Heads Up page. Whether you are a parent, youth sports coach, high school coach, school professional, or health care provider, this site will help you recognise, respond to, and minimise the risk of concussion or other serious brain injury.
- HEADS UP Apps. The CDC Heads Up Concussion and Helmet Safety smart phone app will help you learn how to spot a possible concussion and what to do if you think your child or teen has a concussion or other serious brain injury. The application also includes a 3D helmet fit feature that teaches about proper helmet fit, safety and care. Rocket Blades: the brain safety game is a mobile game app on concussion safety for children aged 6 to 8.
- Patient Information: Sports-related head injury, Nitin Agarwal, Rut Thakkar, Khoi Than, American Association of Neurological Surgeons, (accessed 30 June 2021).
- Sports Concussion Resources, American Academy of Neurology, (accessed 30 June 2021). This page will help guide you in finding useful information to better understand, prevent, identify, diagnose, and treat a concussion.
Sport specific policies and guidelines
Position statements/guidelines
- The management of concussion in Australian Football: with specific provisions for children aged 5-17 years, Australian Football League, (April 2021).
- Statement: Guidelines for concussion management in community football, AFL, (27 April 2021). The AFL has released its guidelines for concussion management in community football and made two key appointments
- AFL statement on updated concussion guidelines, womens.afl, (28 January 2021). The AFL has on Thursday released its updated 2021 AFL/AFLW Concussion Guidelines, which will see players sidelined for at least 12 days if they suffer a concussion. The minimum 12-day return to play protocol is a substantive increase on the previous six days required under the 2020 guidelines. The Concussion Guidelines are reviewed on an annual basis and the current updated version has been prepared by the AFL’s Chief Medical Officer Peter Harcourt and Deputy Chief Medical Officer Michael Makdissi.
Resources
- AFL Community [website], (accessed 30 June 2021). Includes a variety of resources for community clubs and medical practitioners.
- 2017 AFL Concussion Symposium: Advances in Understanding and Management [video presentations], (accessed 30 June 2021).
Research
- An Investigation of Factors Associated With Head Impact Exposure in Professional Male and Female Australian Football Players, Jonathan Reyes, Biswadev Mitra, Andrew McIntosh, et.al, American Journal of Sports Medicine, Volume 48(6), pp.1485-1495, (May 2020). Exposure to head acceleration events (HAEs) has been associated with player sex, player position, and player experience in North American football, ice hockey, and lacrosse. Little is known of these factors in professional Australian football. Video analysis allows HAE verification and characterization of important determinants of injury. Playing situations in which players have limited control of the football are a common cause of impacts. Male players sustained a greater exposure to HAEs compared with female players. Female players, however, sustained higher exposure to HAEs than male players during certain skill executions, possibly reflecting differences in skill development. These findings can therefore inform match and skill development in the emerging professional women’s competition of Australian football.
- Concussion incidence and time-loss in Australian football: A systematic review, Claire McNeel, Gillian M. Clark, Charlotte B. Davies, et.al., Journal of Science and Medicine in Sport, Volume 23(2), pp.125-133, (February 2020). A systematic search of 14 databases using the terms ‘concussion’, and ‘Australian football’ (and variations) was used to obtain records that reported concussion incidence per 1000 players hours across age, sex, and level-of-play. Data were grouped based on how time-loss was applied to the concussion definition. Forty-two studies met inclusion criteria. Incidence rates based on a possible time-loss definition per 1000 player hours, ranged from 2.24 to 17.63 at the elite level, and 0.35 to 14.77 at the community/amateur level. Return-to-play details were reported by six studies and only two studies measured head-impacts in real-time. Several limitations were identified with this literature. First, insufficient return-to-play details precluded a meta-analysis of incidence rates. Second, no longitudinal studies across levels-of-play were found. Third, concussion incidence data for junior and female players were notably scarce.
Reading
- Coroner calls for brain research following former AFL player Danny Frawley's death, Emma Kemp, The Guardian, (23 February 2021). A Victorian coroner is calling for more research into the long-term effects of head knocks in sport, in a report detailing the extent of former AFL player Danny Frawley’s mental health decline in the years and days before the St Kilda great took his own life.
- AFL considering proposal for landmark multimillion-dollar concussion trust for players, Emma Kemp, The Guardian, (17 February 2021). The plan – if accepted by the league – would represent a watershed moment in the recognition and treatment of players suffering from the effects of head injuries.
Position statements/guidelines
- Basketball Concussion Management Guidelines, Dr Peter Harcourt, CMO, Basketball Australia, (19 September 2018).
- Basketball Concussion Management Guidelines, Dr Peter Harcourt in Medical Resource for Basketball Team Physicians, FIBA Medical Commission, pp.27-30, (November 2017).
- National Basketball Association Concussion Policy Summary – 2019-20 Season, National Basketball Association, (2019).
Position statements/guidelines
- Concussion Guidelines, Australian Canoeing, (5 January 2016).
Position statements/guidelines
- Concussion Guidelines, Muaythai Australia, (September 2019).
- Child and Cadet Head and Face Contact Policy, Australian Taekwondo, (12 April 2017). This policy is to ensure the safety of Child and Cadet Division athletes in relation to head and face contact in sparring competitions.
Position statements/guidelines
- Concussion and Head Trauma Policy, Australian Cricket, (31 July 2020).
- Community Cricket: Concussion and Head Trauma Guidelines, Australian Cricket, (December 2019).
- Concussion Management Guidelines, International Cricket Council, (December 2020).
Resources
- Helmet Recommendations, MyCricket Community, (accessed 1 July 2021). Cricket Australia strongly recommends that community associations take all practical steps to adopt the ICC directive and mandate that all junior and senior players wear British Standard 7928:2013 compliant helmets from 2019/20 season onwards when batting, wicket-keeping up to the stumps and fielding in close to the batter.
- Concussion, International Cricket Council medical, (accessed 1 July 2021). The ICC’s Medical Advisory Committee which was established in 2017, provides expert advice in sports medicine issues in international cricket. The four-member Committee which is chaired by Dr Peter Harcourt includes representation from different disciplines within sports medicine and from different cricketing regions.
Research
- Evaluation of CogSport for acute concussion diagnosis in cricket, Kira James, Anna Saw, Richard Saw, et.al., BMJ Open Sport and Exercise Medicine, Volume 7(2), (April 2021). This study demonstrated good clinical utility of CogSport for identifying concussed cricket players, particularly symptoms and Detection, Identification and One Back components. Therefore, CogSport may be considered a useful tool to assist concussion diagnosis in this cohort, and the clinician may place greater weight on the components associated with concussion diagnosis.
- Incidence of Concussion and Head Impacts in Australian Elite-Level Male and Female Cricketers After Head Impact Protocol Modifications, Thomas Hill, John Orchard, and Alex Kountouris Sports Health, Volume 11(20), pp.180-185, (March-April 2019). The rate of concussion in cricket is higher than previously appreciated; however, the majority of patients recovered quickly, and players generally did not miss much playing time as a result. The institution of concussion policies after head impact, including player substitution, appears to have had an effect on increasing reporting of symptoms, resulting in an increase in diagnosis of concussion.
Position statements/guidelines
- Concussion Policy, AusCycling, (July 2020).
- Harrogate Consensus Agreement: Cycling-specific sport related concussion, Jeroen Swart, Helge Reipenhof, Xavier Bigard, et.al., Union Cycliste Internationale (UCI), (2020). There is a pressing need for a specific cycling SRC protocol, especially for fast-paced disciplines of
cycling, such as road cycling. A consensus meeting on cycling SRC was convened to attempt to fill this gap and establish a SRC protocol for cycling. Our aim was to agree on standard terminology, definitions, diagnostic protocols and return-to-race (RTR) protocols for the various cycling disciplines. The intent of this work is to increase the recognition of and sensitivity of diagnosis of SRC within elite road cycling and other disciplines, and as a consequence, improve rider welfare.
Position statements/guidelines
- General Regulations, Article 140 - Protection of Athletes regarding Concussion Protocol, Equestrian Australia, (26 May 2021).
Resources
- Concussion training and resources, Equestrian Australia, (accessed 2 July 2021). Managing and reporting concussion for our Equestrian Sport is mandatory from 1st January 2021.
- National Concussion in Sport - Education and Training, Equestrian Australia, (February 2021).
Research
- Concussion knowledge, attitudes and behaviour in equestrian athletes, Alice Theadom, Duncan Reid, Natalie Hardaker, et.al., Journal of Science and Medicine in Sport, Volume 23(11), pp.1055-1061, (November 2020). The questionnaire was completed by 1486 participants (Mean age = 39.1 ± 15.4). Knowledge of what concussion was, how to recognise it and key symptoms (except poor sleep) was high (>80%). In contrast, awareness of guidelines was moderate (56%) and inability of helmets to prevent concussion was low (12%). Significantly higher levels of knowledge of concussion were identified in females compared with males (t=-6.55 p < 0.001, 95%CI=-3.26 to -1.75). The majority (87%) of participants reported that a helmet should be replaced after a fall, yet 46% reported re-using a helmet following a hit to the head.
- Proposed injury thresholds for concussion in equestrian sports, J. Michio Clark, Kevin Adanty, Andrew Post, et.al., Journal of Science and Medicine in Sport, Volume 23(3), pp.222-236, (March 2020). Twenty-five concussive and 25 non-concussive falls in equestrian sports were reconstructed using a combination of video analysis, computational and physical reconstruction methods. These represented male and female accidents from horse racing and the cross-country phase of eventing. The resulting thresholds for concussion [59 g, 2700 rad/s2, 28 rad/s, 0.24 (MPS), 6.6 kPa and 0.27 (CSMD10) for 50% risk] were consistent with those reported in the literature and represent a unique combination of head kinematic thresholds compared to other sports. Current equestrian helmet standards commonly use a threshold of 250 g and a linear drop to a steel anvil resulting in less than 15 ms impacts. This investigation found that concussive equestrian accidents occurred from oblique impacts to turf or sand with lower magnitude and longer duration impacts (<130 g and >20 ms). This suggests that current equestrian helmet standards may not adequately represent real-world concussive impact conditions and, consequently, there is an urgent need to assess the protective capacity of equestrian helmets under real-world conditions.
Position statements/guidelines
- Mild Traumatic Brain Injury (Concussion) Policy, Australian Flying Disc Association, (15 September 2018).
Position statements/guidelines
- FFA Concussion Guidelines, Football Federation Australia, (January 2018).
Resources
- FIFA Medical provides a course on concussion.
- Football Emergency Medicine Manual 2nd Edition, Kramer, E. and Dvorak, J., FIFA, (2018). Chapter 1.2 - Concussion.
- First aid manual and related healthcare issues for football: for use by first aiders and coaches, Hodgson, L. and Kramer, E., FIFA, (2015).
Research
- Association of Field Position and Career Length With Risk of Neurodegenerative Disease in Male Former Professional Soccer Players, Emma Russell, Daniel Mackay, Katy Stewart, et.al., JAMA Neurology, (2 August 2021). In this cohort study of 7676 Scottish male former professional soccer players and 23 028 general population control individuals matched by sex, year of birth, and area socioeconomic status, risk of neurodegenerative disease among former soccer players varied by field position and career length but was similar across era of participation. Risk of neurodegenerative disease was higher among former professional soccer players with longer careers and among those in nongoalkeeper positions, indicating that factors associated with nongoalkeeper positions should be scrutinized to mitigate risk; meanwhile, strategies to reduce head impact exposure may be advisable to reduce negative outcomes in this population.
- Football’s InfluencE on Lifelong health and Dementia risk (FIELD), Glasgow Brain Injury Research Group (GBIRG), (accessed 1 July 2021). Given growing anxieties over perceived increased risk of dementia in former professional footballers, establishing robust data to inform on late neurodegenerative outcomes of participation in football is a priority to inform public health policy, and the sport. We have brought together a multidisciplinary collaboration of researchers and experts in traumatic brain injury, public health and sport to direct studies to investigate a wide range of physical and mental health outcomes, including neurodegenerative disease, in former footballers.
- Reducing risk of head injury in youth soccer: An extension of behavioral skills training for heading, Laura M. Quintero James W. Moore M. Garrett Yeager, et.al., Journal of Applied Behavior Analysis , Volume 53(1), pp.237-248, (Winter 2020). There is currently limited research on an effective teaching method to improve safe heading technique. In the current study, Behavior Skills Training (BST) was evaluated as a method to teach correct heading techniques to youth soccer players. BST increased the percentage of correct steps for each player based on a task analysis of heading. Based on social validity questionnaires administered to players and the coach, BST was rated as an acceptable form of training. After the final training session, experienced coaches rated each player as having improved from baseline to training.
- Concussion in soccer: a comprehensive review of the literature, James Mooney , Mitchell Self, Karim ReFaey, et.al., Concussion, Volume 5(3), (June 2020). Here, we review articles examining the epidemiology, injury mechanisms, sex differences, as well as the neurochemical, neurostructural and neurocognitive changes associated with soccer-related concussion. From 436 titles and abstracts, 121 full texts were reviewed with a total of 64 articles identified for inclusion. Concussion rates are higher during competitions and in female athletes with purposeful heading rarely resulting in concussion. Given a lack of high-level studies examining sports-related concussion in soccer, clinicians and scientists must focus research efforts on large-scale data gathering and development of improved technologies to better detect and understand concussion.
- Management of concussion in soccer, Vanessa Hubertus, Niklas Marklund and Peter Vajkoczy, Acta Neurochirurgica, Volume 161, pp.425–433, (2019). Reviews the relevance of sport-related concussion for soccer as well as its diagnosis and management. Finally, we provide insight into future directions for research in this field.
Reading
- Soccer balls should have health warning: dementia expert, Michael Lynch, The Age, (3 August 2021). An Australian manufacturer of “safe” soccer balls designed to take the risk out of heading and a leading sports injury researcher who has worked for national and international bodies Football Australia and UEFA have both backed calls to put health warnings on soccer balls.
Position statements/guidelines
- Concussion Policy, Gridiron Australia, (11 August 2019).
Position statements/guidelines
- Motorsport Australia Concussion Management Guidelines, Motorsport Australia, (February 2020).
Research
- Concussion in motorsport? Experience, knowledge, attitudes and priorities of medical personnel and drivers, Stephanie Adams, Anthony Turner, Hugh Richards, Clinical Journal of Sport Medicine, Volume 30(6), pp.568-577, (November 2020). Thirty-one percent of surveyed drivers (age = 37.91 ± 13.49 years: 89% male) reported suffering from concussion in motorsport. Eighty-seven percent of surveyed medical personnel (age = 48.60 91 ± 10.68 years: 74% male) reported experience with concussed drivers and 34% reported feeling pressured to clear a driver with concussion. Gaps in knowledge and misperceptions about concussion were reported in both groups, and disparity between concussion attitudes emerged between drivers and medical personnel. Application of assessment and management procedures varied between medical personnel and there was evidence motorsport policy and concussion guidelines may not be directly followed. According to both medical personnel (77%) and drivers (85%), ‘education and training’ is the top priority area for the sport.
Position statements/guidelines
- Concussion Policy, Australian Polo Federation, (7 June 2019). The Australian Polo Federation fully endorses the Concussion in Sport Australia Position Statement.
Position statements/guidelines
- Concussion Policy and Recognition Tool, Pony Club Australia, (June 2021).
Position statements/guidelines
- Community Rugby League Policy and Guidelines for the Management of Concussion, National Rugby League, (9 March 2021).
