Consensus Statement on Concussion in Sport

The 4th International Conference on Concussion in Sport Held in Zurich, November 2012

Paul McCrory, MBBS, PhD; Willem Meeuwisse, MD, PhD; Mark Aubry, MD; Bob Cantu, MD; Jiri Dvorak, MD; Ruben J. Echemendia, PhD; Lars Engebretsen, MD, PhD; Karen Johnston, MD, PhD; Jeffrey S. Kutcher, MD; Martin Raftery, MBBS; Allen Sills, MD; Brian W. Benson, MD, PhD; Gavin A. Davis, MBBS; Richard G. Ellenbogen, MD; Kevin M. Guskiewicz, PhD, ATC; Stanley A. Herring, MD; Grant Iverson, PhD; Barry D. Jordan, MD, MPH; James Kissick MD, CCFP, Dip Sport Med; Michael McCrea, PhD, ABPP; Andrew S McIntosh, MBiomedE, PhD; David L. Maddocks, LLB, PhD; Michael Makdissi, MBBS, PhD; Laura Purcell, MD, FRCPC; Margot Putukian, MD; Michael Turner MBBS; Kathryn Schneider, PT, PhD; Charles H. Tator, MD, PHD

Disclosures

Clin J Sport Med. 2013;23(2):89-117.

Preamble

This paper is a revision and update of the recommendations developed following the 1^st (Vienna 2001), 2^nd (Prague 2004) and 3^rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.^[1–3]

The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. 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 (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or converted to a digital format. The authors request that the document and/or the accompanying tools be distributed in their full and complete format.

This consensus paper is broken into a number of sections

A summary of concussion and its management, with updates from the previous meetings;
Background information about the consensus meeting process;
A summary of the specific consensus questions discussed at this meeting;
The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT (designed for lay use).

1 2 3 4 5 6

Next Section

Table 1. Graduated return to play protocol
Rehabilitation stage	Functional exercise at each stage of rehabilitation	Objective of each stage
1. No activity	Symptom limited physical and cognitive rest	Recovery
2. Light aerobic exercise	Walking, swimming or stationary cycling keeping intensity <70% maximum permitted heart rateNo resistance training	Increase HR
3. Sport-specific exercise	Skating drills in ice hockey, running drills in soccer. No head impact activities	Add movement
4. Non-contact training drills	Progression to more complex training drills, eg, passing drills in football and ice hockeyMay start progressive resistance training	Exercise, coordination and cognitive load
5. Full-contact practice	Following medical clearance participate in normal training activities	Restore confidence and assess functional skills by coaching staff
6. Return to play	Normal game play

Table 2. Concussion modifiers
Factors	Modifier
Symptoms	Number
	Duration (>10 days)
	Severity
Signs	Prolonged loss of consciousness (LOC) (>1 min), Amnesia
Sequelae	Concussive convulsions
Temporal	Frequency - repeated concussions over time
	Timing - injuries close together in time
	'Recency' - recent concussion or traumatic brain injury (TBI)
Threshold	Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion
Age	Child and adolescent (<18 years old)
Comorbidities and premorbidities	Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders
Medication	Psychoactive drugs, anticoagulants
Behaviour	Dangerous style of play
Sport	High-risk activity, contact and collision sport, high sporting level

