Concussion Guidelines in Amateur Sports

Concussion Guidelines in Amateur Sports: Comparison

Please note this is a comparison between Version 1 by Neil Heron and Version 2 by Vivi Li.

SRC
sports related concussion
guidelines
amateur sports

1. Introduction

It is widely recognised in sports medicine that sports-related concussion (SRC) is one of the most difficult injuries to detect, with more needed to be done to recognise, remove and treat athletes with the condition [1]. In July 2021, the Digital, Culture, Media and Sport Committee (DCIS) released a report on concussion in sport ordered by the House of Commons in the United Kingdom (UK) [2]. This report reignited the media’s interest in SRC due to the heavy criticism of the UK Government and sport’s governing bodies for their failure to reduce the risk of SRC, especially within the amateur athlete population.

An SRC is defined as a traumatic brain injury induced by biomechanical forces, either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head [3]. Thus, athletes do not need to have a head injury to be concussed, which is a common misconception. The Concussion in Sports Group (CISG) is an organisation formed in 2001 following the first International Conference on Concussion in Sport, with the most recent meeting occurring in Berlin in 2016. Following this meeting, an updated consensus statement was released, building upon the principles outlined in previous statements ^[4][5][6][7][4,5,6,7]. The Berlin statement aims to guide those involved with athlete care by providing the latest scientific research on SRC and information on the recognition, diagnosis and management of SRC [8]. Although the statement is not designed to be a clinical practise guideline or legal standard of care, it acts as a framework for the development of sport- specific concussion guidelines published by the governing bodies of sport.

As outlined in the DCIS concussion in sport report, more attention needs to be payed to SRC in the amateur athlete population. Indeed, most sport, in terms of participation numbers, is played at the amateur level. Some aspects of amateur sport may serve to increase the risk of participants suffering from an SRC, such as the reduced access to appropriate protective equipment and the lack of healthcare professionals (HCP) at sporting events and the lack of SRC education for players and coaches. Additionally, some amateur athletes play a number of sports, and it is therefore important that the different SRC guidelines for amateur sports are consistent. This ensures that athletes are not competing in some sports when they are ‘banned’ from playing in other sports due to the different concussion guidelines.

2. Sporting Organisation Guidelines

In total, fifteen sporting organisations met the inclusion criteria, with the organisations investigated shown in Table 1. Concussion guidelines were found for all sporting organisations except British Cycling (BC) and British Equestrian (BE), and as a result were excluded from the report.

Table 1. British sporting organisations under review.

Sport	Sporting Organisation Concussion Guidelines	Sport(s) Played within Organisation

Table 3. Summary of SRC guidelines published by UK sporting organisations continued.

Sporting Organisation
American Football	British American Football Associatio ^[9][15]

3. Compliance with the Berlin Statement

All 13 of the sporting organisations based their concussion protocols on the Berlin statement to varying degrees. Following the convention adopted by the CISG, the findings will be presented using the 11 “R’s” enumerated in the Berlin statement. These include recognise, remove, re-evaluate, rest, refer, recover and return to sport. Rehabilitation, residual effects and risk reduction were not included in this review, as these are more relevant for the use of HCP. Table 2 and Table 3 summarise the contents of the sport-specific concussion guidelines.

Table 2. Summary of SRC guidelines published by UK sporting organisations.