Resources
- Additional resources for sports trainers are available on the NRL website.
Position statements/guidelines
- Concussion Procedure (Rugby Public - Standard Care Pathway), Australian Rugby, (March 2019). The advice within this document is based on the World Rugby Concussion Guidance. This document incorporates the changes to the World Rugby Concussion Laws (Regulation 10, Law 3.11 - Implementation August 1, 2015), and World Rugby’s Operational Definition of Concussion (British Journal of Sports Medicine, March 2016). The advice in this document has been adapted to reflect best practice for the management of concussion for rugby at community levels of the game in Australia. \
- Blue card. In 2018 Rugby Australia’s National Safety Committee approved the recommendation for mandatory use of Blue Cards in all club, school and domestic representative rugby beginning in matches from 1st March 2018.
- World Rugby Concussion Guidance, World Rugby, (accessed 1 July 2021). This World Rugby Concussion Guidance document has been developed to provide guidance and information to persons involved in the Game of Rugby (including the general public) regarding concussion and suspected concussion.
- IRFU Guide to Concussion in the Domestic Game, Irish Rugby Football Union, (2018). The aim of this brochure is to provide information on concussion to those involved in rugby union in Ireland.
- It is time to give concussion an operational definition: a 3-step process to diagnose (or rule out) concussion within 48 h of injury: World Rugby guideline, Raftery MKemp S,Patricios J, Makdissi M and Decq P, British Journal of Sports Medicine, Volume 50(11), pp.642-643, (March 2016). This World Rugby operational definition of concussion was developed with the intent of increasing recognition and sensitivity of diagnosis within the sport and subsequently to improve player welfare and safety. Confirmed cases of concussion must follow the recommended rest and graduated return to play programme that serves as a final part of the serial evaluation process.
Resources
- Other resources relating to Concussion Management are available on the Rugby Australia website.
- World Rugby Concussion Management. Provides a variety of advice and educational resources, as well as the World Rugby Concussion Guidance documents.
- Concussion in rugby: Recognise and Remove, World Rugby, YouTube, (29 September 2014)
- Rugby Smart, New Zealand Rugby/ACC SportSmart, (accessed 1 July 2021). A resource for rugby injury prevention and peak performance. Includes information and guidelines on recognising and treating concussion and return to play.
- IRFU concussion protocols, Irish Rugby Football Union, (accessed 1 July 2021). Provides a variety of resources and videos.
- Headcase, England Rugby, (accessed 1 July 2021). Recognised as one of the UK’s leading concussion awareness and education resources, the RFU’s HEADCASE programme aims to increase understanding and provide information on concussion and other related topics, including how to prevent and manage suspected concussions.
Research
- Getting tough on concussion: how welfare-driven law change may improve player safety—a Rugby Union experience, Martin Raftery, Ross Tucker, Éanna Cian Falvey, British Journal of Sports Medicine, Volume 55(10), pp.527-529, (May 2021). In 2016, World Rugby completed a large-scale study determining the risk factors for head injury in elite rugby. The findings presented a challenge to the game as the traditional safety measures targeted protection of the ball carrier, but this research identified that the tackler was at greater risk of head injury.
- Diagnosed concussion is associated with increased risk for lower extremity injury in community rugby players, Katherine Hunzinger, Katelyn Costantini, C. Buz Swanik, et.al., Journal of Science and Medicine in Sport, Volume 24(4), pp.368-372, (April 2021). Community rugby players with a history of concussion are >2× more likely to also experience an LE-MSI than those without a history of concussion. There were no differences in the odds of LE-MSI between males and females with a history of diagnosed concussion. In line with current World Rugby injury prevention programs, future research should aim to reduce LE-MSI incidence to maximize player safety and wellness through targeted injury prevention and teams should utilize a conservative return to play protocols following concussion.
- Head injury assessment in rugby union: clinical judgement guidelines, Éanna Falvey, Ross Tucker, Gordan Fuller, BMJ Open Sport & Exercise Medicine, Volume 7(2), (April 2021). Clinical judgement is a recognised component of a complete off-field concussion assessment. This study identifies guidance criteria for team medical staff when using clinical judgement in their decision-making process during the World Rugby off-field concussion-assessment screen (HIA1).
- The epidemiology of concussion in professional rugby union in Ireland, Matthew Cosgrave and Sean Williams, Physical Therapy in Sport, Volume 35, pp.99-105, (January 2019). Highlights of this study: Match concussion incidence rate was 18.4/1000 player-match-hours; Overall burden of match concussion was 5 days absence per team per match; Only 13% of players return to play at the minimum recommended recovery time of 6 days; Time loss increases with number of symptoms and symptom severity score; The tackle was responsible for 70% of concussions (tackler 41%; ball carrier 29%).
Position statements/guidelines
- Concussion Management Guidelines, Australian Sailing, (2018)
Research
- Managing head injury risks in competitive skateboarding: what do we know? Andrew Stuart McIntosh, Declan Alexander Patton, Alexander McIntosh, British Journal of Sports Medicine, Volume 55(15), pp.836-842, (July 2021). The majority of previous literature focused on the paediatric population in a recreational setting with little data from competitive skateboarding. Head injuries comprised up to 75% of all injuries and helmet use was less than 35%. Video analysis identified high rates of falls and crashes during competitive skateboarding, but also a capacity for the athletes to control falls and limit head impacts. Less than 5% of competitive skateboarders wore helmets. In addition to dedicated national skateboard helmet standards, there are several national standards for skateboard-styled helmets. All helmets, with the exception of one uncertified helmet, had similar impact attenuation performance; that is, at 0.8 m drop height, 114–148 g; at 1.5 m, 173–220 g; and at 2.0 m, 219–259 g. Impact performance in the second impact was degraded in all helmets tested. The authors conlcude that helmets styled for skateboarding are available ‘off the shelf’ that will offer protection to the head against skull fractures and intracranial injuries in competitive skateboarding. There is an urgent need to commence a programme of research and development to understanding and control head injury risks.
Position statements/guidelines
- Concussion Policy, Softball Australia, (updated 17 May 2021)
Position statements/guidelines
- Concussion policy, Touch Football Australia, (July 2021).
Position statements/guidelines
- Concussion Guideline, UniSport Australia, (March 2019).
Position statements/guidelines
- Concussion Guidance, Water Polo Australia, (7 March 2015).
Position statements/guidelines
- Concussion Policy and Return to Speed Skating Protocol, Australian Ice Racing, (Version 1; March 2019)
- Concussion Policy 2018, Ice Skating Australia, (July 2018)
- Concussion Policy - Version 2 - SCAT5, Olympic Winter Institute of Australia, (August 2017)
- Concussion Policy, Ski and Snowboard Australia, (August 2017).
Research
- Use of the Sport Concussion Assessment Tool 5 (SCAT5) in professional hockey, part 2: which components differentiate concussed and non-concussed players? Jared Bruce, Joanie Thelen, Willem Meeuwisse, et.al., British Journal of Sports Medicine, Volume 55(10), pp.557-565, (2021). We evaluated 1924 professional hockey players at training camp using the National Hockey League (NHL) Modified SCAT5 prior to the 2018–2019 season. Over the course of the season, 314 English-speaking players received SCAT5 evaluations within 1 day of a suspected concussive event. Of these players, 140 (45%) were subsequently diagnosed with concussion by their team physicians.
- Use of the Sport Concussion Assessment Tool 5 (SCAT5) in professional hockey, part 1: cross-cultural normative data, Ruben Echemendia, Joanie Thelen, Willem Meeuwisse, et.al., British Journal of Sports Medicine, Volume 55(10), pp.550-556, (2021). This paper provides comprehensive normative data stratified by language preference and age on the components of the National Hockey League (NHL) Sport Concussion Assessment Tool 5 (SCAT5) in a multilingual sample of professional ice hockey players and compares the findings from a paper form of the NHL SCAT5 with an electronic (App) version of the tool.
Position statements/guidelines
- Concussion Policy, Wrestling Australia, (2015)
Key areas of research
Mechanisms and assessment
Access to resources
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Concussions in Athletics: From Brain to Behaviour, Slobounov S and Sebastianelli W (editors), Springer, (2014). This book addresses the neuro-mechanisms, predispositions, and latest developments in the evaluation and management of concussive injuries. The book is organised in five parts: (1) Evaluation of Concussion and Current Development; (2) Biomechanical Mechanisms of Concussion and Helmets; (3) Neural Substrates, Biomarkers and Brain Imaging of Concussion Research; (4) Pediatric Sport-related Concussions; and (5) Clinical Management and Rehabilitation of Concussions.
- BU-Led Study: CTE May Occur without Concussions, Boston University media release, (January 2018). A new BU-led study suggests that chronic traumatic encephalopathy (CTE) is caused by head injuries, not by concussions. The research explains why 20 percent of athletes who exhibited the early stages of the progressive brain illness postmortem never had a diagnosed concussion.
- Explainer: What is concussion? University of Sydney, (22 June 2017). Dr Adrian Cohen from the University of Sydney explains what causes a concussion and how to best prevent them.
- New tech at UC to spearhead fight against concussion, University of Canberra media release, (6 April 2018). Researchers at the University’s Research Institute for Sport and Exercise (UCRISE) will use a brand-new balance assessment device to comprehensively evaluate athletes with suspected concussion.
- Guidelines for diagnosing and managing pediatric concussion: Recommendations for schools and/or community sports organisations/centres, first edition, Ontario Neurotrauma Foundation, Canada, (June 2014). This document is intended to guide the diagnosis and management of pediatric concussion in children and adolescents age 5 to 18 years.
- Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, Graham R, Rivara F, Ford M, and Spicer C (Editors), National Academy Press, (2013). The Institute of Medicine and National and the Research Council (NRC) in the United States convened the Committee on Sports-Related Concussion to review the available literature on concussions within the context of developmental neurobiology, specifically relating to the causes of concussions, their relationship to impacts to the head or body during sports, the effectiveness of protective devices and equipment, screening for and diagnosis of concussions, their treatment and management, and their long-term consequences. Specific topics included in this report:
- the acute, subacute, and chronic effects of single and repetitive concussive and non-concussive head impacts on the brain;
- risk factors for sports concussions, post-concussion syndrome, and chronic traumatic encephalopathy;
- the spectrum of cognitive, affective, and behavioral alterations that can occur during acute, subacute, and chronic posttraumatic phases;
- physical and biological triggers and thresholds for injury;
- the effectiveness of equipment and sports regulations in preventing injury;
- hospital- and non-hospital-based diagnostic tools; and
- treatments for sports concussions.
- Discriminative Validity of Vestibular Ocular Motor Screening in Identifying Concussion Among Collegiate Athletes: A National Collegiate Athletic Association–Department of Defense Concussion Assessment, Research, and Education Consortium Study, Anthony Kontos, Shawn Eagle, Gregory Marchetti, et.al., American Journal of Sports Medicine, Volume 49(8), pp.2211-2217, (July 2021). Vestibular and ocular motor screening tools, such as the Vestibular/Ocular Motor Screening (VOMS), are recognized as important components of a multifaceted evaluation of sport-related concussion. Previous research has supported the predictive utility of the VOMS in identifying concussion, but researchers have yet to examine the predictive utility of the VOMS among collegiate athletes in the first few days after injury. The findings indicate that individual VOMS items and overall VOMS scores are useful in identifying concussion in collegiate athletes within 3 days of injury. Clinicians can use the cutoffs from this study to help identify concussion in collegiate athletes.
- The Current Status of Concussion Assessment Scales: A Critical Analysis Review, Kaufman, Matthew W.; Su, Charles A.; Trivedi, Nikunj N., et.al., JBJS Reviews, Volume 9(6), (June 2021). Concussion assessment tools may be broadly categorized into (1) screening tests such as the SAC (Standardized Assessment of Concussion), the BESS (Balance Error Scoring System), and the King-Devick (KD) test; (2) confirmatory tests including the SCAT (Sport Concussion Assessment Tool), the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), and the VOMS (Vestibular Oculomotor Screening); and (3) objective examinations such as brain network activation (BNA) analysis, imaging studies, and physiologic markers. The KD, child SCAT3 (cSCAT3), child ImPACT (cImPACT), and VOMS tests may be used to evaluate for concussion in the pediatric athlete. Future work with BNA, functional magnetic resonance imaging, diffusion tensor imaging, and serum biomarkers may provide more objective assessment of concussion, neurologic injury, and subsequent recovery.
- What Is the Impact of Physical Effort on the Diagnosis of Concussion? Dechambre, Xavier, Carling, Christopher, Mrozek, Ségolène, et.al., Clinical Journal of Sport Medicine, Volume 31(3), (May 2021). Sport-related concussion commonly occurs in contact sports such as rugby. To date, diagnosis is based on the realization of clinical tests conducted pitch-side. Yet, the potential effect of prior physical effort on the results of these tests remains poorly understood. The purpose of this study was to determine whether preceding physical effort can influence the outcome of concussion assessments. A cohort of 40 subjects (20 rugby players and 20 athletes from a range of sports). A concussion assessment was performed immediately following physical activity. Following a period of 6 months and under the same experimental conditions, the same cohort performed the same tests in resting conditions. In both cohorts, the comparison for post-exercise and rest assessments demonstrated a most likely moderate-to-very large increase in the number of symptoms, severity of symptoms and BESS score. In the rugby cohort, scores for concentration, delayed memory and SAC, likelyto-most likely decreased following completion of physical activity compared to baseline values. The between-cohort comparison showed a greater impact post-exercise in the rugby players for delayed recall (0.73±0.61, 93/7/1) and SAC score (0.75±0.41, 98/2/0).
- Sensitivity and Specificity of a Multimodal Approach for Concussion Assessment in Youth Athletes, Tiffany Toong, Katherine Wilson, Anne Hunt, et.al., Journal of Sport Rehabilitation, Volume 30(6), (February 2021). To describe and compare the sensitivity and specificity of a multimodal assessment battery (balance, cognition, and upper and lower body strength) versus individual clinical measures at discriminating between concussed youth athletes and noninjured controls when asymptomatic. When asymptomatic, declines in performance on each individual clinical measure were seen in 3% to 22% of the concussion group (sensitivity = 3%–22%) compared with 3% to 13% of the noninjured control group (specificity = 87%–97%) (90% confidence interval). The multimodal battery of all combined clinical measures yielded a sensitivity of 41% and a specificity of 77% (90% confidence interval). Based on discriminative analyses, the multimodal approach was statistically superior compared with an individual measures approach for balance and upper and lower body strength, but not for cognition. Results provide a foundation for understanding which domains of assessment (cognition, balance, and strength) may be sensitive and specific to deficits once symptoms resolve in youth athletes. More work is needed prior to clinical implementation of a preinjury (baseline) to postinjury multimodal approach to assessment following concussion in youth athletes.
- Awareness and Perceived Value of Eye Tracking Technology for Concussion Assessment among Sports Medicine Clinicians: A Multinational Study, Nadja Snegireva, Wayne Derman, Jon Patricios, et.al., The Physician and Sportsmedicine, Volume 48(2), pp.165-172, (2020). Even among sports medicine clinicians who regularly attend to patients with concussions, there is insufficient awareness that concussion can lead to abnormal eye tracking behavior. Lack of exposure to the sensitive eye tracking equipment may be a limiting factor for using eye movement metrics for concussion diagnostics. Facilitating the awareness of objective methods, like eye tracking technology, may help assure the appropriate continuum of identification and treatment for concussed athletes. Increasing educational opportunities and practical experience of clinicians regarding concussive symptoms and potential innovative technology is strongly advocated.