Appendix I. Affiliation and disclosure statement for all authors
Name	Affiliations	Disclosures
WRITING GROUP
Paul McCrory, MBBS, PhD	Associate Professor, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia	Paul McCrory is a co-investigator, collaborator, or consultant on grants relating to mild TBI funded by several governmental organizations. He is Co- Chair of the Australian Centre for Research into Sports Injury and its Prevention (ACRISP), which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). He has a clinical and consulting practice in general and sports neurology. He receives book royalties from McGraw-Hill and was employed in an editorial capacity by the British Medical Journal Publishing Group from 2001–2008. He has been reimbursed by the government, professional scientific bodies, and sporting bodies for presenting research relating to mild TBI and sportrelated concussion at meetings, scientific conferences, and symposiums. He received consultancy fees in 2010 from Axon Sports (US) for the development of educational material (which was not renewed) and has received research funding since 2005 from CogState Inc. He is a cofounder and shareholder in two biomedical companies (involved in eHealth and Compression garment technologies) but does not hold any individual shares in any company related to concussion or brain injury assessment or technology. He did not receive any form of financial support directly related to this manuscript.
Willem H. Meeuwisse, MD, PhD	Professor and Co-Chair, Sport Injury Prevention Research Centre, Faculty of Kinesiology and Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada	Willem Meeuwisse, MD, PhD, has received research grant support through the University of Calgary from the Canadian Institutes of Health Research, Alberta Innovates Health Solutions, the International Football Association (FIFA), Alberta Children's Hospital Research Institute and the Hotchkiss Brain Institute. He is Co-Chair of the Sport Injury Prevention Research Centre, which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). He has a clinical and consulting practice in sport medicine at the University of Calgary Sport Medicine Centre with a focus on sport related concussion. He has received travel funding from FIFA and the Medical Commission of the IOC. From 1998–2012 he was the Editor-in-Chief of the Clinical Journal of Sport Medicine and received editorial support funding from Lippincott- Wolters Kluwer. He receives compensation as a medical consultant to the National Hockey League, may receive royalty from BKIN Technologies, and is a shareholder of Safebrain Canada and PrivIT Healthcare. He did not receive any form of financial support directly related to this manuscript.
Mark Aubry MD, Dip Sport Med	Chief Medical Officer, International Ice Hockey Federation, Switzerland; Member of the IOC Medical Commission Games Group, Co-Director Ottawa Sport Medicine Centre, Ottawa, Ontario, Canada	Mark Aubry, MD, Dip Sport Med, receives travel funding from the IIHF and IOC Medical Commission Games Group for meetings, IIHF Championships and Olympic Games. He did not receive any form of financial support directly related to this manuscript.
Robert C. Cantu, MA, MD	Clinical Professor, Neurosurgery, and Co-Director Center for the Study of Traumatic Encephalopathy, Boston University Medical Center, Boston, Massachusetts	Robert C. Cantu, MA, MD, serves as Vice President, National Operating Committee on Standards for Athletic Equipment (NOCSAE), Co-Founder and Chairman, Medical Director, Sports Legacy (SLI), Waltham, MA, USA; Senior Advisor to NFL's Head, Neck and Spine Committee, Expert witness trial testimony. He did not receive any form of financial support directly related to this manuscript.
Jiří Dvořák, MD, PhD	Professor of Neurology, University of Zurich; Senior Consultant Schulthess Clinic Zurich, Switzerland; Chairman, FMARC (FIFA Medical Assessment and Research Center), Zurich, Switzerland	Jiri Dvorak, MD, PhD, received compensation from his work at FIFA as FIFA Chief Medical Officer, no other compensations or grants have been received. He did not receive any form of financial support directly related to this manuscript.
Ruben J. Echemendia, PhD	Psychological and Neurobehavioral Associates, Inc, State College, Pennsylvania; Adjunct Associate Professor of Psychology, University of Missouri – Kansas City, Missouri	Ruben J. Echemendia, PhD, receives financial compensation as a consultant to the National Hockey League, Major League Soccer, and the U.S. Soccer Federation. He also receives financial compensation as a consultant to Princeton University and has served as a PI or co-PI on grants funded by NOCSAE, AMSSM, and the New Jersey Commission on Brain Injury Research. Dr. Echemendia maintains a private practice focused on clinical neuropsychology, sports neuropsychology, and forensic applications of neuropsychology. He did not receive any form of financial support directly related to this manuscript.
Lars Engebretsen, MD, PhD	Professor, Department of Orthopaedic Surgery, Oslo University Hospital, and Faculty of Medicine, University of Oslo, Norway; Cochair Oslo Sports Trauma Research Center, Oslo, Norway; Head Scientific Activities, International Olympic Committee, Lausanne, Switzerland	Lars Engebretsen, MD, PhD has received research grant support through the University of Oslo from the Norwegian Institutes of Health Research, The Health South East, the International Football Association (FIFA). He is Co-Chair of the Sport Injury Prevention Research Centre, which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). He is the professor and Chair of the Oslo University Orthopadic department. He has been Editor-in-Chief of the BJSM IPHP From 2008. From January 2012 he has been co-editor of The Journal of Bone and Joint Surgery. He did not receive any form of financial support directly related to this manuscript.
Karen M. Johnston, MD, PhD	Neurosurgeon, Division of Neurosurgery, University of Toronto, Ontario, Canada Concussion Management Program, Athletic Edge Sports Medicine, Toronto, Ontario, Canada	Karen M. Johnston, MD, PhD, is a neurosurgeon subspecialized in brain trauma and has a clinical and research focus in sport concussion. She has received research funding through the CIHR, ONF and Innovation Fund, American College of Surgeons, McGill University, Pashby Sport Safety Fund and Think First Canada. She has independently consulted widely with many sport organizations however she has not and has never had a formal reimbursed affiliation with any sport team or sport governing body. She did not receive any form of financial support directly related to this manuscript.