Sporting Organisation	Assessment Tools	Initial Complete Rest (Hours)		GRTP Protocol	Prolonged Recovery	Return to Work/Education	Return to Play		Notes
Sporting Organisation	Assessment Tools	Record Concussion	Multiple Concussions	GRTP Protocol	Medical Clearance	Child	Adult	Child	Notes	Adult
BAFA	SCAT3 PCRT	American Football
48	24	Yes	23	19	Athletes should not be left alone, consume alcohol or drive until all symptoms have gone	Basketball	British Basketball ^[10][16]
BB	Basketball and Wheelchair Basketball
SCAT3	PCRT	NA	NA	Yes	NA23	19	NA	NA	A second concussion within 12 months should be assessed and managed by HCPs	Yes	Boxing	England Boxing ^[11]
EB	[17]	Boxing
NA	24–48	24–48
EB	Yes	39	35	If symptoms >four weeks post injury for children or >two weeks for adults contact your GP	When going back to school, you may need to go back gradually and have some changes to your schedule so that symptoms do not worsen. You should not return to sport until you have returned to full school/learning without symptoms	Yes	Two knockouts in 90 days = 90- day suspension Three knockouts in 12 months = 1-year suspension Loss of Consciousness (LOC): <1 min = 90- day suspension >1 min = 180- day suspension Do not stay alone for the first 24 h post- injury Minimise use of mobile phones, TV, reading and all forms of training and exercise	Three LOC within a 12-month period = 18-month suspension	Cricket	England and Wales Cricket Board ^[12][18]	Cricket
	Yes	ECB	SCAT5 PCRT	NA	24	Yes	23	7	No alcohol, prescription or non- prescription drugs
ECB	Urgent neurological or neurosurgical consultancy before continuing GRTP	Return-to-school guidelines, which include extra-time for assignments/exams, quiet study areas, increased breaks and rest	Yes	Player needs a prolonged recovery period (i.e., three weeks) and/or onward referral.	Yes	Cycling	British Cycling	Road, Off road (MTB), Track, Paracycling, Amateur BMX, Leisure/Sportive & Cyclo-cross
GAA	SCAT5
GAA	VOMS CRT5	Symptoms lasting > 10–14 days should be referred to an appropriate specialist48	Male- 24–48 Female- 48	Yes	A graduated return to school/education strategy is necessary.15	NAMale- 7 Female- 15	NAShould not be left alone for first 24 h. Minimise exposure to TV, PC, laptops, smartphones, tablets, video games etc	Gaelic	Gaelic Athletic Association ^[13][19]	Gaelic, Hurling, Camogie and Handball
Yes	BG	SCAT5 PCRT	NA	48	Yes
BG	Individuals with symptoms >4 weeks for children and >2 weeks for adults may benefit from a supervised multidisciplinary approach	28	14	NA	NA	NA	NA	Gymnastics	British Gymnastics ^[14]
Yes	GBH[20]	Acrobatic Gymnastics, Aerobic Gymnastics, Disability Gymnastics, Men’s Artistic Gymnastics, Rhythmic Gymnastics, TeamGym, Trampoline, Double Mini Tramp, Tumbling and Women’s Artistic Gymnastics
SCAT5	PCRT	NA	24
GBH	Should be assessed and managed by experienced HCP	Yes	23	6	Must be off all medications that modify symptoms of the concussion e.g., painkillers	Athletes should partake in a graduated return to school programme.	NA	Should be assessed and managed by an experienced HCP	Yes	Hockey	GB and England Hockey ^[15][21]	Field Hockey
24–48	Yes	NA	6	NA
BJ	NA	7–10 days	7–10 days
BAFA	NA	A player may need a day or two off work/study to rest and reasonable adjustments made to the player’s normal work/study
EIHA
SCAT5

PCRT
EIHA	NA	NA	NA	NA		Yes	Equestrian	British Eventing ^[16][22]	Dressage, show jumping and cross country
Yes	28
BJ	14	NA	NA	If unconsciousness results from shime waza (strangulation technique) the player may be allowed to return following three days of rest	Yes	NA	Yes	Ice Hockey	England Ice Hockey Association ^[17][23]	Ice Hockey
EN	SCAT5 PCRT	NA	NA	Yes	23
EN	Recovery >10 days need referred to an experienced HCP	Academic and non- academic work should cease until stage two of the GRTP and that workload is reduced until completion of GRTP	6	If no doctor present is suitably trained and experienced in the management of SRC a mandatory two week rest period must occur before commencing GRTP for all ages	NA	If second concussion within a 12-month period or history of multiple concussions (>3) referral to experienced HCP should take place	Yes	Judo	British Judo ^[18][24]	Judo
ERL	SCAT5
ERL	PCRT	48	NA24	Yes	It is reasonable for a student to miss a day or two of studies but extended absence is uncommon and the young person’s academic teacher(s) or tutor should be consulted23	19	Individuals should avoid initially then gradually reintroduce; reading, TV, computer games and driving	Yes	NA	Yes	Netball	England Netball ^[19][25]	Netball
ERU	SCAT5	Yes	23	19	No driving, exercise, minimise screen time		No cognitive (brain) activities e.g., reading, television, computer, video games and smart phones.
NA	NA	No
BB	Concussion lasting longer than 10 days needs specialist assessmentPCRT	24–48	24–48
ERU	Athletes who fail to progress through GRTP should return to their GP for review	In some cases, it may be appropriate for the player to miss a day or two of work/study	NA	Anyone who sustains >2 concussions in a 12-month period should seek advice from their GP	No	Rugby League	England Rugby League ^[20][26]	Rugby League
FA	SCAT5 PCRT	24–48	24–48	Yes	23	19	Should not be left alone within the first 24 h, consume alcohol or drive a motor vehicle	Rugby Union
FA	NA	Students may need to have allowances made for impaired cognition during recovery e.g., extra time	NA	Any player with a second concussion within 12 months should be assessed and managed by an experienced HCP	Yes	England Rugby Union ^[21][27]	Rugby Union, Sevens Rugby, Tag and Touch Rugby
Soccer	Football Association ^[22][28]	Soccer/Football

Abbreviations: BAFA, British American Football Association; BB, British Basketball; EB, England Boxing; ECB, England Cricket Board; BC, British Cycling; GAA, Gaelic Athletic Association; BG, British Gymnastics; GBH, Great British Hockey; BE, British Eventing; EIHA, England Ice Hockey Association, BJ, British Judo; EN, England Netball; ERL, England Rugby League; ERU, England Rugby Union; FA, Football Association.

Abbreviations: SCAT—Sports Concussion Assessment Tool; PCRT—Pocket concussion recognition tool; VOMS—Vestibular Ocular Motor Screening; GRTP—Gradual return to play.

Abbreviations: HCP- Health care professional; GRTP- gradual return to play.