- A review of concussion diagnosis and management in Australian professional sporting codes, Premkumar Gunasekaran,Christopher Hodge, Alan Pearce, et.al., The Physician and Sportsmedicine, Volume 48(1), (2020). The purpose of this study was to explore the publicly available concussion guidelines of the major Australian sporting codes with an aim to identify potential opportunities to develop a national sporting consensus. Twelve sites were visited. There was consensus between many of the sporting organizations in terms of concussion definition, removal of play and sideline testing protocols. A step-wise return-to-play protocol was prevalent across most sports. A number of sporting sites however did not have readily available information.
- Normative Data Set of SWAY Balance Mobile Assessment in Pediatric Athletes, Anderson, Stevi L., Gatens, Dustin, Glatts, Colette. Russo, Stephen A., Clinical Journal of Sports Medicine, Volume 29(5), pp.413-420, (September 2019). Normative scores are described, with results stratified into 4 age groups (5-9, 10-12, 13-17, and 18 years old). Balance scores, overall and within each individual stance score, improved with the age of the participants. Sex effects on balance were only seen in single-leg stances, with females outperforming males. Reaction time was found to be faster in males and improved with age, peaking at 13 to 17 years old and slowing in 18-year-olds.
- Performance Times for the King-Devick Test in Children and Adolescents, Gubanich, Paul J., Gupta, Resmi, Slattery, Eric, Logan, Kelsey, Clinical Journal of Sports Medicine , Volume 29(5), pp.374-378, (September 2019). Four hundred eighty-three participants were included in the final analysis, which included 60.5% girls (n = 292) and 39.5% boys (n = 191). The KD test performance varied by age with a steady decrease in test time yearly from 8 years through 14 years of age, where some plateauing occurred. Baseline scores changed approximately 31 seconds over ages 8 to 18. Analysis of variance results revealed a strong effect of age on overall mean KD time. The KD test performance was not associated with sex or other studied concussion risk factors or comorbid conditions.
- The King–Devick test is not sensitive to self-reported history of concussion but is affected by English language skill, Tracey J. Dicksona, Gordon Waddingtona, F. Anne Terwielb, Lisa Elkington, Journal of Science and Medicine in Sport, Volume 22(Supplement 1), pp.S34-S38, (August 2019). For subjects whose first language is not English, such as in many snowsport resorts, the K–D test may need to be conducted in a person’s native language to provide a valid assessment based upon the time to complete the task.
- What HIRTS athletes? Establishing a unified public policy understanding of Head Impact-Related Trauma in Sport, Jason Chung and Amanda Zink, Journal of Public Health Policy, Volume 40, pp.393–409, (2019). The authors propose a ‘HIRTS framework’ to advance public policy pertaining to head impacts and their effects. Given the scientific ambiguities regarding the definition, diagnosis, and markers of concussion and resulting complications, we encourage international policymakers, clinicians, and public health officials to adopt the following working definitions and concomitant policy recommendations to safeguard athletes’ health and optimize tracking efforts, public education, funding, and government services.
- Sports-related concussion (SRC) assessment in road cycling: a systematic review and call to action, Elliott J, Anderson R, Collins S, et al, BMJ Open Sport and Exercise Medicine, Volume 5(1), (2019). Road cycling poses unique challenges for the assessment of SRC. This review illustrates the lack of published evidence to advise effective means of SRC assessment within road cycling. The Union Cycliste Internationale (UCI) regulations advise the use of SCAT-5 for concussion assessment but this tool is impractical, requiring modification for use in road cycling. We would like to call on the UCI to hold a consensus meeting to establish an evidence-based SRC assessment protocol and return-to-riding protocol for road cycling.
- A systems approach to understanding the identification and treatment of sport-related concussion in community rugby union, Amanda Clacy, Natassia Goode, Rachael Sharman, et.al., Applied Ergonomics, Volume 80, pp.256-264, (October 2019). Through an online survey, 118 members of the amateur (community) rugby union system were asked about their role-specific concussion management responsibilities and strategies. Respondents included players, parents, medics, coaches, club managers, administrators, and volunteers. This study illustrated that the current challenges in the identification and treatment of rugby-related concussion in community sport may be due to role/responsibility confusion and possible overreliance on field-side medics. These findings offer insight into the possible limitations of the current concussion management guidelines and may offer empirically based direction for future revisions.
- International consensus definitions of video signs of concussion in professional sports, Gavin A Davis, et.al., British Journal of Sports Medicine, Volume 53(20), pp.1264-1267. (2019). Respondents representing seven sporting bodies (Australian Football League, Cricket Australia, Major League Baseball, NFL, NHL, National Rugby League, World Rugby) reached consensus on eight video signs of concussion. Thirteen representatives from the seven professional sports ranked the definition components. Consolidation and refinement of the video signs and their definitions resulted in consensus definitions for six video signs of possible concussion: lying motionless, motor incoordination, impact seizure, tonic posturing, no protective action—floppy and blank/vacant look.
- International study of video review of concussion in professional sports, Gavin A Davis, et.al., British Journal of Sports Medicine, Volume 53(20), pp.1299-1304. (2019). Six sports with specific diagnostic criteria and definitions for signs of concussion identified on video review participated in this study (Australian football, American football, world rugby, cricket, rugby league and ice hockey). Video signs common to all sports include lying motionless/loss of responsiveness and motor incoordination. The video signs considered by the majority of sports as most predictive of a diagnosis of concussion include motor incoordination, impact seizure, tonic posturing and lying motionless. Regulatory requirements, sideline availability of video, medical expertise of video reviewers and use of spotters differ across sports and geographical boundaries. By and large, these differences reflect a pragmatic approach from each sport, with limited underlying research and development of the video review process in some instances.
- Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review. Angela Lumba-Brown, Keith Owen Yeates, Kelly Sarmiento, et al., JAMA Pediatrics, Volume 172(11), (November 2018). This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.
- The accuracy and reproducibility of video assessment in the pitch-side management of concussion in elite rugby. Fuller, G.W.; Kemp, S.P.T.; Raftery, M., Journal of Science and Medicine in Sport, Volume 20(3), March 2017, p.246.
- Concussion Baseline Testing: Preexisting Factors, Symptoms, and Neurocognitive Performance. Cottle, Jordan E.; Hall, Eric E.; Patel, Kirtida; Barnes, Kenneth P.; Ketcham, Caroline J., Journal of Athletic Training, Volume 52(2), (February 2017), p.77
- King-Devick Performance Following Moderate and High Exercise Intensity Bouts, Rist, Billymo; Cohen, Adrian; and Pearce, Alan J., International Journal of Exercise Science, Volume 10(4), pp.619 - 628, (2017). Using a randomized crossover design, this study aimed to compare the effect of two intensities of exercise on K-D performance. Twenty males (21.2 ± 1.9 years) completed the K-D test prior to and after 15 min of either moderate (65% of age-predicted maximal heart rate) and high intensity (80% of age-predicted maximal heart rate) exercise bouts, separated by one week. Significant differences were found in working heart rate and ratings of perceived exertion consistent with exercise intensities. K-D performance did not change after moderate exercise, however a significant improvement (5.4%) was observed after high intensity exercise. Based upon these findings, it appears that high intensity exercise can influence test performance and administrators of the test need to be aware of the arousal state a player is prior to K-D test administration to ensure objective measurement.
- Observational Review and Analysis of Concussion: a Method for Conducting a Standardized Video Analysis of Concussion in Rugby League, Andrew J. Gardner, Christopher R. Levi, and Grant L. Iverson, Sports Medicine Open, (December 2017). The aim of this study was to evaluate whether independent raters reliably agreed on the injury characterization when using a standardized observational instrument to record video footage of National Rugby League (NRL) concussions. There appears to be value in expert raters, but less value for naive raters, in using the new Observational Review and Analysis of Concussion (ORAC) Form. The ORAC Form has high inter-rater agreement for most data elements, and it can be used by expert raters evaluating video footage of possible concussion in the NRL.
- Usefulness of Video Review of Possible Concussions in National Youth Rugby League. Gardner, Andrew J.; Kohler, Ryan M. N.; Levi, Christopher R.; Iverson, Grant L., International Journal of Sports Medicine, Volume 38(1), (2017), pp.71-75
- Utility of providing a concussion definition in the assessment of concussion history in former NFL players. Michael L. Alosco, Johnny Jarnagin, Yorghos Tripodis, Brett Martin, Christine Chaisson, Christine M. Baugh, Alcy Torres, Christopher J. Nowinski, Robert C. Cantu and Robert A. Stern, Brain Injury, Vol. 31(8), (2017), pp. 1116-1123.
- Concussed or Not? An Assessment of Concussion Experience and Knowledge Within Elite and Semiprofessional Rugby Union. Mathema, Prabhat; Evans, Daniel; Moore, Isabel S.; Ranson, Craig; Martin, Rhodri, Clinical Journal of Sport Medicine, Volume 26(4), (July 2016), p320
- Measurement Error in the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT): Systematic Review. Alsalaheen, Bara; Stockdale, Kayla; Pechumer, Dana; Broglio, Steven P., Journal of Head Trauma Rehabilitation, Volume 31(4), (July/August 2016), pp.242-251.
- Neuropsychological Testing in Mild Traumatic Brain Injury: What to Do When Baseline Testing Is Not Available. Arnett, Peter; Meyer, Jessica; Merritt, Victoria; Guty, Erin, Sports Medicine and Arthroscopy Review, Volume 24(3), (September 2016), pp.116-122.
- Player and parent concussion knowledge and awareness in youth Australian Rules Football. Hecimovicha, Mark; Kingb, Doug; Maraisc, Ida, Sport Journal, (1 April 2016).
- Reference values for the balance error scoring system in adolescents. Alsalaheen, Bara; McClafferty, Adam; Haines, Jamie; Smith, Laura; Yorke, Amy. Brain Injury, Volume 30(7), (April 2016), pp.914-918.
- The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one, Resch J, Brown C, Schmidt J, Macciocchi S, Blueitt D, Callum CM and Ferrara M, BMJ Open Sport and Exercise Medicine, Volume 2, Issue 1, (19 January 2016).
- Using video analysis for concussion surveillance in Australian football, Makdissi M and Davis G, Journal of Science and Medicine in Sport, Volume 19, Issue 12 (2016).
- A preliminary video analysis of concussion in the National Rugby League, Andrew J. Gardner, Grant L. Iverson, Tanya N. Quinn, Michael Makdissi, Christopher R. Levi, Sandy R. Shultz, Brain Injury , Volume 29(10), (June 2015). Most concussions (83%) occurred during a high tackle, and all injured ball carriers were hit high. Loss of consciousness was observed in 30% of cases. Common observable signs of injury included clutching of the head, balance problems or wobbly legs and a blank or vacant state. There were no post-concussive seizures. All players with loss of consciousness were removed from play. However, only half of the total sample was removed from play and one athlete who was removed returned to play in the same match. Of the players who were removed from play, the large majority returned the following week. Illegal play accounted for 25% of all concussions.
- An evidence-based discussion of heading the ball and concussions in high school soccer, Comstock D, Currie D, Pierpoint L, Grubenhoff A and Fields S, JAMA Pediatrics, (13 July 2015). Concerns have been raised regarding the safety of soccer ball heading (when an athlete attempts to play the ball in the air with his or her head) given the rise in concussion rates, with some calling for a ban on heading among soccer players younger than 14 years. This retrospective analysis used longitudinal surveillance data collected from 2005-2014 in US high schools, for both boys and girls. The analysis indicated that although heading the ball is commonly associated with concussions, the most frequent mechanism was athlete-to-athlete contact.
- Concussion in sport: Conceptual and ethical issues, McNamee M, Partridge B and Anderson L, Kinesiology Review, Volume 4, Issue 2 (2015). This article discusses concussion from philosophical, bioethical, and sports ethical perspectives. The authors identify conceptual differences in approaches to definition and therefore diagnosis of concussion. They also critically review similarities and differences in the leading consensus statements that guide the treatment of concussion diagnosis and treatment in sports. Finally, they present a series of ethical problems, including issues that relate to intervention in the lives of athletes in order to prevent harm, conflicting and competing interests, and confidentiality.
- Detection of concussion using cranial accelerometry, Auerbach P, Baine J, Schott M, Greenhaw A, Acharya M and Smith W, Clinical Journal of Sport Medicine, Volume 25, Number 2 (2015).
- The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: An international Delphi study, Reneker J, Moughiman M and Cook C, Journal of Science and Medicine in Sport, Volume 18, Number 4 (2015). Dizziness after a sports-related concussion is very common and is associated with prolonged recovery. This study was conducted to identify proper clinically administered tests and measures that are useful in differentiating between cervicogenic and other causes of dizziness after a sports-related concussion. A group of 25 experts in the field of concussion and dizziness, representing several medical disciplines, assessed ten clinical tests. Seven of these tests achieved no consensus among the experts. The clinical tests identified as having strong clinical utility are tests used to identify dizziness originating from the vestibular or central nervous system. No clinical tests specific for the cervical region achieved consensus. Expert opinion from different medical professions and even within professions was widely divergent regarding the utility of clinical tests to assess cervical dysfunction.
Licencing restrictions apply to some resources.
All Clearinghouse members
'Australian' members only
'High Performance' members only
Restricted access
Various restrictions
- Concussion in Sport Guidelines – An AIS and AMA Initiative, Dr David Hughes, AIS Chief Medical Officer, Smart Talk Seminar Series, Australian Institute of Sport, Canberra (31 May 2016)
- Sports-related concussion in children and adolescents, Brain Injury Australia Workshop, NSWIS Building, Sydney Olympic Park (13 November 2015)
- Concussion management in community sport - Feature Presentation, Dr Ron Muratore, Chief Medical Officer, National Rugby League, NSW Office for Sport and Recreation, Sports Talks series, (8 October 2014)
- Concussion management in community sport - Club case study, Dennis Lowe, Sports Trainer and Club Official, Penrith Junior Rugby League, Sports Talks (8 October 2014)
- Concussion management in community sport - research, John Searl, Senior Development Manager Regional NSW, ARU, Sports Talks (8 October 2014)
- Traumatic Brain Injury in Athletes: New Concepts, New Dilemmas, James C Puffer MD, Smart Talk Seminar Series, Australian Institute of Sport, Canberra, (16 July 2014)
- Concussion in Sport Australia, Sport Australia, YouTube, (8 October 2018). Every weekend thousands of Australians are concussed while playing sport. Find out how it occurs, how to identify the symptoms and how to treat it. To learn more, visit concussioninsport.gov.au.
- Concussion in Sport Australia: Medical Practitioners, Sport Australia, YouTube, (14 November 2018). Diagnosing concussion can be difficult, even for experienced medical practitioners. Leading sports medicine experts have collaborated to provide contemporary, evidence-based guidelines for the management of concussion in sport.
- Concussion in Sport – Athletes, Australian Institute of Sport, YouTube (20 July 2015). Jayden Warner from the Australian Steelers (National Wheelchair Rugby Team) and Jasmine Simmons (Basketball Australia, Centre of Excellence athlete) share their story on how they managed their concussion. Dr David Hughes (AIS Chief Medical Officer) also provides an important message for all athletes who are suffering with concussion.