Jeffrey S. Kutcher, MD	Associate Professor and Director, Michigan NeuroSport, Departement of Neurology, University of Michigan, Ann Arbor, Michigan	Jeffrey S. Kutcher, MD, is the Director of Michigan NeuroSport, the University of Michigan's academic sports neurology program. He has received research grant support from the National Collegiate Athletic Association and ElMindA, Ltd. He is the Director of the National Basketball Association's Concussion Program and is a paid consultant for the National Hockey League Players' Association. He is a current member of the National Football League Players' Association's Mackey-White TBI Committee. He is also a consulting neurologist for the United States Ski and Snowboard Association. He was a founding member and the first Chairperson of the Sports Neurology Section of the American Academy of Neurology. He did not receive any form of financial support directly related to this manuscript.
Martin Raftery, MBBS FACSP	Chief Medical Officer, International Rugby Board, Dublin, Ireland	No disclosures
Allen Sills, MD, FACS	Associate Professor of Neurosurgery, Orthopaedic Surgery and Rehabilitation, Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee	Allen Sills, MD, FACS, serves on the medical board of the Federation Equestrian Internationale (FEI) and has received travel funding from that organization. He also serves as unpaid neurosurgical consultant to the US Equestrian Foundation, the Southeastern Conference (SEC) Working Group on Concussion, and the Nashville Predators (NHL) hockey team. He has a clinical practice in neurosurgery at the Vanderbilt University Medical Center with a focus on neurological problems in athletes. He did not receive any form of financial support directly related to this manuscript.
COAUTHORS
Brian W. Benson, MD, PhD	Adjunct Research Assistant Professor, Department of Clinical Neurosciences, Faculty of Medicine; Clinical Assistant Professor, Department of Family Medicine; and Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada	Brian W. Benson, MD, PhD, has a clinical and consulting practice in sport medicine at the University of Calgary Sport Medicine Centre with a focus on sport-related concussion. He also serves as Director of the Sport Concussion Clinic at the University of Calgary Sport Medicine Centre and may receive royalty from BKIN Technologies. He did not receive any form of financial support directly related to this manuscript.
Gavin A. Davis, MBBS	Department of Neurosurgery, Austin and Cabrini Hospitals & The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia	Gavin A. Davis, MBBS, has received travel funding from FIFA. He did not receive any form of financial support directly related to this manuscript.
Richard G. Ellenbogen, MD,	Professor and Chairman, Theodore S. Roberts Endowed Chair, Department of Neurological Surgery, University of Washington Seattle, Washington; Co-Chair, NFL Head, Neck and Spine Medical Committee	None declared. (National Football League, Volunteer Consultant to Commissioner. No financial remunerations received). He did not receive any form of financial support directly related to this manuscript.
Kevin M. Guskiewicz, PhD, ATC	Kenan Distinguished Professor and Chair, Department of Exercise and Sport Science; Co-Director, Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina	Kevin Guskiewicz, PhD, ATC, serves on the NCAA's Health and Safety Advisory Committee for Concussion, the NFL's Head Neck and Spine Committee, and the NFLPA's Mackey-White Committee; has received funding for travel and honoraria for lectures on sports concussion for professional organizations, including the IOC and FIFA; has given expert testimony on traumatic brain injury/concussion cases; and has received research funding from the National Institutes of Health, Centers for Disease Control and Prevention, National Operating Committee for Standards in Athletic Equipment, National Collegiate Athletic Association, NFL Charities, NFL Players' Association, USA Hockey, and National Athletic Trainers' Association. He did not receive any form of financial support directly related to this manuscript.
Stanley A. Herring, MD	Clinical Professor, Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington; Co-Medical Director, Seattle Sports Concussion Program; Team Physician, Seattle Seahawks and Seattle Mariners, Seattle, Washington	Stanley A. Herring, MD, serves as a Member, National Football League Head, Neck and Spine Committee; Member, Football and Wellness Committee USA Football; Member, Medical Advisory Board Pop Warner Football; Chair of Medical Advisory Board X2IMPACT, a nonfinancial position. Clinical and consulting practice at Harborview Medical Center focusing on the diagnosis and management of neurological and musculoskeletal injuries with particular interest in spinal disorders in active people and athletes and sports-related concussions. No form of financial support directly related to this manuscript was received.
Grant Iverson, PhD	Neuropsychology Outcome Assessment Laboratory; Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada	Grant Iverson, PhD, has been reimbursed by the government, professional scientific bodies, and commercial organizations for discussing or presenting research relating to mild TBI and sport-related concussion at meetings, scientific conferences, and symposiums. He has a clinical and consulting practice in forensic neuropsychology involving individuals who have sustained mild TBIs (including professional athletes). He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He did not receive any form of financial support directly related to this manuscript.
Barry D. Jordan, MD, MPH	Associate Professor of Clinical Neurology at Weill Medical College of Cornell University, New York, New York; Assistant Medical Director of the Burke Rehabilitation Hospital, White Plains, New York; Chief Medical Officer of the New York State Athletic Commission, New York, New York; National Football League Players Association (NFLPA) Mackey-White Traumatic Brain Injury Committee.	Dr. Jordan has received financial compensation from the National Football League (NFL) Benefits Association for the establishment of a Neurocognitive Disability Benefit for retired players. He also has received financial compensation from Innovative CEUs for developing a medical-based high school coaching education program. In his position as the Chief Medical Officer of the New York State Athletic Commission, Dr. Jordan is a governor's appointed public officer of the State of New York. He maintains an inpatient and outpatient clinical practice at the Burke Rehabilitation Hospital specializing in traumatic brain injury, dementia and sports neurology. Dr. Jordan did not receive any financial support related to this manuscript.
James Kissick MD, CCFP, Dip Sport Med	Sport Medicine Physician, Ottawa Sport Medicine Centre, Ottawa, Ontario, Canada; Clinical Lecturer, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; Team Physician, Canadian National Men's Sledge Hockey Team.	James Kissick has a clinical and consulting practice in sport and exercise medicine at the Ottawa Sport Medicine Centre. He did not receive any form of financial support directly related to this manuscript.
