{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T12:34:50Z","timestamp":1792758890768,"version":"4.5.0"},"reference-count":226,"publisher":"BMJ","issue":"1","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Br J Sports Med"],"accepted":{"date-parts":[[2012,10,30]]},"published-print":{"date-parts":[[2013,1]]},"abstract":"\n Purpose of the statement<\/jats:title>\n \u25b8 To provide an evidence-based, best practises summary to assist physicians with the evaluation and management of sports concussion.<\/jats:p>\n \u25b8 To establish the level of evidence, knowledge gaps and areas requiring additional research.<\/jats:p>\n <\/jats:sec>\n \n Importance of an AMSSM statement<\/jats:title>\n \u25b8 Sports medicine physicians are frequently involved in the care of patients with sports concussion.<\/jats:p>\n \u25b8 Sports medicine physicians are specifically trained to provide care along the continuum of sports concussion from the acute injury to return-to-play (RTP) decisions.<\/jats:p>\n \u25b8 The care of athletes with sports concussion is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion. Competence should be determined by training and experience, not dictated by specialty.<\/jats:p>\n \u25b8 While this statement is directed towards sports medicine physicians, it may also assist other physicians and healthcare professionals in the care of patients with sports concussion.<\/jats:p>\n <\/jats:sec>\n \n Definition<\/jats:title>\n \u25b8 Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process. Concussion is a subset of mild traumatic brain injury (MTBI) which is generally self-limited and at the less-severe end of the brain injury spectrum.<\/jats:p>\n <\/jats:sec>\n \n Pathophysiology<\/jats:title>\n \u25b8 Animal and human studies support the concept of postconcussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell.<\/jats:p>\n \u25b8 Experimental evidence suggests the concussed brain is less responsive to usual neural activation and when premature cognitive or physical activity occurs before complete recovery the brain may be vulnerable to prolonged dysfunction.<\/jats:p>\n <\/jats:sec>\n \n Incidence<\/jats:title>\n \u25b8 It is estimated that as many as 3.8 million concussions occur in the USA per year during competitive sports and recreational activities; however, as many as 50% of the concussions may go unreported.<\/jats:p>\n \u25b8 Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer and basketball.<\/jats:p>\n <\/jats:sec>\n \n Risk factors for sport-related concussion<\/jats:title>\n \u25b8 A history of concussion is associated with a higher risk of sustaining another concussion.<\/jats:p>\n \u25b8 A greater number, severity and duration of symptoms after a concussion are predictors of a prolonged recovery.<\/jats:p>\n \u25b8 In sports with similar playing rules, the reported incidence of concussion is higher in female athletes than in male athletes.<\/jats:p>\n \u25b8 Certain sports, positions and individual playing styles have a greater risk of concussion.<\/jats:p>\n \u25b8 Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury.<\/jats:p>\n \u25b8 Preinjury mood disorders, learning disorders, attention-deficit disorders (ADD\/ADHD) and migraine headaches complicate diagnosis and management of a concussion.<\/jats:p>\n <\/jats:sec>\n \n Diagnosis of concussion<\/jats:title>\n \u25b8 Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion.<\/jats:p>\n \u25b8 Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations.<\/jats:p>\n \u25b8 Standardised assessment tools provide a helpful structure for the evaluation of concussion, although limited validation of these assessment tools is available.<\/jats:p>\n <\/jats:sec>\n \n \u2018Sideline\u2019 evaluation and management<\/jats:title>\n \u25b8 Any athlete suspected of having a concussion should be stopped from playing and assessed by a licenced healthcare provider trained in the evaluation and management of concussions.<\/jats:p>\n \u25b8 Recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (including orientation, past and immediate memory, new learning and concentration), balance tests and further neurological physical examination.<\/jats:p>\n \u25b8 While standardised sideline tests are a useful framework for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined. Their practical usefulness with or without an individual baseline test is also largely unknown.<\/jats:p>\n \u25b8 Balance disturbance is a specific indicator of a concussion, but not very sensitive. Balance testing on the sideline may be substantially different than baseline tests because of differences in shoe\/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injury.<\/jats:p>\n \u25b8 Imaging is reserved for athletes where intracerebral bleeding is suspected.<\/jats:p>\n \u25b8 There is no same day RTP for an athlete diagnosed with a concussion.<\/jats:p>\n \u25b8 Athletes suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status.<\/jats:p>\n <\/jats:sec>\n \n Neuropsychological testing<\/jats:title>\n \u25b8 Neuropsychological (NP) tests are an objective measure of brain\u2013behaviour relationships and are more sensitive for subtle cognitive impairment than clinical exam.<\/jats:p>\n \u25b8 Most concussions can be managed appropriately without the use of NP testing.<\/jats:p>\n \u25b8 Computerised neuropsychological (CNP) testing should be interpreted by healthcare professionals trained and familiar with the type of test and the individual test limitations, including a knowledgeable assessment of the reliable change index, baseline variability and false-positive and false-negative rates.<\/jats:p>\n \u25b8 Paper and pencil NP tests can be more comprehensive, test different domains and assess for other conditions which may masquerade as or complicate assessment of concussion.<\/jats:p>\n \u25b8 NP testing should be used only as part of a comprehensive concussion management strategy and should not be used in isolation.<\/jats:p>\n \u25b8 The ideal timing, frequency and type of NP testing have not been determined.<\/jats:p>\n \u25b8 In some cases, properly administered and interpreted NP testing provides an added value to assess cognitive function and recovery in the management of sports concussions.<\/jats:p>\n \u25b8 It is unknown if use of NP testing in the management of sports concussion helps prevent recurrent concussion, catastrophic injury or long-term complications.<\/jats:p>\n \u25b8 Comprehensive NP evaluation is helpful in the post-concussion management of athletes with persistent symptoms or complicated courses.<\/jats:p>\n <\/jats:sec>\n \n Return to class<\/jats:title>\n \u25b8 Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from a concussion.<\/jats:p>\n <\/jats:sec>\n \n Return to play<\/jats:title>\n \u25b8 Concussion symptoms should be resolved before returning to exercise.<\/jats:p>\n \u25b8 A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact.<\/jats:p>\n \u25b8 If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step.<\/jats:p>\n \u25b8 RTP after concussion should occur only with medical clearance from a licenced healthcare provider trained in the evaluation and management of concussions.<\/jats:p>\n <\/jats:sec>\n \n Short-term risks of premature RTP<\/jats:title>\n \u25b8 The primary concern with early RTP is decreased reaction time leading to an increased risk of a repeat concussion or other injury and prolongation of symptoms.<\/jats:p>\n <\/jats:sec>\n \n Long-term effects<\/jats:title>\n \u25b8 There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae.<\/jats:p>\n \u25b8 Some studies have suggested an association between prior concussions and chronic cognitive dysfunction. Large-scale epidemiological studies are needed to more clearly define risk factors and causation of any long-term neurological impairment.<\/jats:p>\n <\/jats:sec>\n \n Disqualification from sport<\/jats:title>\n \u25b8 There are no evidence-based guidelines for disqualifying\/retiring an athlete from a sport after a concussion. Each case should be carefully deliberated and an individualised approach to determining disqualification taken.<\/jats:p>\n <\/jats:sec>\n \n Education<\/jats:title>\n \u25b8 Greater efforts are needed to educate involved parties, including athletes, parents, coaches, officials, school administrators and healthcare providers to improve concussion recognition, management and prevention.<\/jats:p>\n \u25b8 Physicians should be prepared to provide counselling regarding potential long-term consequences of a concussion and recurrent concussions.<\/jats:p>\n <\/jats:sec>\n \n Prevention<\/jats:title>\n \u25b8 Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play.<\/jats:p>\n \u25b8 Helmets, both hard (football, lacrosse and hockey) and soft (soccer, rugby) are best suited to prevent impact injuries (fracture, bleeding, laceration, etc.) but have not been shown to reduce the incidence and severity of concussions.<\/jats:p>\n \u25b8 There is no current evidence that mouth guards can reduce the severity of or prevent concussions.<\/jats:p>\n \u25b8 Secondary prevention may be possible by appropriate RTP management.<\/jats:p>\n <\/jats:sec>\n \n Legislation<\/jats:title>\n \u25b8 Legislative efforts provide a uniform standard for scholastic and non-scholastic sports organisations regarding concussion safety and management.<\/jats:p>\n <\/jats:sec>\n \n Future directions<\/jats:title>\n \u25b8 Additional research is needed to validate current assessment tools, delineate the role of NP testing and improve identification of those at risk of prolonged post-concussive symptoms or other long-term complications.<\/jats:p>\n \u25b8 Evolving technologies for the diagnosis of concussion, such as newer neuroimaging techniques or biological markers, may provide new insights into the evaluation and management of sports concussion.<\/jats:p>\n 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