- Explainer: What is a concussion? Dr Adrian Cohen, University of Sydney, Sydney Health/Sydney Morning Herald, YouTube, (21 June 2017).
- Scottish Rugby Concussion Study, Scottish Rugby, YouTube, (27 February 2014).
- What happens when you have a concussion? Clifford Robbins, TED-Ed, YouTube, (27 July 2017).
- You can't see a concussion, Sports Medicine Australia, YouTube, (14 March 2016).
Sport concussion assessment tools
Access to resources
Where possible, direct links to full-text and online resources are provided. However, where links are not available, you may be able to access documents directly by searching our licenced full-text databases (note: user access restrictions apply). Alternatively, you can ask your institutional, university, or local library for assistance—or purchase documents directly from the publisher. You may also find the information you’re seeking by searching Google Scholar.
- Sport Concussion Assessment Tool (SCAT5), (2017). The most recent revision of a sport concussion evaluation tool for use by healthcare professionals in the acute evaluation of suspected concussion
- Sport Concussion Assessment Tool Child SCAT5, (2017). For children aged 5 to 12 years, children aged 13 years and older should be assessed using the standard SCAT5.
- Arabic translation and cross-cultural adaptation of Sport Concussion Assessment Tool 5 (SCAT5), Louis Holtzhausen, Sofiane Souissi, Omar Al Sayrafi, et.al., Biology of Sport, Volume 38(1), pp.129-144, (September 2020).
- Sport Concussion Assessment Tool – 3rd edition (SCAT3). Previous edition, 2013.
Statistics and reports
It is difficult to determine the prevalence of sports concussion. No standard national sports injury surveillance system exists in Australia. Data is available on the incidence of hospital emergency treatments, but there are limitations in extracting data related to sports and recreational activity. Additionally, athletes may not seek treatment at hospital (or at all), and overall averages are unlikely to indicate how prevalent concussion is in specific sports.
Access to resources
Where possible, direct links to full-text and online resources are provided. However, where links are not available, you may be able to access documents directly by searching our licenced full-text databases (note: user access restrictions apply). Alternatively, you can ask your institutional, university, or local library for assistance—or purchase documents directly from the publisher. You may also find the information you’re seeking by searching Google Scholar.
- The Management of Concussion in Rugby League. National Rugby League, (26 February 2019). Concussion is relatively common in Rugby League. In the past 4-5 years the incidence in the NRL’s elite competition has been 5-7 concussions per team per season.
- Sports Concussion Resources, American Academy of Neurology, (accessed 15 April 2020). Each year, 1.6 to 3.8 million concussions result from sports/recreation injuries in the United States. Sports concussion can affect athletes of any age, gender, or type or level of sport played. While most concussions result in full recovery, some can lead to more severe injuries if not identified early and treated properly.
- Do rugby league players under-report concussion symptoms? A cross-sectional study of elite teams based in Australia, Longworth T, McDonald A, Cunningham C, et al, BMJ Open Sport & Exercise Medicine, Volume 7(1), (January 2021). A total of 151 male, NRL club contracted rugby league players across three professional clubs participated. The participants completed a voluntary, anonymous survey exploring player demographics, concussion data, under-reporting instances and reasons for under-reporting over the 2018 and 2019 rugby league seasons. Results 17.2% of surveyed players reported sustaining a likely concussion over the past 2 years and not reporting to medical staff. 22% of NRL first grade players admitted to not reporting at least one concussion during the 2018 and 2019 seasons. The most common reason not to report was the player ‘not wanting to be ruled out of the game or training session’ (57.7%), followed by ‘not wanting to let down the coaches or teammates’ (23.1%). 85.4% of surveyed players reported having concussion education by their club in the previous two seasons.
- An Investigation of Factors Associated With Head Impact Exposure in Professional Male and Female Australian Football Players, Jonathan Reyes, Biswadev Mitra, Andrew McIntosh, et.al., American Journal of Sports Medicine , (7 April 2020). Playing situations in which players have limited control of the football are a common cause of impacts. Male players sustained a greater exposure to HAEs compared with female players. Female players, however, sustained higher exposure to HAEs than male players during certain skill executions, possibly reflecting differences in skill development. These findings can therefore inform match and skill development in the emerging professional women’s competition of Australian football.
- Examination of sports and recreation-related concussion among youth ages 12–17: results from the 2018 YouthStyles survey, Kelly Sarmiento, Jill Daugherty, Lara DePadilla and Matthew J. Breiding, Brain Injury, Volume 34(3), (February 2020). Forty-three percent of youth surveyed sustained their most recent concussion while playing on a sports team, 21.1% while playing on a community-based team, and 36.0% while engaged in a sport or recreational activity. Nearly half (45.3%) reported having to miss playing sports or participating in physical activity for at least one day; about two in ten (19.7%) reported having to miss time on their phone or computer for at least one day. Despite wide-spread efforts to promote protocols for SRR concussion among youth, a third of participants in this study did not seek medical care and more than half did not miss at least one day of sports or physical activity participation following a concussion.
- Frequency and Magnitude of Game-Related Head Impacts in Male Contact Sports Athletes: A Systematic Review and Meta-Analysis, Jack V. K. Nguyen, James H. Brennan, Biswadev Mitra and Catherine Willmott, Sports Medicine, Volume 49, pp.1575–1583, (2019). Twenty-one studies met the inclusion criteria with 12 conducted on American Football athletes. Six of these studies were included for meta-analysis. At a threshold of 10g, amateur rugby players sustained the most impacts per player per game, followed by amateur Australian Football and collegiate lacrosse athletes. At thresholds of greater than 14.4g, high school American Football athletes sustained between 19 and 24.4 impacts per player per game. Statistically significant heterogeneity was observed among the included studies, and meta-analysis of impact magnitude was limited.
- Incidence of Concussion and Head Impacts in Australian Elite-Level Male and Female Cricketers After Head Impact Protocol Modifications, Thomas Hill, John Orchard, and Alex Kountouris, Sports Health, Volume 11(20), pp.180-185, (March-April 2019). The rate of concussion in cricket is higher than previously appreciated; however, the majority of patients recovered quickly, and players generally did not miss much playing time as a result. The institution of concussion policies after head impact, including player substitution, appears to have had an effect on increasing reporting of symptoms, resulting in an increase in diagnosis of concussion.
- Lifetime prevalence of self-reported concussion among adolescents involved in competitive sports: A national U.S. study, Philip Veliz, James T. Eckner, Jennifer Zdroik, and John E. Schulenberg, Journal of Adolescent Health , Volume 64(2), pp.272-275, (February 2019). Adolescents who participated in baseball, basketball, football, gymnastics, ice hockey, lacrosse, soccer, track, weightlifting, and „other sports“ had greater odds of reporting multiple diagnosed concussions compared to peers not participating in these sports. Adolescents who participated in tennis had lower odds of reporting any diagnosed concussion or multiple concussions. Females who participated in gymnastics, soccer, and swimming showed a stronger association in reporting a diagnosed concussion when compared to males who participated in these same types of sports.
- The epidemiology of concussion in professional rugby union in Ireland, Matthew Cosgrave and Sean Williams, Physical Therapy in Sport, Volume 35, pp.99-105, (January 2019). Highlights of this study: Match concussion incidence rate was 18.4/1000 player-match-hours; Overall burden of match concussion was 5 days absence per team per match; Only 13% of players return to play at the minimum recommended recovery time of 6 days; Time loss increases with number of symptoms and symptom severity score; The tackle was responsible for 70% of concussions (tackler 41%; ball carrier 29%).
- Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football. Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, et.al., JAMA, 318(4), (July 2017), pp.360–370. In a convenience sample of 202 deceased players of American football from a brain donation program, CTE was neuropathologically diagnosed in 177 players across all levels of play (87%), including 110 of 111 former National Football League players (99%).
- The incidence of concussion in youth sports: a systematic review and meta-analysis, Pfister T, Pfister K, Hagel B, Ghali W and Ronksley P, British Journal of Sports Medicine, Volume 50, Issue 5 (2016). This is a systematic review and meta-analysis of studies assessing the incidence of concussion in youth athletes in the United States. Specifically, the authors estimate the overall risk of concussion in youth sports and compare sport-specific estimates of concussion risk. Of the 698 studies reviewed for eligibility, 23 met the inclusion criteria. The overall risk of concussion (12 sports, males and females 18 years and younger) was estimated at 0.23 incidence rate per 1000 athlete exposures. The three sports with the highest incidence rates were rugby (4.18), ice hockey (1.20) and American football (0.53), and the lowest occurred in volleyball, baseball and cheerleading at 0.03, 0.06 and 0.07, respectively. Quality of the included studies varied, with the majority of studies not reporting age and gender-specific incidence rates or an uniform operational definition for concussion.
- Trends in Sports- and Recreation-Related Traumatic Brain Injuries Treated in US Emergency Departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. Coronado, Victor G.; Haileyesus, Tadesse; Cheng, Tabitha A. et.al., Journal of Head Trauma Rehabilitation, Volume 30(3), (May/June 2015), pp.185–197. The rates of ED-treated Sports- and recreation-related traumatic brain injuries (SRR-TBIs) increased during 2001-2012, affecting mainly persons aged 0 to 19 years and males in all age groups. Increases began to appear in 2004 for females and 2006 for males. Activities associated with the largest number of TBIs varied by sex and age. Reasons for the reported increases in ED visits are unknown but may be associated with increased awareness of TBI through increased media exposure and from campaigns, such as the Centers for Disease Control and Prevention's Heads Up. Prevention efforts should be targeted by sports and recreational activity, age, and sex.
- A preliminary video analysis of concussion in the National Rugby League, Gardner AJ, Stanwell P, Levi CR, et al., Brain Injury, Volume 29(10), pp.1182-1185, (2015). Most concussions (83%) occurred during a high tackle, and all injured ball carriers were hit high. Loss of consciousness was observed in 30% of cases. Common observable signs of injury included clutching of the head, balance problems or wobbly legs and a blank or vacant state. There were no post-concussive seizures. All players with loss of consciousness were removed from play. However, only half of the total sample was removed from play and one athlete who was removed returned to play in the same match. Of the players who were removed from play, the large majority returned the following week. Illegal play accounted for 25% of all concussions.
- Comparing severe injuries by sex and sport in collegiate-level athletes: A descriptive epidemiological study, Hurtubise J, Beech C and Macpherson A, International Journal of Athletic Therapy and Training, Volume 20, Number 4 (2015).
- Motivations for underreporting suspected concussion in college athletics, Davies S and Bird B, Journal of Clinical Sport Psychology, Volume 9, Number 2 (2015).
- Sports-related concussion in helmeted vs unhelmeted athletes: Who fares worse? Zuckerman S, Lee Y, Odom M, Forbes J, Solomon G and Sills A, International Journal of Sports Medicine, Volume 36, Number 5 (2015).
Risks and mitigation
Access to resources
Where possible, direct links to full-text and online resources are provided. However, where links are not available, you may be able to access documents directly by searching our licenced full-text databases (note: user access restrictions apply). Alternatively, you can ask your institutional, university, or local library for assistance—or purchase documents directly from the publisher. You may also find the information you’re seeking by searching Google Scholar.
- Explainer: What is concussion? University of Sydney, (22 June 2017). Dr Adrian Cohen from the University of Sydney explains what causes a concussion and how to best prevent them.
- The impact of litigation, regulation, and legislation on sport concussion management, Bonds G, Edwards W, Spradley B and Phillips T, The Sport Journal , United States Sports Academy, (23 March 2015). This review looks at the impact of litigation, regulation, and legislation on sport concussion management in the United States.
Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, Graham R, Rivara F, Ford M, and Spicer C (Editors), National Academy Press, (2013). The Institute of Medicine and National and the Research Council (NRC) in the United States convened the Committee on Sports-Related Concussion to review the available literature on concussions within the context of developmental neurobiology, specifically relating to the causes of concussions, their relationship to impacts to the head or body during sports, the effectiveness of protective devices and equipment, screening for and diagnosis of concussions, their treatment and management, and their long-term consequences. Specific topics included in this report:
- the acute, subacute, and chronic effects of single and repetitive concussive and non-concussive head impacts on the brain;
- risk factors for sports concussions, post-concussion syndrome, and chronic traumatic encephalopathy;
- the spectrum of cognitive, affective, and behavioral alterations that can occur during acute, subacute, and chronic posttraumatic phases;
- physical and biological triggers and thresholds for injury;
- the effectiveness of equipment and sports regulations in preventing injury;
- hospital- and non-hospital-based diagnostic tools; and
- treatments for sports concussions.
- A Social-Marketing Intervention and Concussion-Reporting Beliefs, Dee Warmath, Andrew P. Winterstein, Journal of Athletic Training, Volume 55(10), pp.1035-1045, (October 2020). Concussion-symptom education remains the primary approach used by athletic trainers to address underreporting of possible sport-related concussions. Social marketing represents an untapped approach to promote concussion reporting by communicating the benefits or consequences of reporting or not reporting, respectively. A total of 468 competitive collegiate club sport athletes at a large US university who engaged in 1 of 46 sports with various levels of concussion risk. Participants were randomly assigned by team to 1 of 3 conditions. The treatment condition was a social-marketing program focused on the possible consequences of the reporting decision. The control condition was traditional concussion-symptom education based on the National Collegiate Athletic Association's publication, “Concussion: A Fact Sheet for Student-Athletes.” An additional condition mirrored the traditional symptom education but included a less clinical delivery. Club sport athletes exposed to consequence-based social marketing showed higher levels of positive reporting beliefs and lower levels of negative reporting beliefs than athletes exposed to traditional or revised symptom education. We observed no differences between the traditional and revised symptom-education programs. Exposure to consequence-based marketing decreased negative beliefs about reporting (B = −0.165, P = .01) and increased positive beliefs about reporting (B = 0.165, P = .01).
- Assessment of HEADS UP online training as an educational intervention for sports officials/athletic trainers, Jill Daugherty, Lara De Padilla, Kelly Sarmiento, Journal of Safety Research, Volume 74, pp.133-141, (September 2020). We hypothesized that sports officials’ and athletic trainers’ concussion-related knowledge, attitudes, and behavioral intentions will improve from pre- and post-test after completing CDC’s HEADS UP online concussion training course. The SOs and ATs who participated in the HEADS UP online training had a high level of concussion knowledge before taking the course: 90% or more of respondents could identify the correct response for at least seven of the 13 knowledge questions in the pre-test. Still, the course was effective at improving the respondents’ knowledge about return-to-play protocols and concussion reporting. Further, SOs and ATs demonstrated improvement in their concussion-related attitudes and behavioral intentions between the pre- and post-test.
- Mitigating the Consequences of Subconcussive Head Injuries, Eric Nauman, Thomas Talavage, Paul Auerbach, Annual Review of Biomedical Engineering, Volume 22, pp.387-407, (June 2020). Subconcussive head injury represents a pathophysiology that spans the expertise of both clinical neurology and biomechanical engineering. From both viewpoints, the terms injury and damage, presented without qualifiers, are synonymously taken to mean a tissue alteration that may be recoverable. For clinicians, concussion is evolving from a purely clinical diagnosis to one that requires objective measurement, to be achieved by biomedical engineers. Subconcussive injury is defined as subclinical pathophysiology in which underlying cellular- or tissue-level damage (here, to the brain) is not severe enough to present readily observable symptoms. Our concern is not whether an individual has a (clinically diagnosed) concussion, but rather, how much accumulative damage an individual can tolerate before they will experience long-term deficit(s) in neurological health. This concern leads us to look for the history of damage-inducing events, while evaluating multiple approaches for avoiding injury through reduction or prevention of the associated mechanically induced damage.