Michael McCrea, PhD, ABPP	Professor & Director of Brain Injury Research, Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin	Michael McCrea, PhD, has been funded by the United States Department of Defense, U.S. Defense Veterans Brain Injury Center (DVBIC), NFL Charities, National Collegiate Athletic Association (NCAA), National Operating Committee on Standards for Athletic Equipment (NOCSAE), National Federation of High School Associations (NFHS), and other funding organizations over the past decade. Dr. McCrea is a member of the NFL Head, Neck and Spine Committee and has served on several U.S. national panels for scientific review and policy making relevant to sport-related concussion. He has been funded by BrainScope, Inc. for prior studies, but receives no direct compensation from BrainScope or other industry entities or sports organizations. Dr. McCrea is co-author of the Standardized Assessment of Concussion (SAC). He receives no financial compensation or support from publication or distribution of the SAC. He is currently principal investigator (PI) on a study by the U.S. Department of Defense comparing several computerized neurocognitive assessment tools for the assessment of sport-related concussion. He did not receive any form of financial support directly related to this manuscript.
Andrew S McIntosh, BAppSci (PT), MBiomedE, PhD	Adjunct Associate Professor, Australian Centre for Research into Injury in Sports and its Prevention, Monash Injury Research Institute, Monash University; Adjunct Associate Professor, Transport and Road Safety Research, Faculty of Science, the University of New South Wales; Director, McIntosh Consultancy and Research Pty Ltd. Sydney, Australia	Andrew McIntosh in a self-employed consultant. In the area of sport and sports injury research he has received grant support through UNSW from the Australian Research Council, NSW Racing, the IRB, the ARU, and the AFL. As a consultant In the area of sport and sports injury he has undertaken paid work for the Australian Racing Board, McLaren F1, the IRB and Albion. He has received travel funding from the International Rugby Board, IIHF, FIFA and the Medical Commission of the IOC. He did not receive any form of financial support directly related to this manuscript.
David L. Maddocks, LLB, PhD	Barrister & Solicitor, Perry Maddocks Trollope Lawyers, Melbourne, Australia; Neuropsychologist in private practice.	David Maddocks, LLB, PhD, has received research grant support through the Australian Football League (AFL). He provides consultancy medico-legal advice to the AFL. He has received travel funding from FIFA. He did not receive any form of financial support directly related to this manuscript.
Michael Makdissi, MBBS, PhD	Research Fellow, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Melbourne, Australia; Research Fellow, Centre for Health, Exercise & Sports Medicine, and Physiotherapy Department, University of Melbourne, Melbourne, Australia	Michael Makdissi, MBBS, PhD, has received research grant support through The Florey Institute of Neurosciences and Mental Health from the National Health and Medical Research Council, the Australian Football League (AFL) and AFL Medical Officers Association. He has received travel funding from FIFA. He has a clinical and consulting practice in sports medicine. He did not receive any form of financial support directly related to this manuscript.
Laura Purcell, MD, FRCPC	Associate Clinical Professor, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada; Pediatric Sport Medicine Physician, David Braley Sport Medicine and Rehabilitation Centre, McMaster University, Hamilton, Ontario, Canada; President, Paediatric Sport and Exercise Medicine Section, CPS	No disclosures
Margot Putukian, MD	Director of Athletic Medicine, Head Team Physician, Princeton University, Princeton, New Jersey; Associate Clinical Professor, Robert Wood Johnson Medical School at University of Medicine and Dentistry of New Jersey (UMDNJ), Piscataway Township, New Jersey	Margot Putukian, MD, has received research grant support through the new Jersey Commission on Brain Injury, the American Medical Society for Sports Medicine (AMSSM) and the National Operating Committee on Standards for Athletic Equipment (NOCSAE). She is the chair of the US Lacrosse Sports Science & Safety Committee and also serves on the National Football League (NFL) Head, Neck and Spine Committee, chairing the Return to Play subcommittee for the NFL. She works as a team physician for Princeton University, as well as team physician for the US Men's National Lacrosse Team and for US Soccer. She is a consultant on concussion for the Centers for Disease Control and Prevention (CDC) and the National Collegiate Athletic Association (NCAA). She is a past president for the AMSSM and currently is president of the AMSSM Foundation. Dr. Putukian does not receive any financial compensation for her work with the AMSSM, NFL, US Lacrosse, CDC or NCAA. She did not receive any form of financial support directly related to this manuscript.
Kathryn Schneider, PT, PhD	Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada	Kathryn Schneider, PT, PhD has received research grant support through the University of Calgary from the Alberta Centre for Child, Family and Community Research. She has a clinical and consulting practice in physiotherapy at Evidence Sport and Spinal and Centric Health with a focus on sport related concussion. She did not receive any form of financial support directly related to this manuscript.
Charles H. Tator, MD, PHD	Professor of Neurosurgery, Toronto Western Hospital and University of Toronto, Ontario, Canada; Senior Scientist, Krembil Neuroscience Centre, Toronto, Ontario, Canada; Founder, ThinkFirst Canada; Board Member, Parachute Canada.	Charles Tator is a consultant to ImpaKt Protective, and is co-chair of the Concussion Awareness and Recognition Committee of the Ontario Neurotrauma Foundation. He is Chair of ThinkFirst's Concussion Education and Awareness Committee, and Project Director of the Canadian Sports Concussion Project at the Krembil Neuroscience Centre. He is Director of the Ontario Concussion Centres Consortium. He has received research grants from many public sources including the Canadian Institute for Health Research, and the Ontario Brain Institute. He did not receive any financial support related to this manuscript.
Michael Turner, MBBS	Chief Medical Adviser, British Horseracing Authority, London, United Kingdom	Michael Turner is employed as Chief Medical Adviser by the British Horseracing Authority and the Lawn Tennis Association. He has received travel funding from FIFA, the IOC, the ACSM and Gruppoforte (Physiomind) for attending conferences and lecturing. In addition to travel funding, most conference organisers also provided free registration and support for accommodation. He did not receive any form of financial support directly related to this manuscript.

