1. Concussion Update:
Review of 5th International Conference on Concussion in Sport in Berlin October 2016
April 28, 2017

2. HEADLINE, ARIAL BLACK ALL CAPS – CENTERED

3. Background
1st meeting Vienna Started as a group of professionals IIHF, IOC, and FIFA
IRB added to 2nd meeting Prague 2004
3rd and 4th meetings Zurich 2008 and Participants chosen to create a broad-based non- government, non-advocacy panel from researchers in clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training and sports science.

4. Changes in Berlin to prior guidelines
Document is divided into 11 sections:
11 R’s of concussion-Recognize; Remove; Re- evaluate; Rest; Rehabilitation; Refer; Recover; Return to sport; Reconsider; Residual effects and sequelae; Risk reduction
One of the standout features of the Berlin CISG meeting was the engagement by experts from the TBI, dementia, imaging and biomarker world in the process and as coauthors of the systematic reviews

5. Recognize
Definition SRC: part of TBI spectrum with structural change or result of reversible physiologic change
Role of technology measuring head impact is not well defined as variable results in current studies
SCAT 5 is most well established rigorously developed tool for sideline assessment. Most useful “immediately” after injury (less useful 3-5 days after injury). Baseline not necessary
Symptom checklist has utility immediately and for tracking follow up
If baseline SCAT 5 is used, testing environment should be similar for suspected acute concussion evaluation

6. Recognize
Other useful sideline assessment tools include clinical reaction time, gait/balance assessment, video-observable signs and oculomotor screening.
Serial evaluation process for suspected concussion recommended to identify the delayed onset SRC individuals
Comprehensive evaluation involves review of 6 clinical domains for abnormalities from baseline

7. Recognize: Clinical Domains
Somatic, cognitive or emotional symptoms
Physical signs (LOC, amnesia, neuro deficit)
Balance impairment
Behavioral changes (reaction time)
Cognitive impairment
Sleep/wake disturbance

8. Remove
Once SRC is diagnosed, player should be removed from continued participation
Final determination of diagnosis of SRC and disposition (RTP) is a medical decision based on clinical judgment

9. Re-evaluate
This is opportunity for comprehensive history and detailed neurological exam (including mental status/cognition, oculomotor function, gross sensorimotor, coordination, gait, vestibular function and balance)
Assess whether clinical status of athlete is improving or deteriorating
Assess whether emergent care/referral is warranted (need for imaging, etc)
Neuropsychological assessment (aids decision making but not sole basis for medical decision making)
Advanced neuroimaging, fluid biomarkers and genetic testing are important research tools only
Computer based NP testing is widely used due to wide availability and limited availability of qualified neuropsychologists in this setting. Not equivalent to complete NP assessment.

10. Rest
Acute phase (<48 hrs) physical and cognitive rest to ease discomfort and promote recovery by minimizing energy demands on brain.
After 48 hrs, should be encouraged to become gradually and progressively more active as symptoms allow

11. Rehabilitation
SRC can result in diverse symptoms and problems and treatment should be individualized as needed. Treatment considerations include directed care of concurrent C-spine injury, disruption in vestibular system, and psychological issues.
Monitored active rehab programs with controlled sub-symptom threshold sub maximal exercise has shown benefit

12. Refer
Persistent symptoms: failure of normal clinical recovery in timeframe expected (10-14 days adults, 4 weeks in children)
Treatment individualized and target specific medical, physical and psychosocial factors
Treatment should be multidisciplinary and collaborative and may include: symptom limited exercise program, formal PT, CBT, pharmacotherapy

13. Recover
Large majority of athletes recover from a clinical perspective within a month from date of injury.
Strongest and most consistent indicator of slower recovery is severity of initial symptoms
Development of sub acute migraine or depression are likely risk factors for persistent symptoms >1 month
Children, adolescents, young adults with pre-existing mental health issues or migraine headaches also likely at risk for persistent symptoms >1 month
ADHD, learning disabilities may require more help with academic accommodations during recovery but have not been shown to be at increased risk for persistent symptoms overall
Teenage years (high school age) have been shown to be at greater risk for persistent symptoms. Females>Males
Lots of different modalities (MRI, DTI, MRS, HR, fluid biomarkers, etc) to measure physiologic recovery exist but none have the ability to define a single physiologic timeframe to recovery. Studies do suggest physiologic recovery outlasts clinical recovery which supports gradual return with “buffer zone” integrated.

14. Recover
While many studies have tried to show a correlation between injury severity characteristics and greater acute effects or prolonged recovery, results have been inconclusive
Post injury clinical factors (severity of cognitive deficits, post traumatic headache or migraine, dizziness, oculomotor dysfunction, depression) have been shown to be associated with worse outcomes
Low level of symptoms the day after the injury has been shown as a favorable predictor for recovery

15. Return to sport (RTS) Graduated stepwise rehabilitation strategy
Note: An initial period of 24–48 hours of both relative physical rest and cognitive rest is recommended before beginning the RTS progression.
There should be at least 24 hours (or longer) for each step of the progression. If any symptoms worsen during exercise, the athlete should go back to the previous step. Resistance training should be added only in the later stages (stage 3 or 4 at the earliest). If symptoms are persistent (e.g., more than 10–14 days in adults or more than 1 month in children), the athlete should be referred to a healthcare professional who is an expert in the management of concussion.

