Davis et al. (2023). Definition of sport-related concussion: The 6^th International Conference on Concussion in Sport. British Journal of Sports Medicine, 57 (11), 617-618. https://doi.org/10.1136/bjsports-2022-106650

• The Concussion in Sport Group (CISG) proposed a conceptual definition of SRC in 2001. This definition has undergone updates and modifications at subsequent CISG meetings, with the most recent being in Berlin in 2016. In preparation for the 6th International Conference on Concussion in Sport, the scientific committee considered that the Berlin definition may require further modification to align with more recent scientific evidence relating to advances in our understanding of the pathophysiology of SRC.

Hohmann et al. (2024). On-field and pitch-side (sideline) assessment of sports concussion in collision sports: An expert consensus statement using the modified Delphi technique. Arthroscopy, 40(2), 449-459. https://doi.org/10.1016/j.arthro.2023.06.026

• Conclusion: Consensus was achieved for 85% of the clinical signs indicating concussion. On-field and pitch-side assessment should include the observation of the mechanism, a clinical examination, and cervical spine assessment. Of the 19 signs and red flags requiring removal from play, consensus was reached for 74%. Normal clinical examination and HIA with no signs of concussion allow return to play. Video assessment should be mandatory for professional games but should not replace clinical decision-making. Sports Concussion Assessment Tool, Glasgow Coma Scale, vestibular/ocular motor screening, Head Injury Assessment Criteria 1, and Maddocks questions are useful tools. Guidelines are helpful for non-health professionals.

Davis & Makdissi (2020). Commentary: Sensitivity and specificity of on-field visible signs of concussion in the National Football League. Neurosurgery, 87(3), E296–E297. https://doi.org/10.1093/neuros/nyaa063

• Conclusion: In the NFL, the diagnosis of concussion cannot be made from on-field visible signs alone. The VS checklist is one part of the comprehensive sideline/acute evaluation of concussion, and the diagnosis remains a multimodal clinical decision.

Davis & Makdissi (2016). Use of video to facilitate sideline concussion diagnosis and management decision-making. Journal of Science and Medicine in Sport, 19(11), 898–902. https://doi.org/10.1016/j.jsams.2016.02.005

• Conclusion: This study suggests that the implementation of a flowchart model could improve timely assessment of concussion, and it identifies the video signs that should trigger automatic removal from play.

Gardner et al. (2018). The use of sideline video review to facilitate management decisions following head trauma in Super Rugby. Sports Medicine - Open, 4(1), 20. https://doi.org/10.1186/s40798-018-0133-4

• Conclusion: These findings suggest that access to sideline video review is an important supplementary component to identify potential concussions; however, there is a critical need for improved systems and processes to reduce the likelihood of missing an incident.

Makdissi & Davis (2016). The reliability and validity of video analysis for the assessment of the clinical signs of concussion in Australian football. Journal of Science and Medicine in Sport, 19(10), 859–863. https://doi.org/10.1016/j.jsams.2016.02.015

• Conclusion: Video analysis may be a useful adjunct to the side-line assessment of a possible concussion. Video analysis however should not replace the need for a thorough multimodal clinical assessment.

Reyes et al. (2022). Visible signs of concussion and cognitive screening in community sports. Journal of Neurotrauma, 39(1–2), 122–130. https://doi.org/10.1089/neu.2020.7425

• Conclusion: All with positive signs of concussion players observed to have a blank/vacant look demonstrated clinically significant decline on the Standardized Assessment of Concussion (SAC). Detection of visible signs of concussion represents a rapid, real-time method for screening players suspected of concussion in community sports where video technology and medical personnel are rarely present. Consistent with community guidelines, it is recommended that all players with positive signs of concussion be immediately removed from play for further concussion screening.

Davis et al. (2019). International study of video review of concussion in professional sports. British Journal of Sports Medicine, 53(20), 1299–1304. https://doi.org/10.1136/bjsports-2018-099727

• Conclusion: The use of video analysis in assisting medical staff with the diagnosis or identification of potential concussion is well established across different sports internationally. The diagnostic criteria used and the expertise of the video review personnel are not clearly established, and research efforts would benefit from a collaborative harmonisation across sporting codes.

Davis et al. (2019). International consensus definitions of video signs of concussion in professional sports. British Journal of Sports Medicine, 53(20), 1264–1267. https://doi.org/10.1136/bjsports-2019-100628

• Conclusion: These video signs and definitions have reached international consensus, are indicated for use by professional sporting bodies and will form the basis for further collaborative research.

Echemendia et al. (2023). Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: A systematic review. British Journal of Sports Medicine, 57(11), 722–735. https://doi.org/10.1136/bjsports-2022-106661

• Conclusion: Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes.

Echemendia et al. (2023). Introducing the Sport Concussion Assessment Tool 6 (SCAT6). British Journal of Sports Medicine, 57, 619-621. https://doi.org/10.1136/bjsports-2023-106849

• The original Sport Concussion Assessment Tool (SCAT) was published in 2005 and contained educational information, a concussion symptoms scale and information on management of concussion. In the years that followed several iterations of the SCAT have been published, informed by empirical data, systematic reviews and clinical experience. Each iteration of the SCAT evolved along with the scientific literature, with each version increasingly representing the complexity and multimodal nature of SRC assessment.