NB: All panelists received travel funding and accommodation from the Concussion in Sport Group to attend the Consensus meeting in Zurich, Switzerland.

Appendix I

Affiliation and Disclosure Statement for All Authors

Name	Affiliations	Disclosures
WRITING GROUP
Paul McCrory, MBBS, PhD	Associate Professor, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia	Paul McCrory is a co-investigator, collaborator, or consultant on grants relating to mild TBI funded by several governmental organizations. He is Co- Chair of the Australian Centre for Research into Sports Injury and its Prevention (ACRISP), which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). He has a clinical and consulting practice in general and sports neurology. He receives book royalties from McGraw-Hill and was employed in an editorial capacity by the British Medical Journal Publishing Group from 2001–2008. He has been reimbursed by the government, professional scientific bodies, and sporting bodies for presenting research relating to mild TBI and sportrelated concussion at meetings, scientific conferences, and symposiums. He received consultancy fees in 2010 from Axon Sports (US) for the development of educational material (which was not renewed) and has received research funding since 2005 from CogState Inc. He is a cofounder and shareholder in two biomedical companies (involved in eHealth and Compression garment technologies) but does not hold any individual shares in any company related to concussion or brain injury assessment or technology. He did not receive any form of financial support directly related to this manuscript.
Willem H. Meeuwisse, MD, PhD	Professor and Co-Chair, Sport Injury Prevention Research Centre, Faculty of Kinesiology and Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada	Willem Meeuwisse, MD, PhD, has received research grant support through the University of Calgary from the Canadian Institutes of Health Research, Alberta Innovates Health Solutions, the International Football Association (FIFA), Alberta Children's Hospital Research Institute and the Hotchkiss Brain Institute. He is Co-Chair of the Sport Injury Prevention Research Centre, which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). He has a clinical and consulting practice in sport medicine at the University of Calgary Sport Medicine Centre with a focus on sport related concussion. He has received travel funding from FIFA and the Medical Commission of the IOC. From 1998–2012 he was the Editor-in-Chief of the Clinical Journal of Sport Medicine and received editorial support funding from Lippincott- Wolters Kluwer. He receives compensation as a medical consultant to the National Hockey League, may receive royalty from BKIN Technologies, and is a shareholder of Safebrain Canada and PrivIT Healthcare. He did not receive any form of financial support directly related to this manuscript.
Mark Aubry MD, Dip Sport Med	Chief Medical Officer, International Ice Hockey Federation, Switzerland; Member of the IOC Medical Commission Games Group, Co-Director Ottawa Sport Medicine Centre, Ottawa, Ontario, Canada	Mark Aubry, MD, Dip Sport Med, receives travel funding from the IIHF and IOC Medical Commission Games Group for meetings, IIHF Championships and Olympic Games. He did not receive any form of financial support directly related to this manuscript.
Robert C. Cantu, MA, MD	Clinical Professor, Neurosurgery, and Co-Director Center for the Study of Traumatic Encephalopathy, Boston University Medical Center, Boston, Massachusetts	Robert C. Cantu, MA, MD, serves as Vice President, National Operating Committee on Standards for Athletic Equipment (NOCSAE), Co-Founder and Chairman, Medical Director, Sports Legacy (SLI), Waltham, MA, USA; Senior Advisor to NFL's Head, Neck and Spine Committee, Expert witness trial testimony. He did not receive any form of financial support directly related to this manuscript.
Jiří Dvořák, MD, PhD	Professor of Neurology, University of Zurich; Senior Consultant Schulthess Clinic Zurich, Switzerland; Chairman, FMARC (FIFA Medical Assessment and Research Center), Zurich, Switzerland	Jiri Dvorak, MD, PhD, received compensation from his work at FIFA as FIFA Chief Medical Officer, no other compensations or grants have been received. He did not receive any form of financial support directly related to this manuscript.
Ruben J. Echemendia, PhD	Psychological and Neurobehavioral Associates, Inc, State College, Pennsylvania; Adjunct Associate Professor of Psychology, University of Missouri – Kansas City, Missouri	Ruben J. Echemendia, PhD, receives financial compensation as a consultant to the National Hockey League, Major League Soccer, and the U.S. Soccer Federation. He also receives financial compensation as a consultant to Princeton University and has served as a PI or co-PI on grants funded by NOCSAE, AMSSM, and the New Jersey Commission on Brain Injury Research. Dr. Echemendia maintains a private practice focused on clinical neuropsychology, sports neuropsychology, and forensic applications of neuropsychology. He did not receive any form of financial support directly related to this manuscript.