16. Return to sport

17. Reconsider (special populations)
No difference in recommendations for management based on skill level of athlete
Treatment recommendations are designed to be applied to athletes age 18 and older. Child and adolescent guidelines are for athletes age 18 and younger (Child 5-12 yr, adolescent yr). Need more research into specific nuances applicable to these age populations. Children and adolescents shouldn’t return to sport until they have returned to school, but early introduction of symptom limited light activity is appropriate.
Schools should have SRC policy in place including education to teachers, staff, students and parents with appropriate academic accommodations and support

18. Reconsider-Return to school
Stage
Aim
Activity
Goal 1
Daily activities at home that do not give the child symptoms
Typical activities of the child during the day as long as they do not increase symptoms (eg, reading, texting, screen time). Start with 5–15 min at a time and gradually build up
Gradual return to typical activities 2
School Activities
Homework, reading or other cognitive activities outside of the classroom
Increase tolerance to cognitive work 3
Return to school part time
Gradual introduction of schoolwork. May need to start with a partial school day or with increased breaks during the day
Increase academic activities 4
Return to school full time
Gradually progress school activities until a full day can be tolerated
Return to full academic activities and catch up on missed work

19. Residual effects and sequelae
The literature on neurobehavioral sequelae and long-term consequences of exposure to recurrent head trauma is inconsistent.
Clinicians need to be mindful of the potential for long-term problems such as cognitive impairment, depression, etc in the management of all athletes
Need to keep in mind CTE as potential sequelae though cause and effect relationship has not been clearly established

20. Risk reduction
Detailed SRC history is important because it offers the opportunity to identify high risk athlete (for injury and poor recovery) and it provides an opportunity for concussion education
Evidence supports helmet use for ski/snowboard in injury prevention
Possible benefit of mouthguard in reducing risk but thus far results in studies are mixed
Disallowed body checking in youth hockey (<13yo) has consistently demonstrated decreased incidence of SRC
Vision training in collegiate American football may reduce SRC
Limiting contact in youth FB decreased head impacts but no evidence that translates into decreased SRC incidence
Other rule changes have not shown effect in SRC incidence
Rule changes with no effect include: fair play rules in youth hockey, tackle training without equipment in youth FB, tackle training in pro rugby

21. Risk Reduction
Need clear understanding of potentially modifiable risk factors to design studies that will evaluate appropriate prevention interventions for effective risk reduction
When considering making rule changes, need to include consideration of impact of those changes not only on concussion incidence but also on psychological and sociocultural aspects of sports
Knowledge translation important
Treatment is ever evolving and ongoing education is the mainstay of progress in this field

22. SCAT 3 vs SCAT 5
Tool renumbered to coincide with numerical consensus conference.
Reorganized flow of assessment.
Immediate on field assessment with red flags listed for consideration of removal from play to further evaluation. Observable signs listed.
Maddocks questions unchanged
C-spine assessment along with GCS

23. SCAT 3 vs SCAT 5
Symptom evaluation now includes question about what % of normal do you feel right now and why not if not 100%?
Immediate memory includes 10 word recall option, digits backward has 2 trials for each (stop after two negatives)
SCAT 5 includes neurological screen
Similar update to Child SCAT 5

24. Conclusion
Science of sport related concussion (SRC) is constantly evolving and individual management and return to play decisions remain in the realm of clinical judgment
Many areas of research have been identified in the latest consensus meeting and up to date care requires keeping up with new findings as published

25. References
Aubry M , Cantu R , Dvorak J , et al; Concussion in Sport (CIS) Group. Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna Clin J Sport Med 2002;12:6–11.
McCrory P, Johnston K , Meeuwisse W , et al; Summary and agreement statement of the 2nd international conference on concussion in sport, Prague Br J Sports Med 2005;39:i78–i86.
McCrory P , Meeuwisse W , Johnston K , et al; Consensus statement on concussion in sport – the 3rd international conference on concussion in sport held in Zurich, November Phys Sportsmed 2009;37:141–59.
McCrory P, Meeuwisse WH , Aubry M , et al; Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November Br J Sports Med 2013;47:250–8.

26. References
Meeuwisse WH, Schneider KJ, Dvořák J , et al; The Berlin process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport. Br J Sports Med 2017;51:873–876.
McCrory P, Meeuwisse W, Dvorak J, et al; Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October Br J Sports Med 2017;51:
Sport concussion assessment tool - 5th edition. Br J Sports Med 2017;51:
Sport concussion assessment tool for children ages 5 to 12 years. Br J Sports Med 2017;51: