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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
- 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]. 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 |
|---|---|---|
| American Football | British American Football Associatio [9] | American Football |
| Basketball | British Basketball [10] | Basketball and Wheelchair Basketball |
| Boxing | England Boxing [11] | Boxing |
| Cricket | England and Wales Cricket Board [12] | Cricket |
| Cycling | British Cycling | Road, Off road (MTB), Track, Paracycling, Amateur BMX, Leisure/Sportive & Cyclo-cross |
| Gaelic | Gaelic Athletic Association [13] | Gaelic, Hurling, Camogie and Handball |
| Gymnastics | British Gymnastics [14] | Acrobatic Gymnastics, Aerobic Gymnastics, Disability Gymnastics, Men’s Artistic Gymnastics, Rhythmic Gymnastics, TeamGym, Trampoline, Double Mini Tramp, Tumbling and Women’s Artistic Gymnastics |
| Hockey | GB and England Hockey [15] | Field Hockey |
| Equestrian | British Eventing [16] | Dressage, show jumping and cross country |
| Ice Hockey | England Ice Hockey Association [17] | Ice Hockey |
| Judo | British Judo [18] | Judo |
| Netball | England Netball [19] | Netball |
| Rugby League | England Rugby League [20] | Rugby League |
| Rugby Union | England Rugby Union [21] | Rugby Union, Sevens Rugby, Tag and Touch Rugby |
| Soccer | Football Association [22] | 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.
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 | Return to Play | Notes | ||
|---|---|---|---|---|---|---|---|
| Child | Adult | Child | Adult | ||||
| BAFA | SCAT3 PCRT |
48 | 24 | Yes | 23 | 19 | Athletes should not be left alone, consume alcohol or drive until all symptoms have gone |
| BB | SCAT3 PCRT |
NA | NA | Yes | 23 | 19 | NA |
| EB | NA | 24–48 | 24–48 | Yes | 39 | 35 | 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 |
| ECB | SCAT5 PCRT |
NA | 24 | Yes | 23 | 7 | No alcohol, prescription or non- prescription drugs |
| GAA | SCAT5 VOMS CRT5 |
48 | Male- 24–48 Female- 48 |
Yes | 15 | Male- 7 Female- 15 |
Should not be left alone for first 24 h. Minimise exposure to TV, PC, laptops, smartphones, tablets, video games etc |
| BG | SCAT5 PCRT |
NA | 48 | Yes | 28 | 14 | NA |
| GBH | SCAT5 PCRT |
NA | 24 | Yes | 23 | 6 | Must be off all medications that modify symptoms of the concussion e.g., painkillers |
| EIHA | SCAT5 PCRT |
NA | 24–48 | Yes | NA | 6 | NA |
| BJ | NA | 7–10 days | 7–10 days | Yes | 28 | 14 | If unconsciousness results from shime waza (strangulation technique) the player may be allowed to return following three days of rest |
| EN | SCAT5 PCRT |
NA | NA | Yes | 23 | 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 |
| ERL | SCAT5 PCRT |
48 | 24 | Yes | 23 | 19 | Individuals should avoid initially then gradually reintroduce; reading, TV, computer games and driving |
| ERU | SCAT5 PCRT |
24–48 | 24–48 | Yes | 23 | 19 | No driving, exercise, minimise screen time No cognitive (brain) activities e.g., reading, television, computer, video games and smart phones. |
| 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 |
Abbreviations: SCAT—Sports Concussion Assessment Tool; PCRT—Pocket concussion recognition tool; VOMS—Vestibular Ocular Motor Screening; GRTP—Gradual return to play.
Table 3. Summary of SRC guidelines published by UK sporting organisations continued.
| Sporting Organisation | Prolonged Recovery | Return to Work/Education | Record Concussion | Multiple Concussions | Medical Clearance |
|---|---|---|---|---|---|
| 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 | NA | NA | No |
| BB | Concussion lasting longer than 10 days needs specialist assessment | NA | NA | A second concussion within 12 months should be assessed and managed by HCPs | Yes |
| EB | 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):
|
Yes |
| 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 |
| GAA | Symptoms lasting > 10–14 days should be referred to an appropriate specialist | A graduated return to school/education strategy is necessary. | NA | NA | Yes |
| BG | Individuals with symptoms >4 weeks for children and >2 weeks for adults may benefit from a supervised multidisciplinary approach | NA | NA | NA | Yes |
| GBH | Should be assessed and managed by experienced HCP | Athletes should partake in a graduated return to school programme. | NA | Should be assessed and managed by an experienced HCP | Yes |
| EIHA | NA | NA | NA | Yes | |
| BJ | NA | NA | Yes | NA | Yes |
| 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 | NA | If second concussion within a 12-month period or history of multiple concussions (>3) referral to experienced HCP should take place | Yes |
| ERL | NA | 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 consulted | Yes | NA | Yes |
| 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 |
| 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 |
Abbreviations: HCP- Health care professional; GRTP- gradual return to play.
This entry is adapted from the peer-reviewed paper 10.3390/ijerph19031072
References
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