Lars Engebretsen, MD, PhD	Professor, Department of Orthopaedic Surgery, Oslo University Hospital, and Faculty of Medicine, University of Oslo, Norway; Cochair Oslo Sports Trauma Research Center, Oslo, Norway; Head Scientific Activities, International Olympic Committee, Lausanne, Switzerland	Lars Engebretsen, MD, PhD has received research grant support through the University of Oslo from the Norwegian Institutes of Health Research, The Health South East, the International Football Association (FIFA). He is Co-Chair of the Sport Injury Prevention Research Centre, which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). He is the professor and Chair of the Oslo University Orthopadic department. He has been Editor-in-Chief of the BJSM IPHP From 2008. From January 2012 he has been co-editor of The Journal of Bone and Joint Surgery. He did not receive any form of financial support directly related to this manuscript.
Karen M. Johnston, MD, PhD	Neurosurgeon, Division of Neurosurgery, University of Toronto, Ontario, Canada Concussion Management Program, Athletic Edge Sports Medicine, Toronto, Ontario, Canada	Karen M. Johnston, MD, PhD, is a neurosurgeon subspecialized in brain trauma and has a clinical and research focus in sport concussion. She has received research funding through the CIHR, ONF and Innovation Fund, American College of Surgeons, McGill University, Pashby Sport Safety Fund and Think First Canada. She has independently consulted widely with many sport organizations however she has not and has never had a formal reimbursed affiliation with any sport team or sport governing body. She did not receive any form of financial support directly related to this manuscript.
Jeffrey S. Kutcher, MD	Associate Professor and Director, Michigan NeuroSport, Departement of Neurology, University of Michigan, Ann Arbor, Michigan	Jeffrey S. Kutcher, MD, is the Director of Michigan NeuroSport, the University of Michigan's academic sports neurology program. He has received research grant support from the National Collegiate Athletic Association and ElMindA, Ltd. He is the Director of the National Basketball Association's Concussion Program and is a paid consultant for the National Hockey League Players' Association. He is a current member of the National Football League Players' Association's Mackey-White TBI Committee. He is also a consulting neurologist for the United States Ski and Snowboard Association. He was a founding member and the first Chairperson of the Sports Neurology Section of the American Academy of Neurology. He did not receive any form of financial support directly related to this manuscript.
Martin Raftery, MBBS FACSP	Chief Medical Officer, International Rugby Board, Dublin, Ireland	No disclosures
Allen Sills, MD, FACS	Associate Professor of Neurosurgery, Orthopaedic Surgery and Rehabilitation, Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee	Allen Sills, MD, FACS, serves on the medical board of the Federation Equestrian Internationale (FEI) and has received travel funding from that organization. He also serves as unpaid neurosurgical consultant to the US Equestrian Foundation, the Southeastern Conference (SEC) Working Group on Concussion, and the Nashville Predators (NHL) hockey team. He has a clinical practice in neurosurgery at the Vanderbilt University Medical Center with a focus on neurological problems in athletes. He did not receive any form of financial support directly related to this manuscript.
COAUTHORS
Brian W. Benson, MD, PhD	Adjunct Research Assistant Professor, Department of Clinical Neurosciences, Faculty of Medicine; Clinical Assistant Professor, Department of Family Medicine; and Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada	Brian W. Benson, MD, PhD, has a clinical and consulting practice in sport medicine at the University of Calgary Sport Medicine Centre with a focus on sport-related concussion. He also serves as Director of the Sport Concussion Clinic at the University of Calgary Sport Medicine Centre and may receive royalty from BKIN Technologies. He did not receive any form of financial support directly related to this manuscript.
Gavin A. Davis, MBBS	Department of Neurosurgery, Austin and Cabrini Hospitals & The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia	Gavin A. Davis, MBBS, has received travel funding from FIFA. He did not receive any form of financial support directly related to this manuscript.
Richard G. Ellenbogen, MD,	Professor and Chairman, Theodore S. Roberts Endowed Chair, Department of Neurological Surgery, University of Washington Seattle, Washington; Co-Chair, NFL Head, Neck and Spine Medical Committee	None declared. (National Football League, Volunteer Consultant to Commissioner. No financial remunerations received). He did not receive any form of financial support directly related to this manuscript.
Kevin M. Guskiewicz, PhD, ATC	Kenan Distinguished Professor and Chair, Department of Exercise and Sport Science; Co-Director, Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina	Kevin Guskiewicz, PhD, ATC, serves on the NCAA's Health and Safety Advisory Committee for Concussion, the NFL's Head Neck and Spine Committee, and the NFLPA's Mackey-White Committee; has received funding for travel and honoraria for lectures on sports concussion for professional organizations, including the IOC and FIFA; has given expert testimony on traumatic brain injury/concussion cases; and has received research funding from the National Institutes of Health, Centers for Disease Control and Prevention, National Operating Committee for Standards in Athletic Equipment, National Collegiate Athletic Association, NFL Charities, NFL Players' Association, USA Hockey, and National Athletic Trainers' Association. He did not receive any form of financial support directly related to this manuscript.