- Reducing risk of head injury in youth soccer: An extension of behavioral skills training for heading, Laura M. Quintero James W. Moore M. Garrett Yeager, et.al., Journal of Applied Behavior Analysis , Volume 53(1), pp.237-248, (Winter 2020). There is currently limited research on an effective teaching method to improve safe heading technique. In the current study, Behavior Skills Training (BST) was evaluated as a method to teach correct heading techniques to youth soccer players. BST increased the percentage of correct steps for each player based on a task analysis of heading. Based on social validity questionnaires administered to players and the coach, BST was rated as an acceptable form of training. After the final training session, experienced coaches rated each player as having improved from baseline to training.
- What they know and who they are telling: Concussion knowledge and disclosure behaviour in New Zealand adolescent rugby union players, Danielle M. Salmon,Jody Mcgowan,S. John Sullivan, et.al., Journal of Sport Sciences, (8 April 2020). The purpose of this study was to survey high school rugby players from a range of ethnic, geographic and socioeconomic backgrounds in New Zealand (NZ) to gain an understanding of concussion knowledge, awareness of NZ Rugby’s (NZR) guidelines and attitudes towards reporting behaviours. Male and female high school rugby players (n= 416) from across NZ were surveyed. The findings indicated that 69% of players had sustained a suspected concussion, and 31% had received a medical diagnosis of concussion. 63% of players indicated they were aware of NZR’s guidelines. Māori and Pasifika players were less likely to be aware of the guidelines compared to NZ European. Guideline awareness was significantly higher for those from high decile schools when compared to low; however, when ethnicity and school locations were controlled for this became non-significant. The coach was the key individual for the provision of concussion information and disclosure of symptoms for players.
- The Influence of Psychological Factors on the Incidence and Severity of Sports-Related Concussions: A Systematic Review, Lily N. Trinh, Symone M. Brown, Mary K. Mulcahey, American Journal of Sports Medicine, (8 November 2019). The initial search identified 1195 articles. Ten studies met our inclusion criteria and were included in our analysis. Factors such as meanness, aggression, and psychoticism were associated with an increased incidence of SRCs. Baseline traits of irritability, sadness, nervousness, and depressive symptoms were associated with worse symptomatology after SRCs. In young athletes, preexisting psychiatric illnesses, family history of psychiatric illness, and significant life stressors were associated with an increased risk of developing postconcussion syndrome after SRCs.
- Insomnia and daytime sleepiness: risk factors for sports-related concussion, Adam C. Raikes, Amy Athey, Pamela Alfonso-Miller, et.al., Sleep Medicine, Volume 58, pp.66-74, (June 2019). Insomnia and daytime sleepiness are independently associated with increased sports-related concussion risk. More completely identifying bidirectional relationships between concussions and sleep requires further research. Clinicians and athletes should be cognizant of this relationship and take proactive measures – including assessing and treating sleep-disordered breathing, limiting insomnia risk factors, improving sleep hygiene, and developing daytime sleepiness management strategies – to reduce sports-related concussion risk and support overall athletic performance.
- Effectiveness of the US Centers for Disease Control and Prevention HEADS UP coaches’ online training as an educational intervention, Jill Daugherty, Lara DePadilla, Kelly Sarmiento, Health Education Journal , Volume 78(7), (May 2019). HEADS UP training improved coaches’ knowledge on select topics and helped them feel more comfortable about responding to concussion among their athletes. This study provides insight into how to better focus future HEADS UP concussion health education efforts to fit coaches’ informational needs.
- What the research says about concussion risk factors and prevention strategies for youth sports: A scoping review of six commonly played sports, Dana Waltzman and Kelly Sarmiento, Journal of Safety Research , Volume 68, pp.157-172, (February 2019). This scoping review summarizes current research on concussion risk factors and primary prevention strategies in specific sports (football, ice hockey, soccer, lacrosse, basketball, and wrestling) focused on youth athletes and identifies research gaps to help inform future efforts.
- Musculoskeletal Injury Risk After Sport-Related Concussion: A Systematic Review and Meta-analysis, April L. McPherson, et.al., American Journal of Sports Medicine, Volume 47(7), (2019). Eight studies met inclusion criteria for meta-analysis. Meta-analysis results indicated that athletes who had a concussion had 2 times greater odds of sustaining a MSK injury than athletes without concussion. In addition, athletes with concussion demonstrated a higher incidence of MSK injury after return to sport compared with nonconcussed athletes. Further analysis showed that both male and female athletes with concussion were at an increased risk of MSK injury compared with their respective same-sex, nonconcussed controls. Based on the evidence of higher risk of MSK injuries after concussion, standard clinical assessments for athletes with concussion should include not only physical symptoms and cognitive function before return to sport but also neuromuscular risk factors associated with increased risk for MSK injuries.
- The magnitude of translational and rotational head accelerations experienced by riders during downhill mountain biking, Howard Hurst, Stephen Atkins, Ben D. Dickinson, Journal of Science and Medicine in Sport, Volume 21(12), pp.1256-1261, (December 2018). Sixteen male downhill cyclists (age 26.4 ± 8.4 years; stature 179.4 ± 7.2 cm; mass 75.3 ± 5.9 kg) were monitored during two rounds of the British Downhill Series. Riders performed two runs on each course wearing a triaxial accelerometer behind the right ear. The means of the two runs for each course were used to determine differences between courses for mean and maximum peak translational (g) and rotational accelerations (rad/s2) and impact duration for each course. Findings indicate that downhill riders may be at risk of sustaining traumatic brain injuries and course design influences the number and magnitude of accelerations.
- Age of first exposure to American football and long-term neuropsychiatric and cognitive outcomes. M L Alosco, A B Kasimis, J M Stamm, et.al., Translational Psychiatry, Volume 7, (19 September 2017). This research examined the association between age of first exposure (AFE) to football and behavior, mood, and cognition in a large cohort of former amateur and professional football players. The sample included 214 former football players without other contact sport history. Results indicate that there was no interaction between AFE and highest level of play. Younger AFE to football, before age 12 in particular, was associated with increased odds for impairment in self-reported neuropsychiatric and executive function in 214 former American football players. Longitudinal studies will inform youth football policy and safety decisions.
- Convergence insufficiency identifies athletes at risk of prolonged recovery from sport-related concussion, DuPrey K, Webner D, Lyons A, Kucuk C, Ellis J and Cronholm P, The American Journal of Sports Medicine, (16 May 2017).
- Development, implementation and assessment of a concussion education programme for high school student-athletes, Caron J, Rathwell S, Delaney J, Johnston K, Ptito A and Bloom G, Journal of Sports Sciences , (17 January 2017).
- Development of the Sports Organization Concussion Risk Assessment Tool (SOCRAT). Yeung, A.; Munjal, V.; Virji-Babul, N. Brain Injury. Volume 31(4), pp.542-549, (February 2017).
- A systematic review of education programmes to prevent concussion in rugby union. Fraas, Michael R.; Burchiel, Jessica, European Journal of Sport Science, Vol. 16(8), pp.1212, (November 2016).
- Player and parent concussion knowledge and awareness in youth Australian Rules Football. Hecimovicha, Mark; Kingb, Doug; Maraisc, Ida, Sport Journal, (1 April 2016).
- An evidence-based discussion of heading the ball and concussions in high school soccer, Comstock D, Currie D, Pierpoint L, Grubenhoff A and Fields S, JAMA Pediatrics, (13 July 2015). Concerns have been raised regarding the safety of soccer ball heading (when an athlete attempts to play the ball in the air with his or her head) given the rise in concussion rates, with some calling for a ban on heading among soccer players younger than 14 years. This retrospective analysis used longitudinal surveillance data collected from 2005-2014 in US high schools, for both boys and girls. The analysis indicated that although heading the ball is commonly associated with concussions, the most frequent mechanism was athlete-to-athlete contact.
- Sports-related concussion in helmeted vs unhelmeted athletes: Who fares worse? Zuckerman S, Lee Y, Odom M, Forbes J, Solomon G and Sills A, International Journal of Sports Medicine, Volume 36, Number 5 (2015).
Licencing restrictions apply to some resources.
All Clearinghouse members
'Australian' members only
'High Performance' members only
Restricted access
Various restrictions
- Concussion in Sport Guidelines – An AIS and AMA Initiative, Dr David Hughes, AIS Chief Medical Officer, Smart Talk Seminar Series, Australian Institute of Sport, Canberra (31 May 2016)
- Sports-related concussion in children and adolescents, Brain Injury Australia Workshop, NSWIS Building, Sydney Olympic Park (13 November 2015)
- Concussion management in community sport - Feature Presentation, Dr Ron Muratore, Chief Medical Officer, National Rugby League, NSW Office for Sport and Recreation, Sports Talks series, (8 October 2014)
- Concussion management in community sport - Club case study, Dennis Lowe, Sports Trainer and Club Official, Penrith Junior Rugby League, Sports Talks (8 October 2014)
- Concussion management in community sport - research, John Searl, Senior Development Manager Regional NSW, ARU, Sports Talks (8 October 2014)
- Traumatic Brain Injury in Athletes: New Concepts, New Dilemmas, James C Puffer MD, Smart Talk Seminar Series, Australian Institute of Sport, Canberra, (16 July 2014)
- Head Games: how much of you are you willing to lose for a game? Director: Steve James, (2012). (available from Clearinghouse for Sport VIDEO V RC394.C7.1)
Treatment, recovery and return to play (RTP)
Access to resources
Where possible, direct links to full-text and online resources are provided. However, where links are not available, you may be able to access documents directly by searching our licenced full-text databases (note: user access restrictions apply). Alternatively, you can ask your institutional, university, or local library for assistance—or purchase documents directly from the publisher. You may also find the information you’re seeking by searching Google Scholar.
- Concussions in Athletics: From Brain to Behaviour, Slobounov S and Sebastianelli W (editors), Springer, (2014). This book addresses the neuro-mechanisms, predispositions, and latest developments in the evaluation and management of concussive injuries. The book is organised in five parts: (1) Evaluation of Concussion and Current Development; (2) Biomechanical Mechanisms of Concussion and Helmets; (3) Neural Substrates, Biomarkers and Brain Imaging of Concussion Research; (4) Pediatric Sport-related Concussions; and (5) Clinical Management and Rehabilitation of Concussions.
- Novel Approach to Concussion Return-to-Play Decisions Based on Canadian Research, Derek Johnston, SIRC, (24 June 2020). New research from Université Laval is setting the stage for quicker return-to-play decisions that satisfy all the necessary player safety protocols by tapping into the expertise of licenced health care providers involved as team therapists. The four-year research project was led by Dr. Pierre Frémont, a practising sport physician and one of Canada’s leading authorities on concussions.
- The Role of Nutrition in Sub-Concussion Injury Protection, Ashley Armstrong, SIRCuit, (2 Apri 2020). The goal of this article is to examine nutrition-related strategies that show promise in being protective to the brain in sports that experience a high volume of sub-concussive injuries. Both dietary patterns and nutritional supplementation have shown promise in this area when strategies are adopted both before and after impacts. The article will provide general dietary guidelines and explore specific nutrients and supplements that show strong evidence around neuroprotection.
- The Role of Nutrition in Sport Concussion Recovery, Ashley Armstrong, SIRCuit, (6 November 2019). Although much of the research is still in its infancy, the integration of a safe and low risk nutritional approach may not only be protective, but have the potential to enhance recovery. Outlined below are some key interventions that should be considered in post-sport concussion treatment.
- Guidelines for diagnosing and managing pediatric concussion: Recommendations for schools and/or community sports organisations/centres, first edition, Ontario Neurotrauma Foundation, Canada (June 2014). This document is intended to guide the diagnosis and management of pediatric concussion in children and adolescents age 5 to 18 years.
- Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, Graham R, Rivara F, Ford M, and Spicer C (Editors), National Academy Press, (2013). The Institute of Medicine and National and the Research Council (NRC) in the United States convened the Committee on Sports-Related Concussion to review the available literature on concussions within the context of developmental neurobiology, specifically relating to the causes of concussions, their relationship to impacts to the head or body during sports, the effectiveness of protective devices and equipment, screening for and diagnosis of concussions, their treatment and management, and their long-term consequences. Specific topics included in this report:
- the acute, subacute, and chronic effects of single and repetitive concussive and non-concussive head impacts on the brain;
- risk factors for sports concussions, post-concussion syndrome, and chronic traumatic encephalopathy;
- the spectrum of cognitive, affective, and behavioral alterations that can occur during acute, subacute, and chronic posttraumatic phases;
- physical and biological triggers and thresholds for injury;
- the effectiveness of equipment and sports regulations in preventing injury;
- hospital- and non-hospital-based diagnostic tools; and
- treatments for sports concussions.
- The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis, Kathryn Carter, Alexandra Pauhl, Anita Christie, Medicine & Science in Sports & Exercise, Volume 53(9), pp.1835-1845, (September 2021). This systematic review and meta-analysis demonstrates that current evidence supports the notion that physical activity is beneficial in decreasing postconcussive symptoms in both the acute and chronic phases after concussion. The results indicate that unimodal subthreshold aerobic activity may be the best course of action compared with multimodal interventions. Despite this growing body of evidence, additional research is needed to determine the optimal intensity, duration, and time to initiation of aerobic exercise after concussion.
- Use of Supervised Exercise During Recovery Following Sports-Related Concussion, Popovich, Michael; Almeida, Andrea; Freeman, Jeremiah, et.al., Clinical Journal of Sport Medicine, Volume 31(2), pp.127-132, (March 2021). One hundred ninety-four consecutive new patient charts were reviewed. Patients were included if they were seen within 30 days of sustaining a SRC, and their medical records included all required data elements. One hundred twenty-six patients were included in the analysis. Symptomatic patients who initiated SE within 16 days of SRC (n = 24) were compared with those who did not undergo SE or initiated SE after postinjury day 16 (n = 84). Age, sex, history of previous concussions, injury severity, relevant comorbidities, and other treatments received were included in the analysis. No serious adverse events occurred in the early SE group. Early SE was associated with earlier return to sport (HR = 2.35, P = 0.030). The early SE group had fewer days from SRC until clearance for return to sport (mean 26.5 ± 11.2 days vs 35.1 ± 26.5 days, P = 0.020). There was a trend toward fewer symptomatic days in the early SE group (P = 0.054).
- Pediatric Post-Traumatic Headache and Implications for Return to Sport: A Narrative Review, Samantha Irwin, Joanne Kacperski, Reena G. Rastogi, Headache: the journal of head and face pain, Volume 60(6), pp.1076-1092, (June 2020). Pediatric neurologists with special qualification in headache collaborated on this narrative review. Literature was searched up until Oct 2019 for articles pertaining to post-traumatic headache (PTH), concussion, mTBI, and the return of a pediatric athlete to sport after mTBI. Article inclusion was at the discretion of the authors. There was author consensus regarding all recommendations made. The authors recommend that strict adherence to the guidelines that return to sport cannot occur until a child is symptom free at rest, off any medication, may be unreasonable in certain situations. Symptom stability is the proposed new concept for return to sport.
- Concussive Events: Using the Evidence to Guide Physical Therapist Practice, Journal of Orthopaedic and Sports Physical Therapy, Volume 50(4), pp.170-217, (April 2020). The clinical practice guideline published in the April 2020 issue of JOSPT outlines the role of physical therapy examination and management after a concussive event.
- Postconcussion Exertion Evolution Clinical and Behavioral Considerations, Register-Mihalik, Johna K., Callahan, Christine E., Current Sports Medicine Reports, Volume 19(4), pp.151-156, (April 2020). This review will outline recent evidence concerning both rest and exertion postconcussion through the lens of the socioecological model to more rapidly promote policy and practice changes.
- Improving Concussion Care for Athletes with Intellectual Disabilities, Fudge, Jessie, Current Sports Medicine Reports, Volume 19(4), pp.131-132, (April 2020).
- Return to Learn: Academic Effects of Concussion in High School and College Student-Athletes, Acacia Holmes, Zhongxue Chen, Lilian Yahng, David Fletcher, and Keisuke Kawata, Frontiers in Pediatrics, Volume 8(57), (March 2020). Our data indicate that concussions can induce negative symptoms in the academic setting regardless of age. The post-concussion difficulties in academic performance may be a grade-dependent manner, where concussions triggered difficulty in math among high school students and in reading and computer use among college students. It is clear that there is a need for guidelines and accommodations to support students with concussion in academic settings, and the guideline should reflect the age-dependent response to concussions.
- The Effects of Aerobic Exercise on Postconcussion Symptoms in Patients With Persistent Symptoms: A Critically Appraised Topic, Timothy A. Kulpa, et.al., International Journal of Athletic Therapy and Training, Volume 25(1), pp.4-11, (2020). There is moderate and sufficient SORT Level B evidence to support the inclusion of subsymptom threshold (SST) exercise in the multimodal treatment plan for patients suffering from persistent symptoms after concussion. All five included studies reported moderate to very large effects ranging from d = 0.72 to d = 10.64 in reducing symptoms after the implementation of SST aerobic exercise. Additionally, two studies also identified moderate and very large effects (d = 0.77, d = 2.56) favoring aerobic exercise over stretching interventions. These results indicate that this treatment has potential clinical utility and is a viable option to reduce symptoms in patients with postconcussion syndrome and persistent symptoms following concussion.
- Effectiveness of return to activity and return to school protocols for children postconcussion: a systematic review, DeMatteo C, Bednar ED, Randall S, et al, BMJ Open Sport and Exercise Medicine, Volume 6(1), (2020). The current data support the recommendation that children in the acute stage postconcussion should undergo 1–2 days physical and cognitive rest as they initiate graduated RTA/RTS protocols. Prolonged rest may increase reported symptoms and time to recovery. Further interventional studies are needed to evaluate the effectiveness of RTA/RTS protocols in youth with concussion.
- Early Controlled Exercise and Timing of Treatment Following Concussion: A Critically Appraised Topic, Nicholas Hattrup, Hannah Gray, Mark Krumholtz and Tamara C. Valovich McLeod, Journal of Sport Rehabilitation, Volume 29(3), pp.360-366, (2020). There is grade B evidence to demonstrate early controlled aerobic exercise, either alone or in combination with a multimodal treatment plan, may reduce the duration of symptoms following recovery and appears to cause little to no adverse events.
- Does Early Low-Intensity Aerobic Exercise Hasten Recovery in Adolescents With Sport-Related Concussion? Ryan D. Henke, Savana M. Kettner, Stephanie M. Jensen, Journal of Sport Rehabilitation, Volume 29(2), pp.248-252, (2020). The results of this review suggest subsymptom exacerbation LIAEX administered within 10 days following SRC in adolescents does not appear to delay recovery and may result in greater symptom reduction and faster medical clearance than rest. Clinicians who consider applying the LIAEX protocols, as described in the clinical bottom line, should emphasize to their patients that any exercise or activity should be below the threshold of symptom exacerbation. Information in this critically appraised topic should be reviewed in 3 years or after the publication of high-quality RCTs on this topic to determine if the recommendations suggested earlier should be modified.
- Rehabilitation Utilizing Controlled Aerobic Activity in Patients With a Concussion: A Critically Appraised Topic, Janelle Prince, Eric Schussler and Ryan McCann, Journal of Sport Rehabilitation, Volume 29(1), pp.122-126, (2020). Based on the Centre for Evidence-Based Medicine level of evidence criteria, there is grade A evidence to support the safety of controlled aerobic exercise in rehabilitation of an SRC. The included studies are randomized controlled trials that utilized consistent, good-quality patient-rated evidence to drive their results.
- Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury, Catherine C. Quatman-Yates, Airelle Hunter-Giordano, Kathy K. Shimamura, et.al., Journal of Orthopaedic and Sports Physical Therapy, Volume 50(4), pp.CPG1-CPG73, (April 2020). Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event.
- Concussion Recovery Timeline of High School Athletes Using A Stepwise Return-to-Play Protocol: Age and Sex Effects, Kaori Tamura, Troy Furutani, Ross Oshiro, Yukiya Oba, Ayaka Ling, and Nathan Murata, Journal of Athletic Training, Volume 55(1), pp.6-10, (January 2020). Implementation of a stepwise return-to-play (RTP) protocol has become the standard management strategy for high school athletes to ensure a safe RTP after concussion. The detailed characteristics of the recovery timeline throughout the steps of an RTP protocol have not been delineated among the adolescent population. Our study provides an estimated stepwise concussion recovery timeline for adolescent student-athletes. Clearance to start step 3 was the benchmark for the recovery timeline, as the duration of the exercise portion of the protocol was consistent across the age and sex groups.
- The use of an intensive physical exertion test as a final return to play measure in concussed athletes: a prospective cohort, Cameron M. Marshall, et.al., The Physician and Sportsmedicine, Volume 47(2), (2019). A total of 759 athletes performed the GGT/mGGT in the study period. Although all asymptomatic, 14.6% of concussed athletes failed the GGT/mGGT while attempting to achieve RTP clearance. Statistically significant relationships were found between failure of the test and symptom severity score on initial presentation and self-reported history of pre-morbid anxiety. When taken together, sex, age, and pre-morbid anxiety significantly predicted the length of time between injury and RTP clearance.
- Mapping brain recovery after concussion: From acute injury to 1 year after medical clearance, Nathan W. Churchill, et.al., Neurology, Volume 93(21), (November 2019). This study provides the first longitudinal evaluation of concussion focused on time of RTP and 1 year after medical clearance, using multiple different MRI measures to assess brain structure and function. These findings significantly enhance our understanding of the natural course of brain recovery after a concussion.
- The Effects of Early Physical Activity Compared to Early Physical Rest on Concussion Symptoms, Landon Lempke, Abbis Jaffri and Nicholas Erdman, Journal of Sport Rehabilitation, Volume 28(1), pp.99-105, (2019). Using the 2011 Oxford Centre for Evidence-Based Medicine taxonomy, level 3 evidence supports the recommendation that early physical activity during the acute phase of a concussion is associated with decreased symptom severity and duration. A lack of high-quality studies and inconsistent interventions limits this recommendation.
- Management of concussion in soccer, Vanessa Hubertus, Niklas Marklund and Peter Vajkoczy, Acta Neurochirurgica, Volume 161, pp.425–433, (2019). Reviews the relevance of sport-related concussion for soccer as well as its diagnosis and management. Finally, we provide insight into future directions for research in this field.
- Factors Affecting Recovery Trajectories in Pediatric Female Concussion, Desai, Natasha, et.al., Clinical Journal of Sport Medicine, Volume 29(5), pp.361-367, (September 2019). Pediatric females, on average, presented later to specialty care for evaluation after SRC than males. Females also took longer to recover on 5 markers of recovery: time to return to school without accommodations, time to return to noncontact exercise, time to return to full sport, time to recovery of neurocognitive function on computerized testing, and time to clinical recovery of vision and vestibular deficits on examination including smooth pursuits, saccades, gaze stability, near point of convergence, and balance. These sex-based differences in recovery disappeared when controlling for time to presentation to specialty care.
- Comparison of Rest to Aerobic Exercise and Placebo-like Treatment of Acute Sport-Related Concussion in Male and Female Adolescents, Barry S. Willer, Mohammad N. Haider, Itai Bezherano, et.al., Archives of Physical Medicine and Rehabilitation, Volume 100(12), pp.2267-2275, (August 2019). 151 adolescent athletes (aged 13-18 years) presenting within 10 days of SRC (mean, 5 days after injury) received a recommendation for rest (rest group [RG]). Their outcomes were compared with matched samples of adolescents assigned to aerobic exercise (exercise group [EG]) or placebo-like stretching (placebo group [PG]). The RG recovered in 16 days, which was significantly delayed compared with EG (13d). The PG recovered in 17 days. Four percent of the EG, 14% of the PG, and 13% of the RG had delayed recovery. There was no difference in recovery time or delayed recovery between male participants and female participants across groups. Female participants prescribed rest experienced an increase in symptoms vs the other groups.
- A Physiologically Based Approach to Prescribing Exercise Following a Sport-Related Concussion, Phillip R. Worts, Scott O. Burkhart and Jeong-Su Kim, Sports Medicine, Volume 49, pp.683-706, (February 2019). A growing body of evidence indicates that initiating exercise earlier in the recovery process following a concussion may reduce symptom burden and lower the incidence of post-concussion syndrome. Preliminary findings appear promising, but data on the appropriate exercise prescription for patients who recently sustained a concussion are limited. We reviewed the literature in healthy individuals and patients with concussion and post-concussion syndrome to develop a physiologically based exercise prescription for the days following a concussion. Using this, practitioners may shorten the rest period and initiate controlled exercise earlier during the recovery process following a concussion.
- Management of concussion in soccer, Vanessa Hubertus, Niklas Marklund and Peter Vajkoczy, Acta Neurochirurgica, Volume 161, pp.425–433, (January 2019). Review the relevance of sport-related concussion for Soccer as well as its diagnosis and management. Finally, we provide insight into future directions for research in this field.
- What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic review, Purcell LK, Davis GA, Gioia GA., British Journal of Sports Medicine, Volume 53(4), (2019). Schools should have a concussion policy and offer individualised academic accommodations to students recovering from sport-related concussion (SRC) on return to school (RTS); a medical letter should be provided to facilitate provision/receipt of academic accommodations; students should have early, regular medical follow-up following SRC to help with RTS and monitor recovery; students may require temporary absence from school after SRC; clinicians should assess risk factors/modifiers that may prolong recovery and require more intensive academic accommodations.
- Concussion, microvascular injury, and early tauopathy in young athletes after impact head injury and an impact concussion mouse model, Chad A Tagge Andrew M Fisher Olga V Minaeva, et.al., Brain, (18 January 2018). Based on post-mortem examination of 4 teenagers and further experiments with both mice and computer modelling, the researchers examined the development and potential mechanisms of CTE. The authors argue that collectively, their results raise concern that repetitive neurotrauma, independent of concussion, may induce early CTE brain pathologies, even in teenagers and young adults. Cumulative exposure to such injuries may also increase risk for other tau protein neurodegenerative diseases, including Alzheimer’s disease (Stein et al., 2015b). These considerations are important not only for understanding and differentiating concussion, TBI, and CTE, but also to inform clinical practice, return-to-play protocols, and public health policy.
- A prospective investigation of changes in the sensorimotor system following sports concussion. An exploratory study, Julie A. Hides, Melinda M.Franettovich Smith, M. Dilani Mendis, et.al., Musculoskeletal Science and Practice, Volume 29, (June 2017). During the playing season, 14 post-concussion assessments were performed within 3–5 days of injury. Significantly decreased sway velocity and increased size/contraction of trunk muscles, were identified. Whilst not significant overall, large inter-individual variation of test results for cervical proprioception and the vestibular system was observed. Preliminary findings post-concussion suggest an altered balance strategy and trunk muscle control with splinting/over-holding requiring consideration as part of the development of appropriate physiotherapy management strategies.
- Convergence insufficiency identifies athletes at risk of prolonged recovery from sport-related concussion, DuPrey K, Webner D, Lyons A, Kucuk C, Ellis J and Cronholm P, The American Journal of Sports Medicine, (16 May 2017).
- Diagnostic terminology, athlete status, and history of concussion affect return to play expectations and anticipated symptoms following mild traumatic brain injury. Kelly, Kiersten; Erdal, Kristi. Journal of Clinical and Experimental Neuropsychology, Volume 39(6), (August 2017), pp.587-595.
- Predictors of clinical recovery from concussion: a systematic review, Iverson GL, Gardner AJ, Terry DP, et al., British Journal of Sports Medicine, Volume 51(12), 2017. A systematic review of factors that might be associated with, or influence, clinical recovery from sport-related concussion. Clinical recovery was defined functionally as a return to normal activities, including school and sports, following injury. The most consistent predictor of slower recovery from concussion is the severity of a person’s acute and subacute symptoms. The development of subacute problems with headaches or depression is likely a risk factor for persistent symptoms lasting greater than a month. Those with a preinjury history of mental health problems appear to be at greater risk for having persistent symptoms. Those with attention deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at substantially greater risk. There is some evidence that the teenage years, particularly high school, might be the most vulnerable time period for having persistent symptoms—with greater risk for girls than boys.
- Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review, Simon M. Rice, Alexandra G. Parker, Simon Rosenbaum, Alan Bailey, Daveena Mawren, and Rosemary Purcell, Sports Medicine , (20 November 2017). Consistent with current recommendations to assess mood disturbance in post-concussive examinations, current evidence suggests a link between sports-related concussion and depression symptoms in elite athletes. Causation cannot be determined at this stage of enquiry because of the lack of well-designed, prospective studies. More research is required that considers a range of mental health outcomes in diverse samples of elite athletes/sports.
- A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Gagnon, I.; Grilli, L.; Friedman, D.; Iverson, G. L., Scandinavian Journal of Medicine and Science in Sports, Volume 26(3), (March 2016), p.299.
- Cognitive and physical symptoms of concussive injury in children: a detailed longitudinal recovery study. Crowe, Louise; Collie, Alex; Hearps, Stephen; Dooley, Julian; Clausen, Helen; Maddocks, David; McCrory, Paul; Davis, Gavin; Anderson, Vicki, British Journal of Sports Medicine, Vol. 50(5), (March 2016), p311
- Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents, Grool A, Aglipay M, Momoli F, et.al., JAMA, Volume 316, Issue 23 (2016).
- Clinical management of sport-related concussion: Developing a roadmap to a successful outcome, Guskiewicz K and Teel E, Kinesiology Review, Volume 4, Issue 2 (2015). In order to promote the most successful outcomes following concussion, a multifaceted team of individuals is required for appropriate injury diagnosis and management. This review explores the primary roles of sports medicine personnel in the diagnosis, management and recovery from sports concussion.
- Cognitive and physical symptoms of concussive injury in children: a detailed longitudinal recovery study, Crowe L, Collie A, Hearps S, Dooley J, Clausen H, Maddocks D, McCrory P, Davis G and Anderson V, British Journal of Sports Medicine , Volume 50, Issue 5 (2016).
- Mild Traumatic Brain Injury and Post-concussion Syndrome: Treatment and Related Sequela for Persistent Symptomatic Disease. Bramley, Harry; Hong, Justin; Zacko, Christopher; Royer, Christopher; Silvis, Matthew, Sports Medicine and Arthroscopy Review, Volume 24(3), (September 2016), pp.123-129.
- Movement disorders and motor impairments following repeated head trauma: A systematic review of the literature 1990–2015. Ozolins, Bede; Aimers, Nicole; Parrington, Lucy; Pearce, Alan J. Brain Injury, Volume 30(8), (April 2016), pp.937-947.
