International Consensus on Sports Concussion: Summary for Schools

Concussion continues to be a common and current topic in sports and the secondary school setting. The usual amount of time between statements is four years; however, because of the COVID-19 pandemic, the most recent guidelines were delayed by two years. This caused six years to separate the 5th and 6th International Consensus conferences and their resulting statements.

The “Consensus Statement on Concussion in Sport” from the October 2022 International Conference in Amsterdam was published in June 2023 – with some significant changes to how concussions should be managed. These updates are important to school administrators to ensure that policies reflect the most current best-practice recommendations. An annual review of concussion policy and protocol is recommended, and given these consensus changes, revisions of local policy are probably warranted.

From an administrator’s perspective, implementing the updates may seem daunting; however, the benefits far outweigh the short-term effort. Not only does updating concussion policy demonstrate to parents and the community that student safety and appropriate treatment of concussion is of highest priority, but it also strengthens risk mitigation for the school.

First and foremost, it is critical that on-site athletics stakeholders including athletic directors, coaches, athletic trainers, school nurses and team physicians must all be on the same page, consistent and supportive of one another and the consensus statement. This unified approach not only stands up to legal scrutiny, but ultimately, and most importantly, protects students’ health and welfare.

At the conclusion of 10 systematic reviews that screened more than 78,000 citations, and completing nearly 1,500 full-text reviews, the international panel of experts agreed on the following updates and revisions that pertain most directly to the school-aged student-athlete:

1. A refined definition of “concussion” includes injury mechanism of a blow to the head, neck or body. Since less than nine percent of concussions result in loss of consciousness, this is not required for diagnosis. The consensus also states that concussion does not show up on standard imaging, so a negative x-ray, CT or MRI at the emergency department does not rule out this injury.

2. Recommendations for rule modifications and warm-up routines. Eliminating body checking in youth/teen hockey is a suggested rule change, as it resulted in 58 percent reduction in concussion. Limiting the number and duration of contact practices, intensity of contact in practices and strategies restricting collision time in practices in American football across all age groups is also suggested. Investigative studies showed these changes led to a 64 percent reduction in practice-related concussions. In addition, mouthguards in youth hockey studies yielded positive results in reducing concussions, and to consider this as a rule as well.

3. The introduction of the SCAT6. The familiar sideline tool has been updated, and an additional office version (SCOAT) has been created for follow-up medical evaluations. Both the sideline SCAT, and office SCOAT tools have a child version for students aged 8-12 years. The SCAT6 is valid and reliable up to 72 hours post-injury and is a recognized and common tool.

4. Strict rest is NOT beneficial. Relative rest is defined as activities of daily living, and light, symptom limited physical exercise (such as walking), and may begin during the first 24-48 hours after injury. Reduced screen time in the first 48 hours is warranted but may not be effective beyond that. This will be beneficial for students as many schools now use laptops, tablets or similar devices for notetaking, assignments and testing. “Rest and wait” until symptom free are no longer recommended as an appropriate recovery strategy.

5. Revised strategies for return-to-learn. Prolonged absence from school has been determined to be detrimental to concussion recovery, as well as to overall wellness. Therefore, it is recommended that students return to school as soon as tolerable. Even if minimal learning is taking place, return to school, before return to learn, improves recovery. Adjustments to mitigate symptom triggers (i.e., Billed hat or sunglasses if sensitive to lights, taking frequent breaks, postponing tests), and half-day attendance can help students better tolerate the school environment.

6. Updated return-to-sport protocol. The revision allows for aerobic rehab activities to occur even when symptoms are still present, rather than restricting physical activity until completely symptom-free. Resolution of concussion symptoms is still required prior to returning to non-contact practice. The document addresses professional, international and parasport competitors, in addition to student-athletes. Experts summarized the best-practice standards in such a way as to simplify and streamline the protocols, for better understanding and compliance. The consensus is organized into “The 11 R’s”:

• Recognize: knowing the 24 signs and symptoms of concussion, as well as common mechanisms of injury.

• Reduce: mitigation of risk wherever possible, with equipment, policy and rule changes.

• Remove: using assessment tools to discontinue play, such as SCAT6, child SCAT6 and Concussion Recognition Tool (CRT- for non-medical personnel).

• Re-Eval: more detailed assessment by appropriately trained and qualified health-care providers, such as certified athletic trainers, physicians, nurse practitioners, physician assistants, school nurses, etc.).

• Rest and Exercise: relative vs. strict rest in the first 24-48 hours, and symptom limited exercise thereafter.

• Refer: symptoms lasting more than four weeks should be referred for more specialized care.

• Rehab: by health-care providers who are up to date with current best-practice guidelines.

• Recovery: not just self-reported resolution of symptoms, but use of objective test measures.

• Return to School/Learn/Sport: student-athlete returns to school as soon as possible, even if no learning is taking place; academic load is gradually increased to tolerance, within symptom limits. Return to sport allows for rehab prior to complete symptom resolution.

• Reconsider: how long-term effects of continued contact, sub-concussive blows and concussion can impact quality of life in the present as well as years in the future.

• Retire: criteria to assist in the decision to discontinue participation in contact sports.

Concussion research will continue to evolve, and organizational policies must respond accordingly. School administrators best serve their students, districts and communities by staying up to date with peer-reviewed, evidence-based guidelines. As anyone in the field of education would agree, developing young minds and preparing them for the future should also include protecting them. Preventing brain injuries, and responding appropriately is simply common sense, and utilizing a valuable resource such as the 6th International Consensus Statement on Concussion in Sport makes these responsibilities more manageable.

Reference
Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine 2023;57:695-711.