Stanley A. Herring, MD	Clinical Professor, Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington; Co-Medical Director, Seattle Sports Concussion Program; Team Physician, Seattle Seahawks and Seattle Mariners, Seattle, Washington	Stanley A. Herring, MD, serves as a Member, National Football League Head, Neck and Spine Committee; Member, Football and Wellness Committee USA Football; Member, Medical Advisory Board Pop Warner Football; Chair of Medical Advisory Board X2IMPACT, a nonfinancial position. Clinical and consulting practice at Harborview Medical Center focusing on the diagnosis and management of neurological and musculoskeletal injuries with particular interest in spinal disorders in active people and athletes and sports-related concussions. No form of financial support directly related to this manuscript was received.
Grant Iverson, PhD	Neuropsychology Outcome Assessment Laboratory; Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada	Grant Iverson, PhD, has been reimbursed by the government, professional scientific bodies, and commercial organizations for discussing or presenting research relating to mild TBI and sport-related concussion at meetings, scientific conferences, and symposiums. He has a clinical and consulting practice in forensic neuropsychology involving individuals who have sustained mild TBIs (including professional athletes). He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He did not receive any form of financial support directly related to this manuscript.
Barry D. Jordan, MD, MPH	Associate Professor of Clinical Neurology at Weill Medical College of Cornell University, New York, New York; Assistant Medical Director of the Burke Rehabilitation Hospital, White Plains, New York; Chief Medical Officer of the New York State Athletic Commission, New York, New York; National Football League Players Association (NFLPA) Mackey-White Traumatic Brain Injury Committee.	Dr. Jordan has received financial compensation from the National Football League (NFL) Benefits Association for the establishment of a Neurocognitive Disability Benefit for retired players. He also has received financial compensation from Innovative CEUs for developing a medical-based high school coaching education program. In his position as the Chief Medical Officer of the New York State Athletic Commission, Dr. Jordan is a governor's appointed public officer of the State of New York. He maintains an inpatient and outpatient clinical practice at the Burke Rehabilitation Hospital specializing in traumatic brain injury, dementia and sports neurology. Dr. Jordan did not receive any financial support related to this manuscript.
James Kissick MD, CCFP, Dip Sport Med	Sport Medicine Physician, Ottawa Sport Medicine Centre, Ottawa, Ontario, Canada; Clinical Lecturer, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; Team Physician, Canadian National Men's Sledge Hockey Team.	James Kissick has a clinical and consulting practice in sport and exercise medicine at the Ottawa Sport Medicine Centre. He did not receive any form of financial support directly related to this manuscript.
Michael McCrea, PhD, ABPP	Professor & Director of Brain Injury Research, Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin	Michael McCrea, PhD, has been funded by the United States Department of Defense, U.S. Defense Veterans Brain Injury Center (DVBIC), NFL Charities, National Collegiate Athletic Association (NCAA), National Operating Committee on Standards for Athletic Equipment (NOCSAE), National Federation of High School Associations (NFHS), and other funding organizations over the past decade. Dr. McCrea is a member of the NFL Head, Neck and Spine Committee and has served on several U.S. national panels for scientific review and policy making relevant to sport-related concussion. He has been funded by BrainScope, Inc. for prior studies, but receives no direct compensation from BrainScope or other industry entities or sports organizations. Dr. McCrea is co-author of the Standardized Assessment of Concussion (SAC). He receives no financial compensation or support from publication or distribution of the SAC. He is currently principal investigator (PI) on a study by the U.S. Department of Defense comparing several computerized neurocognitive assessment tools for the assessment of sport-related concussion. He did not receive any form of financial support directly related to this manuscript.
Andrew S McIntosh, BAppSci (PT), MBiomedE, PhD	Adjunct Associate Professor, Australian Centre for Research into Injury in Sports and its Prevention, Monash Injury Research Institute, Monash University; Adjunct Associate Professor, Transport and Road Safety Research, Faculty of Science, the University of New South Wales; Director, McIntosh Consultancy and Research Pty Ltd. Sydney, Australia	Andrew McIntosh in a self-employed consultant. In the area of sport and sports injury research he has received grant support through UNSW from the Australian Research Council, NSW Racing, the IRB, the ARU, and the AFL. As a consultant In the area of sport and sports injury he has undertaken paid work for the Australian Racing Board, McLaren F1, the IRB and Albion. He has received travel funding from the International Rugby Board, IIHF, FIFA and the Medical Commission of the IOC. He did not receive any form of financial support directly related to this manuscript.
David L. Maddocks, LLB, PhD	Barrister & Solicitor, Perry Maddocks Trollope Lawyers, Melbourne, Australia; Neuropsychologist in private practice.	David Maddocks, LLB, PhD, has received research grant support through the Australian Football League (AFL). He provides consultancy medico-legal advice to the AFL. He has received travel funding from FIFA. He did not receive any form of financial support directly related to this manuscript.
Michael Makdissi, MBBS, PhD	Research Fellow, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Melbourne, Australia; Research Fellow, Centre for Health, Exercise & Sports Medicine, and Physiotherapy Department, University of Melbourne, Melbourne, Australia	Michael Makdissi, MBBS, PhD, has received research grant support through The Florey Institute of Neurosciences and Mental Health from the National Health and Medical Research Council, the Australian Football League (AFL) and AFL Medical Officers Association. He has received travel funding from FIFA. He has a clinical and consulting practice in sports medicine. He did not receive any form of financial support directly related to this manuscript.
Laura Purcell, MD, FRCPC	Associate Clinical Professor, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada; Pediatric Sport Medicine Physician, David Braley Sport Medicine and Rehabilitation Centre, McMaster University, Hamilton, Ontario, Canada; President, Paediatric Sport and Exercise Medicine Section, CPS	No disclosures
Margot Putukian, MD	Director of Athletic Medicine, Head Team Physician, Princeton University, Princeton, New Jersey; Associate Clinical Professor, Robert Wood Johnson Medical School at University of Medicine and Dentistry of New Jersey (UMDNJ), Piscataway Township, New Jersey	Margot Putukian, MD, has received research grant support through the new Jersey Commission on Brain Injury, the American Medical Society for Sports Medicine (AMSSM) and the National Operating Committee on Standards for Athletic Equipment (NOCSAE). She is the chair of the US Lacrosse Sports Science & Safety Committee and also serves on the National Football League (NFL) Head, Neck and Spine Committee, chairing the Return to Play subcommittee for the NFL. She works as a team physician for Princeton University, as well as team physician for the US Men's National Lacrosse Team and for US Soccer. She is a consultant on concussion for the Centers for Disease Control and Prevention (CDC) and the National Collegiate Athletic Association (NCAA). She is a past president for the AMSSM and currently is president of the AMSSM Foundation. Dr. Putukian does not receive any financial compensation for her work with the AMSSM, NFL, US Lacrosse, CDC or NCAA. She did not receive any form of financial support directly related to this manuscript.
Kathryn Schneider, PT, PhD	Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada	Kathryn Schneider, PT, PhD has received research grant support through the University of Calgary from the Alberta Centre for Child, Family and Community Research. She has a clinical and consulting practice in physiotherapy at Evidence Sport and Spinal and Centric Health with a focus on sport related concussion. She did not receive any form of financial support directly related to this manuscript.
Charles H. Tator, MD, PHD	Professor of Neurosurgery, Toronto Western Hospital and University of Toronto, Ontario, Canada; Senior Scientist, Krembil Neuroscience Centre, Toronto, Ontario, Canada; Founder, ThinkFirst Canada; Board Member, Parachute Canada.	Charles Tator is a consultant to ImpaKt Protective, and is co-chair of the Concussion Awareness and Recognition Committee of the Ontario Neurotrauma Foundation. He is Chair of ThinkFirst's Concussion Education and Awareness Committee, and Project Director of the Canadian Sports Concussion Project at the Krembil Neuroscience Centre. He is Director of the Ontario Concussion Centres Consortium. He has received research grants from many public sources including the Canadian Institute for Health Research, and the Ontario Brain Institute. He did not receive any financial support related to this manuscript.
Michael Turner, MBBS	Chief Medical Adviser, British Horseracing Authority, London, United Kingdom	Michael Turner is employed as Chief Medical Adviser by the British Horseracing Authority and the Lawn Tennis Association. He has received travel funding from FIFA, the IOC, the ACSM and Gruppoforte (Physiomind) for attending conferences and lecturing. In addition to travel funding, most conference organisers also provided free registration and support for accommodation. He did not receive any form of financial support directly related to this manuscript.

NB: All panelists received travel funding and accommodation from the Concussion in Sport Group to attend the Consensus meeting in Zurich, Switzerland.