- On-field management and return-to-play in sports-related concussion in children: Are children managed appropriately? Haran, Harini P.; Bressan, Silvia; Oakley, Ed; Davis, Gavin A.; Anderson, Vicki; Babl, Franz E., Journal of Science and Medicine in Sport, Volume 19(3), (March 2016), pp.194-199.
- The persistent influence of concussion on attention, executive control and neuroelectric function in preadolescent children, Moore D, Pindus D, Raine L, Drollette E, Scudder M, Ellemberg D and Hillman C, International Journal of Psychophysiology, Volume 99, p85-95 (2016).
- Removal From Play After Concussion and Recovery Time, R.J. Elbin, Alicia Sufrinko, Philip Schatz, Jon French, Luke Henry, Scott Burkhart, Michael W. Collins, Anthony P. Kontos, Pediatrics , (August 2016).
- The Role of Nutritional Supplements in Sports Concussion Treatment. Ashbaugh, Andrew; McGrew, Christopher, Current Sports Medicine Reports, Volume 15(1), (January/February 2016), p.16
- Cognitive-motor integration deficits in young adult athletes following concussion, Brown J, Dalecki M, Hughes C, Macpherson A and Sergio L, BMC Sports Science, Medicine and Rehabilitation, Volume 7 (2015).
- The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: An international Delphi study, Reneker J, Moughiman M and Cook C, Journal of Science and Medicine in Sport, Volume 18, Number 4 (2015). Dizziness after a sports-related concussion is very common and is associated with prolonged recovery. This study was conducted to identify proper clinically administered tests and measures that are useful in differentiating between cervicogenic and other causes of dizziness after a sports-related concussion. A group of 25 experts in the field of concussion and dizziness, representing several medical disciplines, assessed ten clinical tests. Seven of these tests achieved no consensus among the experts. The clinical tests identified as having strong clinical utility are tests used to identify dizziness originating from the vestibular or central nervous system. No clinical tests specific for the cervical region achieved consensus. Expert opinion from different medical professions and even within professions was widely divergent regarding the utility of clinical tests to assess cervical dysfunction.
- Recognizing the symptoms of mental illness following concussions in the sports community: A need for improvement, Topolovec-Vranic J, Zhang S, Wong H, Lam E, Jing R, Russell K and Cusimano M, Plos One, (4 November 2015).
- Sleep disturbance and neurocognitive function during the recovery from a sport-related concussion in adolescents (abstract), Kostyun R, Milewski M and Hafeez I, American Journal of Sports Medicine, Volume 43, Number 3 (2015).
- HeadSmart. Provides an end-to-end sports concussion solution for grassroots schools and clubs and recreational athletes.
Licencing restrictions apply to some resources.
All Clearinghouse members
'Australian' members only
'High Performance' members only
Restricted access
Various restrictions
- Concussion in Sport Guidelines – An AIS and AMA Initiative, Dr David Hughes, AIS Chief Medical Officer, Smart Talk Seminar Series, Australian Institute of Sport, Canberra (31 May 2016) only
- Sports-related concussion in children and adolescents, Brain Injury Australia Workshop, NSWIS Building, Sydney Olympic Park (13 November 2015)
- Concussion management in community sport - Feature Presentation, Dr Ron Muratore, Chief Medical Officer, National Rugby League, NSW Office for Sport and Recreation, Sports Talks series, (8 October 2014)
- Concussion management in community sport - Club case study, Dennis Lowe, Sports Trainer and Club Official, Penrith Junior Rugby League, Sports Talks (8 October 2014)
- Concussion management in community sport - research, John Searl, Senior Development Manager Regional NSW, ARU, Sports Talks (8 October 2014)
- Traumatic Brain Injury in Athletes: New Concepts, New Dilemmas, James C Puffer MD, Smart Talk Seminar Series, Australian Institute of Sport, Canberra, (16 July 2014)
- Concussion in Sport Australia, Sport Australia, YouTube, (8 October 2018). Every weekend thousands of Australians are concussed while playing sport. Find out how it occurs, how to identify the symptoms and how to treat it. To learn more, visit concussioninsport.gov.au.
- Concussion in Sport Australia: Medical Practitioners, Sport Australia, YouTube, (14 November 2018). Diagnosing concussion can be difficult, even for experienced medical practitioners. Leading sports medicine experts have collaborated to provide contemporary, evidence-based guidelines for the management of concussion in sport.
- Concussion in Sport – Athletes, Australian Institute of Sport, YouTube (20 July 2015). Jayden Warner from the Australian Steelers (National Wheelchair Rugby Team) and Jasmine Simmons (Basketball Australia, Centre of Excellence athlete) share their story on how they managed their concussion. Dr David Hughes (AIS Chief Medical Officer) also provides an important message for all athletes who are suffering with concussion.
- Concussion management and return to learn, Doc Mike Evans, YouTube, (27 August 2017).
- Concussion Videos, Centers for Disease Control and Prevention, US Department of Health and Human Services. Watch pro athletes tell their stories, experts give their insights, and teens and parents discuss concussion.
- Concussions: Don't Hide It, Report It, Take Time to Recover, NCAA, YouTube, (29 July 2011)
- Concussions in Sports – Mayo Clinic. Mayo Clinic, YouTube, (27 September 2012). A young female athlete shares her story along with David Dodick, M.D., neurologist and concussion expert at Mayo Clinic in Arizona, about the road to recovery after a sports concussion.
Potential long term effects
Access to resources
Where possible, direct links to full-text and online resources are provided. However, where links are not available, you may be able to access documents directly by searching our licenced full-text databases (note: user access restrictions apply). Alternatively, you can ask your institutional, university, or local library for assistance—or purchase documents directly from the publisher. You may also find the information you’re seeking by searching Google Scholar.
- A third of kids develop a mental health problem after concussion, Murdoch Childrens Research Institute, EurekAlert!, (29 April 2021). The research, led by the Murdoch Children's Research Institute (MCRI) and published in the British Journal of Sports Medicine, found mental health should be evaluated as part of standard pediatric concussion assessment and management.
- Volleyball star Hayley Hodson had it all, until blows to her head changed everything, Patrick Hruby, yahoo!new/Los Angeles Times, (9 December 2020). Something was wrong with Hayley Hodson. She had come to Stanford as the country’s top volleyball recruit, an Olympic hopeful whose high school mornings in Newport Beach were self-scheduled down to the minute, the better to start classes early so she could lift weights before afternoon practice. Now Hodson could barely get out of bed.
- Football and dementia: heading must be banned until the age of 18, Keith Parry, Eric Anderson, Howard Hurst, The Conversation, (24 November 2020). Alarm bells are ringing in sport about the risk of a group of chronic, neuro-degenerative diseases, commonly understood as dementia. There is an increasingly large body of evidence which has identified that small, repetitive collisions of the brain inside the skull cause this disease.
- Concussion can accelerate ageing of the brain – research from the rugby pitch, Tom Owens, Chris Marley, Damian Bailey, The Conversation, (16 October 2020). By working closely with elite rugby union players, our research has now helped us to understand the impact of concussion on the brain as we get older. We have shown that brain function in a young player with a history of concussion is on a par with someone in their 60s. In simple terms, concussion seems to accelerate biological brain ageing by as much as three decades.
- Here’s what we know about CTE, the brain condition that affected Danny Frawley, Richelle Mychasiuk, Sandy Shultz, Stuart McDonald, The Conversation, (4 September 2020). Frawley’s is the second confirmed case of CTE in a former AFL player, while two former NRL players are also thought to have had the condition.
- BU-Led Study: CTE May Occur without Concussions, Boston University media release, (January 2018). A new BU-led study suggests that chronic traumatic encephalopathy (CTE) is caused by head injuries, not by concussions. The research explains why 20 percent of athletes who exhibited the early stages of the progressive brain illness postmortem never had a diagnosed concussion.
- Association of Field Position and Career Length With Risk of Neurodegenerative Disease in Male Former Professional Soccer Players, Emma Russell, Daniel Mackay, Katy Stewart, et.al., JAMA Neurology, (2 August 2021). In this cohort study of 7676 Scottish male former professional soccer players and 23 028 general population control individuals matched by sex, year of birth, and area socioeconomic status, risk of neurodegenerative disease among former soccer players varied by field position and career length but was similar across era of participation. Risk of neurodegenerative disease was higher among former professional soccer players with longer careers and among those in nongoalkeeper positions, indicating that factors associated with nongoalkeeper positions should be scrutinized to mitigate risk; meanwhile, strategies to reduce head impact exposure may be advisable to reduce negative outcomes in this population.
- Chronic Neurophysiological Effects of Repeated Head Trauma in Retired Australian Male Sport Athletes, Alan Pearce, Dawson Kidgell, Mark Tommerdahl, et.al., Fronteirs in Neurology, (March 2021). Retired male athletes with a history of playing contact sports and repeated head trauma (n = 122) were divided into two groups: those who expressed concerns regarding their mental and cognitive health (“symptomatic”: n = 83), and those who did not express any ongoing concerns (“asymptomatic”: n = 39). Both groups were compared to age-matched male controls (n = 50) with no history of concussions or participation in contact sports, an absence of self-reported cognitive, or mood impairments. Transcranial magnetic stimulation (TMS) and vibrotactile stimulation were used to assess corticomotor and somatosensory pathways respectively. TMS and vibrotactile stimulation were correlated to self-reported responses using the Fatigue and Related Symptom Survey. Linear regression was used to associate concussion history with TMS, somatosensory variables. This study shows that retired contact sport athletes expressing chronic symptoms showed significant pathophysiology compared to those with no ongoing concerns and non-concussed controls. Further, there is a linear dose-response relationship between number of reported concussions and abnormal neurophysiology. Neurophysiological assessments such as TMS and somatosensory measures represent useful and objective biomarkers to assess cortical impairments and progression of neuropsychological impairment in individuals with a history of repeated head trauma.
- Mental health and suicide in former professional soccer players, Russell ER, McCabe T, Mackay DF, et.al., Journal of Neurology, Neurosurgery & Psychiatry, Volume91 (12), pp.1256-1260, (November 2020). There is growing recognition of an association between contact sports participation and increased risk of neurodegenerative disease, including Alzheimer’s disease and chronic traumatic encephalopathy. In addition to cognitive impairment, a range of mental health disorders and suicidality are proposed as diagnostic features of traumatic encephalopathy syndrome, the putative clinical syndrome associated with chronic traumatic encephalopathy. However, to date, epidemiological data on contact sport participation and mental health outcomes are limited. Among a population of former professional soccer players with known high neurodegenerative disease mortality, hospital admissions for common mental health disorders were lower than population controls, with no difference in suicide. Our data provide support for the reappraisal of currently proposed diagnostic clinical criteria for traumatic encephalopathy syndrome, in particular the inclusion of mental health outcomes.
- Comprehensive Neuropsychiatric and Cognitive Characterization of Former Professional Football Players: Implications for Neurorehabilitation, Alex R. Terpstra, et.al., Frontiers in Neurology, (7 August 2019). Compared to control participants, former professional football players scored significantly higher on the PAI Depression, Mania, and Aggression scales, and significantly lower on response inhibition. (2) Relative to controls, former players with >3 concussions (x ;= 6.1), but not former players with ≤ 3 concussions (x = 2.0), showed (i) significantly higher scores on the PAI Depression scale, (ii) significantly more MINI clinical diagnoses overall, and manic/hypomanic episodes specifically, and (iii) significantly poorer executive function. (3) Mediation analysis revealed that concussion exposure had a significant indirect effect on PAI Depression, Mania, and Aggression via inconsistency of responding on the go/no-go task.
- Long-Term Cognitive Performance of Retired Athletes with Sport-Related Concussion: A Systematic Review and Meta-Analysis, Yanjie Zhang, et.al., Brain Sciences, Volume 9(8), (August 2019). A total of 11 studies that included 792 participants (534 retired athletes with SRC) were identified. The results indicated that the retired athletes with SRCs, compared to the non-concussion group, had significant cognitive deficits in verbal memory, delayed recall, and attention. Additionally, meta-regression demonstrated that the period of time between testing and the last concussion is significantly associated with reduced verbal memory, and increasing age is significantly associated with the verbal memory, immediate recall, and delay recall.
- Influence of playing rugby on long-term brain health following retirement: a systematic review and narrative synthesis, Joice Cunningham, Steven Broglio, Fiona Wilson, BMJ Open Sport and Exercise Medicine, (2018). This review systematically identified and studied six cross-sectional studies of living retired male or female rugby players in which at least one cognitive test was used as an outcome measure were included. Overall findings are mixed. Methodological biases reduce the overall study quality and limited the conclusions that can be drawn. Current evidence suggests that large gaps remain in the understanding of the cause-and-effect relationships between playing rugby and long-term brain health in retired players.
- A history of concussions is associated with symptoms of common mental disorders in former male professional athletes across a range of sports, Vincent Gouttebarge, Haruhito Aoki, Michael Lambert, et.al., The Physician and Sportsmedicine, Volume 45(4), pp.443-449, (September 2017). The primary aim of this study was to explore the relationship between sports career-related concussions and the subsequent occurrence of symptoms of CMD among former male professional athletes retired from football (soccer), ice hockey and rugby (union). From 1,957 former professional athletes contacted, a total of 576 (29%) completed the questionnaire. Of these, 23% had not incurred a concussion during their career, 34% had two or three, 18% four or five, and 11% six or more concussions. The number of sports career-related concussions was a predictor for all outcome measures (β = 0.072–0.109; P ≤ 0.040). Specifically, former professional athletes who reported a history of four or five concussions were approximately 1.5 times more likely to report symptoms of CMD, rising to a two- to five-fold increase in those reporting a history of six or more sports career-related concussions.
- A Comparison of Cognitive Function in Former Rugby Union Players Compared with Former Non-Contact-Sport Players and the Impact of Concussion History. Hume, Patria; Theadom, Alice; Lewis, Gwyn; et.al., Sports Medicine, Vol. 47(6), pp.1209, (June 2017).
- A systematic review of potential long-term effects of sport-related concussion, Manley G, Gardner AJ, Schneider KJ, et al., British Journal of Sports Medicine, Volume 51(12), 2017. Multiple concussions appear to be a risk factor for cognitive impairment and mental health problems in some individuals. More research is needed to better understand the prevalence of chronic traumatic encephalopathy and other neurological conditions and diseases, and the extent to which they are related to concussions and/or repetitive neurotrauma sustained in sports.
- Age of first exposure to American football and long-term neuropsychiatric and cognitive outcomes. M L Alosco, A B Kasimis, J M Stamm, et.al., Translational Psychiatry, Volume 7, (19 September 2017). This research examined the association between age of first exposure (AFE) to football and behavior, mood, and cognition in a large cohort of former amateur and professional football players. The sample included 214 former football players without other contact sport history. Results indicate that there was no interaction between AFE and highest level of play. Younger AFE to football, before age 12 in particular, was associated with increased odds for impairment in self-reported neuropsychiatric and executive function in 214 former American football players. Longitudinal studies will inform youth football policy and safety decisions.
- Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football. Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, et.al., JAMA, 318(4), (July 2017), pp.360–370. In a convenience sample of 202 deceased players of American football from a brain donation program, CTE was neuropathologically diagnosed in 177 players across all levels of play (87%), including 110 of 111 former National Football League players (99%).
- Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review, Simon M. Rice, Alexandra G. Parker, Simon Rosenbaum, Alan Bailey, Daveena Mawren, and Rosemary Purcell, Sports Medicine , (20 November 2017). Consistent with current recommendations to assess mood disturbance in post-concussive examinations, current evidence suggests a link between sports-related concussion and depression symptoms in elite athletes. Causation cannot be determined at this stage of enquiry because of the lack of well-designed, prospective studies. More research is required that considers a range of mental health outcomes in diverse samples of elite athletes/sports.
- Chronic Traumatic Encephalopathy (CTE) and Former National Football League Player Suicides. Abreu, Marcos A.; Cromartie, Fred J.; Spradley, Brandon D., Sport Journal, (29 January 2016).
- Evidence for acute electrophysiological and cognitive changes following routine soccer heading, Di Virgilio T, Hunter A, Wilson L, Stewart W, Goodall S, Howatson G, Donaldson D and Ietswaart M, EBioMedicine, (18 October 2016).
- Mild Traumatic Brain Injury and Post-concussion Syndrome: Treatment and Related Sequela for Persistent Symptomatic Disease. Bramley, Harry; Hong, Justin; Zacko, Christopher; Royer, Christopher; Silvis, Matthew, Sports Medicine and Arthroscopy Review, Volume 24(3), pp.123-129, (September 2016).
- Movement disorders and motor impairments following repeated head trauma: A systematic review of the literature 1990–2015. Ozolins, Bede; Aimers, Nicole; Parrington, Lucy; Pearce, Alan J. Brain Injury, Volume 30(8), pp.937-947, (April 2016).
- The persistent influence of concussion on attention, executive control and neuroelectric function in preadolescent children, Moore D, Pindus D, Raine L, Drollette E, Scudder M, Ellemberg D and Hillman C, International Journal of Psychophysiology, Volume 99, pp.85-95, (2016).
- Subconcussive Blows to the Head: A Formative Review of Short-term Clinical Outcomes. Belanger, Heather G.; Vanderploeg, Rodney D.; McAllister, Thomas, Journal of Head Trauma Rehabilitation, Volume 31(3), pp.159-166, (May/June 2016).
- Chronic traumatic encephalopathy pathology in a neurodegenerative disorders brain bank, Bieniek K, Ross O, Cormier K, et.al., Acta Neuropathol, (30 October 2015).
- Cognitive-motor integration deficits in young adult athletes following concussion, Brown J, Dalecki M, Hughes C, Macpherson A and Sergio L, BMC Sports Science, Medicine and Rehabilitation, Volume 7, (2015).
- Recognizing the symptoms of mental illness following concussions in the sports community: A need for improvement, Topolovec-Vranic J, Zhang S, Wong H, Lam E, Jing R, Russell K and Cusimano M, Plos One, (4 November 2015).
- Repeated head trauma is associated with smaller thalamic volumes and slower processing speed: the Professional Fighters’ Brain Health Study, Bernick C, et.al., British Journal of Sports Medicine, (29 January 2015).
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- Traumatic Brain Injury in Athletes: New Concepts, New Dilemmas, James C Puffer MD, Smart Talk Seminar Series, Australian Institute of Sport, Canberra, (16 July 2014)
- Scottish Rugby Concussion Study, Scottish Rugby, YouTube, (27 February 2014).
- Australian Sports Brain Bank. Established in 2018, as collaboration between the University of Sydney and Royal Prince Alfred (RPA) Hospital, the aim of the Sports Brain Bank is to define the spectrum of brain changes found in sportspeople who have had one or more episodes of concussion (mild traumatic brain injury or mTBI), by examination of brain tissue removed at autopsy. More information about the project, and about how to donate or support the organisation is available on the website.
- VA-BU-CLF Brain Bank. The largest tissue repository in the world focused on traumatic brain injury (TBI) and CTE. The brain bank contains more than 425 brains, including over 270 brains that have been diagnosed with CTE using the recently defined NINDS criteria for the diagnosis of CTE. Dr. McKee and her team of neuropathologists and other investigators have published a large number of studies focused on CTE which are listed on the website along with further information about the purpose of the research.
Differences between genders
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- Australian research shows female athletes have a higher rate of concussion and a prolonged recovery time, Patrick Galloway, ABC news , (2 October 2019). "There is data emerging to suggest that in gender-similar sports, females show twice the incidence of concussion as males," said Jen McCloy, the co-founder of SidelinesDr, which manages Australia's first centralised database for concussion statistics
- Sex-Related Differences in the Incidence, Severity, and Recovery of Concussion in Adolescent Student-Athletes Between 2009 and 2019, Theodore Hannah, Adam Li, Zachary Spiera, et.al., American Journal of Sports Medicine, Volume 49(7), pp.1929-1937, (June 2021). The Immediate Post-Concussion Assessment and Cognitive Testing results of 11,563 baseline and 5216 postinjury tests were used to calculate the incidence of concussion of adolescent male and female student-athletes ages 12 to 22 years (median, 15 years). The postinjury tests of 3465 male and 1751 female student-athletes evaluated for concussion or head trauma were used to assess differences in the Severity Index (SI) and recovery. When we controlled for demographic differences, female participants had higher odds of concussion and higher SI after concussion. This discrepancy in SI was a result of differences in Symptom and Processing Speed composite scores between male and female participants, respectively. We found no effect of sex on time to recovery when controlling for initial concussion SI.
- Do male and female adolescents report symptoms differently after concussion? Bara Alsalaheen, Andrea Almeida, James Eckner, et.al., Brain Injury, Volume 35(6), pp.698-704, (March 2021). A cross-sectional examination of sex differences in symptoms reported by adolescents upon initial concussion evaluation at a concussion clinic. Nine hundred and eighty-six adolescents completed the Sport Concussion Assessment Tool (SCAT5) symptom checklist. Chi-square and Mann-Whitney U tests were used for differences in the presence and severity of symptoms, respectively. Sex differences in global indices of symptom distress were compared. The greater frequency and severity of concussion symptoms reported by female adolescents highlights the importance of considering sex as a modifier for the management of concussion.
- Clinical Recovery Timelines following Sport-Related Concussion in Men's and Women's Collegiate Sports, Abigail Bretzin, Carrie Esopenko, Bernadette D'Alonzo, et.al., Journal of Athletic Training, (February 2021). College varsity and club sports. Patients or Other Participants: SRCs sustained by student-athletes (N=1,974; 38.7% female) participating in Ivy League sports were tracked from 2013/14-2018/19. There were significant differences in recovery timelines between sexes. Females experienced longer symptom duration and time to return-to-academics compared to male athletes, but females and males presented similar timelines for return-to-athletics.
- Sex-Related Differences in Neurosensory Alterations Following Blunt Head Injury, Angela Lumba-Brown, Kian Niknam, Jordan Cornwell, et.al., Frontiers in Neurology, (September 2020). Analyses were performed using an established single University dataset of 177 male and female collegiate varsity athletes who were diagnosed with concussion/mild traumatic brain injury between September 2013 and October 2019. Descriptive and comparative analyses were performed on individual and grouped acute concussion assessments pertaining to neurosensory alterations obtained within 72 h of injury using components of the Sports Concussion Assessment Tool Version 5 and Vestibular/Ocular-Motor Screening. Females had significantly more abnormal smooth pursuit (p-value: 0.045), convergence (p-value: 0.031), and visual motion sensitivity tests results (p-value: 0.023) than males. There were no differences in neurosensory alterations when grouped by overall auditory, vestibular, or oculomotor impairments. The majority of sports-related concussions occurred during football (50, 28.25%), wrestling (21, 11.86%), water polo (15, 8.47%), and basketball (14, 7.91%).
- Sex-Related Differences in the Effects of Sports-Related Concussion: A Review, Inga K. Koerte, Vivian Schultz, Valerie J. Sydnor, et.al., Journal of Neuroimaging, Volume 30(4), pp.387-409, (July/August 2020). A literature search inclusive of articles published to March 2020 was performed using PubMed. The studies were reviewed and discussed with regard to the methods used. Findings from these studies remain mixed with regard to the effect of sex on clinical symptoms, concussion-related alterations in brain structure and function, and recovery trajectories. Nonetheless, there is initial evidence to suggest that sex-related differences following concussion are important to consider in efforts to develop objective biomarkers for the diagnosis and prognosis of concussion.
- Women Are at Higher Risk for Concussions Due to Ball or Equipment Contact in Soccer and Lacrosse, Ling, Daphne; Cheng, Jennifer; Santiago, Kristen; et.al., Clinical Orthopaedics and Related Research, Volume 478(7), pp.1469-1479, (July 2020). The mechanism or activity underlying concussions differs between male and female athletes across different sports. This finding remains the same regardless of whether there are rule differences between the men’s and women’s games. The implementation of other interventions are required to further ensure player safety, including protective head equipment, concussion prevention training, or rules limiting player contact in the men’s game.
- Concussion incidence and recovery in Swedish elite soccer — Prolonged recovery in female players, Fredrik Vedung, Sofie Hänni, Yelverton Tegner, et.al., Scandinavian Journal of Medicine and Science in Sports, Volume 30(5), pp.947-957, (May 2020). In Swedish elite soccer, the concussion incidence was 1.19/1000 without gender differences. Most players recovered to play within 4 weeks post-injury. Almost one third of players continued to play at time of concussion. Female players had worse initial symptoms and longer return-to-play time than males, and a prolonged recovery beyond 3 months was only observed among female players.
- An Investigation of Factors Associated With Head Impact Exposure in Professional Male and Female Australian Football Players, Jonathan Reyes, Biswadev Mitra, Andrew McIntosh, et.al., American Journal of Sports Medicine, Volume 48(6), pp.1485-1495, (May 2020). Playing situations in which players have limited control of the football are a common cause of impacts. Male players sustained a greater exposure to HAEs compared with female players. Female players, however, sustained higher exposure to HAEs than male players during certain skill executions, possibly reflecting differences in skill development. These findings can therefore inform match and skill development in the emerging professional women’s competition of Australian football.
- Female adolescents demonstrate greater oculomotor and vestibular dysfunction than male adolescents following concussion, Margot Gray, Julie Wilson, Morgan Potter, et.al., Physical Therapy in Sport, Volume 42, pp.68-74, (March 2020). 197 female (median age = 15.2 years) and 381 male (median age = 14.6 years) pediatric patients seen for a concussion, evaluated 9.3 ± 5.2 (mean ± SD) days post-concussion. Our results indicate that within the first three weeks of a concussion, female pediatric patients demonstrated increased odds of exhibiting abnormal near point of convergence, and tandem gait test performance compared to male patients.
- Sex-Based Differences in the Incidence of Sports-Related Concussion: Systematic Review and Meta-analysis, Jennifer Cheng, Brittany Ammerman, Kristen Santiago, et.al., Sports Health: A multidisciplinary approach , Volume 11(6), (2019). Thirty-eight studies met the eligibility criteria and were included in the meta-analysis. Soccer and basketball demonstrated significantly higher incidence of concussions in females compared with males. Sex-based differences in concussion incidence rates for baseball/softball, ice hockey, lacrosse, swimming/diving, and track and field were not statistically significant. In the meta-regression analysis, there were no significant effects on the rate ratio when evaluating study design, setting, and population.
- Factors Affecting Recovery Trajectories in Pediatric Female Concussion, Desai, Natasha, et.al., Clinical Journal of Sport Medicine, Volume 29(5), pp.361-367, (September 2019). Pediatric females, on average, presented later to specialty care for evaluation after SRC than males. Females also took longer to recover on 5 markers of recovery: time to return to school without accommodations, time to return to noncontact exercise, time to return to full sport, time to recovery of neurocognitive function on computerized testing, and time to clinical recovery of vision and vestibular deficits on examination including smooth pursuits, saccades, gaze stability, near point of convergence, and balance. These sex-based differences in recovery disappeared when controlling for time to presentation to specialty care.
- Comparison of Rest to Aerobic Exercise and Placebo-like Treatment of Acute Sport-Related Concussion in Male and Female Adolescents, Barry S. Willer, Mohammad N. Haider, Itai Bezherano, et.al., Archives of Physical Medicine and Rehabilitation, Volume 100(12), pp.2267-2275, (August 2019). 151 adolescent athletes (aged 13-18 years) presenting within 10 days of SRC (mean, 5 days after injury) received a recommendation for rest (rest group [RG]). Their outcomes were compared with matched samples of adolescents assigned to aerobic exercise (exercise group [EG]) or placebo-like stretching (placebo group [PG]). The RG recovered in 16 days, which was significantly delayed compared with EG (13d). The PG recovered in 17 days. Four percent of the EG, 14% of the PG, and 13% of the RG had delayed recovery. There was no difference in recovery time or delayed recovery between male participants and female participants across groups. Female participants prescribed rest experienced an increase in symptoms vs the other groups.
- Predictors of clinical recovery from concussion: a systematic review, Iverson GL, Gardner AJ, Terry DP, et al., British Journal of Sports Medicine, Volume 51(12), 2017. A systematic review of factors that might be associated with, or influence, clinical recovery from sport-related concussion. Clinical recovery was defined functionally as a return to normal activities, including school and sports, following injury. The most consistent predictor of slower recovery from concussion is the severity of a person’s acute and subacute symptoms. The development of subacute problems with headaches or depression is likely a risk factor for persistent symptoms lasting greater than a month. Those with a preinjury history of mental health problems appear to be at greater risk for having persistent symptoms. Those with attention deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at substantially greater risk. There is some evidence that the teenage years, particularly high school, might be the most vulnerable time period for having persistent symptoms—with greater risk for girls than boys.
- Sex Differences in Time to Return-to-Play Progression After Sport-Related Concussion. Stone, Sarah; Lee, Bobby; Garrison, J. Craig; Blueitt, Damond; Creed, Kalyssa, Sports Health: A Multidisciplinary Approach, Volume 9(1), p.41, (January/February 2017).
- Sport Concussion and the Female Athlete, Resch, Jacob E. et al., Clinics in Sports Medicine, Volume 36(4), pp.717 - 739, (October 2017). The purpose of the current review was to summarize the ever-growing body of literature surrounding SC and the female athlete. The current literature supports sex differences on preinjury and postinjury neurocognitive test performance, symptom reporting, and susceptibility to and potential risk for protracted recoveries from SC. Taking this evidence into account, the authors support the need for an individualized approach to SC management based on premorbid functioning, individual risk factors, and clinical presentation after injury, regardless of biological sex.
- Comparing severe injuries by sex and sport in collegiate-level athletes: A descriptive epidemiological study, Hurtubise J, Beech C and Macpherson A, International Journal of Athletic Therapy and Training, Volume 20, Number 4 (2015).
- Differences in symptom reporting between males and females at baseline and after a sports-related concussion: A systematic review and meta-analysis, Brown D, Elass J, Miller A, Reed L and Reneker J, Sports Medicine, Volume 45, (14 May 2015). It is generally regarded that females have more symptomatic presentation than males at all time-points on the concussion spectrum. This review assessed whether differences exist by gender at baseline (pre-season) or post-concussion for self-reported symptoms. Twenty-one studies met the inclusion criteria for analysis. At baseline, females were significantly more likely to report symptoms; such as headache, emotional disturbances, vision or sleep problems. Post-concussion, only one symptom demonstrated significant difference by gender; females were less likely to report confusion than males.
Reviewed by: Australasian Sport Information Network
Last updated: 24 August 2021
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