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Sports physiotherapyJun 14, 2023

Osman Hassan Ahmed sat on international expert panel that has updated concussion management guidance

Physiotherapist Osman Hassan Ahmed is one of 31 expert researchers and clinicians who have written a paper that unveils updated recommendations on caring for athletes who have, or who are at risk of, concussion. The consensus statement on concussion in sport took more than five years to complete and is based on evidence gathered and distilled by more than 100 international experts.

The authors suggest an interdisciplinary working group should be set up to guide research studies into the possible long-term effects of concussion on health. Among a host of recommendations on rehabilitation strategies, the statement recommends cervico-vestibular rehabilitation – physiotherapy exercises to reduce symptoms and improve function for those experiencing dizziness – for those with neck pain and/or headaches lasting for more than 10 days.

Dr Hussain is based at the physiotherapy department at University Hospitals Dorset NHS Foundation Trust and the Football Association Centre for Para Football Research in Burton upon Trent. His PhD, which he completed at the University of Otago in New Zealand in 2012, was titled ‘The development of an early educational programme for adolescents with a concussion'.

The group’s statement – published today (15 June) in the British Journal of Sports Medicine – is based on outcomes that were formulated at an international Conference on Concussion in Sport, which was held in Amsterdam last October.

Photo Credit: Shutterstock
All young people playing ice hockey should wear mouth guards, as should adult players


New consensus process

The statement is informed by 10 systematic reviews and methodology that influenced the new consensus process. In a bid to be transparent and inclusive, the process involved anonymous voting, alternative viewpoints, open declarations of potential conflicts of interest, and included the views of athletes, a focus on para-athletes, and ethical perspectives.  

New evidence-based strategies for returning to active sport and education after concussion include early exercise and treatment recommendations, preventive approaches and targeted rehabilitation. The authors also call for the creation of a working group to guide research on the potential long-term effects of concussion on health in the future. 

We encourage clinicians and sports organisations to adapt these recommendations to their own geographic and cultural environments to optimise the care of athletes who have sustained, or who are at risk of, concussion [Kathryn Schneider]

Key recommendations include


* neuromuscular training: aerobic, balance, strength, agility exercises +/-neck-specific components – in warm-ups 
* use mouthguards in ice hockey (all ages)
* implementing laws and protocols, such as mandatory removal from play after actual or suspected concussion

* healthcare professional to give clearance for a 'return to play'

* education of coaches, parents, and athletes on the signs and symptoms of concussion

Early interventions

* a strict rest isn’t recommended: there is now stronger evidence that light intensity physical activity (such as routine activities of daily living) and aerobic exercise (such as walking and stationary cycling) can aid recovery, as can limiting ‘screen time’ during the first 48 hours

* for those experiencing dizziness, neck pain and/or headaches for more than 10 days, the statement recommends cervico-vestibular rehabilitation – physiotherapy exercises to reduce symptoms and improve function

* rehabilitation should be targeted to the needs of the individual

Persisting symptoms 
* multidisciplinary team assessment to identify the types, pattern, and severity of symptoms and any other contributory factors is advised for those with symptoms lasting more than four weeks 

* advanced neuroimaging, biomarkers (chemical signals from nerves or blood vessels), genetic tests, and other emerging technologies to assess recovery are useful for research into the diagnosis, outlook, and recovery from sports-related concussion (these are, as yet, some way off from being used in clinical practice)

Return to education and sport
* academic support may be needed for some athletes in the form of a return to learn strategy: this can include modified school attendance, limiting screen time, avoiding any contact sports or game play, extra time to complete assignments/homework or tests

* light intensity activity in the early phases of the return to sport strategy is now recommended, with full sports participation usually occurring within a month of injury

* manage athletes on an individual basis, accounting for specific factors that may affect their recovery, such as a history of migraine, anxiety and social factors

Potential long-term effects
* the statement refers to an ‘increasing societal concern about possible problems with later in life brain health in former athletes, such as mental health problems, cognitive impairment and neurological diseases’

* studies tracking the mental health of people over time (cohort studies) have found that former amateur and professional athletes do not seem to be at heightened risk of depression or suicidality later in life

* similarly, no heightened risk of neurological disease has been reported in former amateur athletes in these types of study. But some studies of former professional athletes have reported an association between playing professional American football and professional soccer and neurological disease in later life

* but the studies to date on the links between early sports participation and later life dementia and neurological disease are limited because they haven’t been able to adjust for a range of potentially highly influential factors, says the statement

Some remaining evidence gaps 

* there is limited evidence on managing sports-related concussion in five-to-12-year-olds and in para sport athletes, who are known to be at heightened risk of sports related concussion

* there is also little research on concussion in certain regions of the world, and in diverse cultural contexts, sex and genders

Consensus statement co-chair Kathryn Schneider said: ‘This statement sets out a range of new evidence-based recommendations, including those for concussion prevention as well as new versions of the concussion assessment tools and return to sport and school/learning strategies.’ 

Dr Schneider, who is based at the University of Calgary in Canada, added: ‘We encourage clinicians and sports organisations around the globe to adapt these recommendations to their own geographic and cultural environments to optimise the care of athletes who have sustained, or who are at risk of, concussion.'

To read the full version of the article – titled Consensus statement on concussion in sport: the Sixth International Conference on Concussion in Sport: Amsterdam October 2022 doi 10.1136/bjsports-2023-106898 – click 

 Twitter: #ConcussionInSport

Author: Ian A McMillan
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