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


Clin J Sport Med. 2013;23(2):89-117. 

In This Article

Special Populations

The Child and Adolescent Athlete

The evaluation and management recommendations contained herein can be applied to children and adolescents down to the age of 13 years. Below that age, children report concussion symptoms different from adults and would require age-appropriate symptom checklists as a component of assessment. An additional consideration in assessing the child or adolescent athlete with a concussion is that the clinical evaluation by the healthcare professional may need to include both patient and parent input, and possibly teacher and school input when appropriate.[98–104] A child SCAT3 has been developed to assess concussion (see appendix) for individuals aged 5–12 years.

The decision to use NP testing is broadly the same as the adult assessment paradigm, although there are some differences. The timing of testing may differ in order to assist planning in school and home management. If cognitive testing is performed, then it must be developmentally sensitive until late teen years due to the ongoing cognitive maturation that occurs during this period, which in turn limits the utility of comparison to either the person's own baseline performance or to population norms.[20] In this age group, it is more important to consider the use of trained paediatric neuropsychologists to interpret assessment data, particularly in children with learning disorders and/or ADHD who may need more sophisticated assessment strategies.[56,57,98]

It was agreed by the panel that no return to sport or activity should occur before the child/adolescent athlete has managed to return to school successfully. In addition, the concept of 'cognitive rest' was highlighted with special reference to a child's need to limit exertion with activities of daily living that may exacerbate symptoms. School attendance and activities may also need to be modified to avoid provocation of symptoms. Children should not be returned to sport until clinically completely symptom-free, which may require a longer time frame than for adults.

Because of the different physiological response and longer recovery after concussion and specific risks (eg, diffuse cerebral swelling) related to head impact during childhood and adolescence, a more conservative RTP approach is recommended. It is appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents. It is not appropriate for a child or adolescent athlete with concussion to RTP on the same day as the injury, regardless of the level of athletic performance. Concussion modifiers apply even more to this population than adults and may mandate more cautious RTP advice.

Elite Versus Non-elite Athletes

All athletes, regardless of the level of participation, should be managed using the same treatment and RTP paradigm. The available resources and expertise in concussion evaluation are of more importance in determining management than a separation between elite and non-elite athlete management. Although formal NP testing may be beyond the resources of many sports or individuals, it is recommended that, in all organised high-risk sports, consideration be given to having this cognitive evaluation, regardless of the age or level of performance.

Chronic Traumatic Encephalopathy (CTE)

Clinicians need to be mindful of the potential for long-term problems in the management of all athletes. However, it was agreed that chronic traumatic encephalopathy (CTE) represents a distinct tauopathy with an unknown incidence in athletic populations. It was further agreed that a cause and effect relationship has not as yet been demonstrated between CTE and concussions or exposure to contact sports.[105–114] At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also recognised that it is important to address the fears of parents/athletes from media pressure related to the possibility of CTE.