The SCAT6 (2023). British Journal of Sports Medicine, 57, 622-631. https://doi.org/10.1136/bjsports-2023-107036

Patricios et al. (2023). Beyond acute concussion assessment to office management: A systematic review informing the development of a Sport Concussion Office Assessment Tool (SCOAT6) for adults and children. British Journal of Sports Medicine, 57(11), 737–748. https://doi.org/10.1136/bjsports-2023-106897

• Conclusion: Current SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed.

Patricios et al. (2023). Introducing the Sport Concussion Office Assessment Tool 6 (SCOAT6). British Journal of Sports Medicine, 57(11), 648–650. https://doi.org/10.1136/bjsports-2023-106860

• As part of the 6th International Consensus Conference on Concussion in Sport, the author group was tasked with developing a clinical tool better suited to evaluating and managing SRC in the days and weeks after the acute (first 72 hours) period postinjury. The Sport Concussion Office Assessment Tool 6 (SCOAT6), for use in athletes 13 years and older, is the product of the 6th International Consensus Conference on Concussion in Sport aimed at assisting Health Care Professionals (HCPs) in an office-based, multimodal assessment of SRC. A child version for use in children ages 8–12 years is described separately in this issue.5 Consistent with the principles of previous consensus conference outputs, the Sport Concussion Office Assessment Tool 6 (SCOAT6) will be freely available.

The SCOAT6 (2023). British Journal of Sports Medicine, 57(11), 651–667. https://doi.org/10.1136/bjsports-2023-106859

Davis et al. (2023). Introducing the Child Sport Concussion Assessment Tool 6 (Child SCAT6). British Journal of Sports Medicine, 57(11), 632–635. https://doi.org/10.1136/bjsports-2023-106853

• During 6th International Conference on Concussion in Sport held in Amsterdam in 2022, the CISG reviewed the evidence to implement improvements to the Child SCAT5 and develop the Child SCAT6.

Child SCAT6. (2023). British Journal of Sports Medicine, 57(11), 636–647. https://doi.org/10.1136/bjsports-2023-106982

Davis et al. (2023). Introducing the Child Sport Concussion Office Assessment Tool 6 (Child SCOAT6). British Journal of Sports Medicine, 57(11), 668–671. https://doi.org/10.1136/bjsports-2023-106858

• Based on feedback from clinicians, the CISG scientific committee determined that a tool for assessment and management of SRC in the subacute period (beyond 72 hours post-injury) would be useful, and established the process for development of the Sport Concussion Office Assessment Tool 6 (SCOAT6).5 Consistent with the approach for the SCAT and Child SCAT, the requirement for an age-appropriate version of the SCOAT6 for children aged 8–12 years led to the development of the Child SCOAT6.

Child SCOAT6. (2023). British Journal of Sports Medicine, 57(11), 672–688. https://doi.org/10.1136/bjsports-2023-106984

Echemendia et al. (2023). Introducing the Concussion Recognition Tool 6 (CRT6). British Journal of Sports Medicine, 57, 689-691. https://doi.org/10.1136/bjsports-2023-106851

• The SCAT has been revised several times, including the most recent SCAT6. The SCAT6 and its predecessors were designed for use by healthcare professionals (HCPs). However, HCPs are rarely present at many, if not most, sporting and recreational activities, particularly at the community level involving children and adolescents. Understanding this void in concussion care, the CISG designed the Pocket SCAT2 in 2009 following the 3rd International Consensus Conference in Zurich3 as a tool to assist the layperson recognise the signs and symptoms of suspected SRC at all ages. The tool was also designed to provide guidance for removing an athlete from activity and seeking further medical assessment. The Pocket SCAT2 was revised by the CISG in 20124 and renamed the Pocket Concussion Recognition Tool (CRT) and subsequently the CRT 5 (CRT5).5 This paper introduces the most recent version, the CRT6.

The CRT6 (2023). British Journal of Sports Medicine, 57(11), 692-694. https://doi.org/10.1136/bjsports-2023-107021

Hohmann et al. (2023). Return to sports following sports-related concussion in collision sports: An expert consensus statement using the modified Delphi technique. Arthroscopy, 0(2),460-469. https://doi.org/10.1016/j.arthro.2023.06.027

• Conclusion: Consensus was achieved for 10 of the 25 return to sport (RTS) criteria: early RTS can be considered earlier than 48 to 72 hours if athletes are completely symptom-free with no headaches, a normal clinical, ocular and balance examination. A graduated RTS should be used but should be individualized. Only 2 of the 9 assessment tools were considered to be useful: Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening. RTS is mainly a clinical decision. Only 31% of the baseline assessment items achieved consensus: baseline assessments should be performed at collegiate and professional levels using a combination of neurocognitive and clinical tests. The panel disagreed on the number of recurrent concussions that should be season- or career-ending.

Yeates et al. (2023). What tests and measures accurately diagnose persisting post-concussive symptoms in children, adolescents and adults following sport-related concussion? A systematic review. British Journal of Sports Medicine, 57, 780-788. https://doi.org/10.1136/bjsports-2022-106657

• Conclusion: The diagnosis of persisting post-concussive symptoms continues to rely on symptom report, preferably using standardised symptom rating scales. The existing research does not indicate that any other specific tool or measure has satisfactory accuracy for clinical diagnosis. Future research drawing on prospective, longitudinal cohort studies could help inform clinical practice.

Mito et al. (2022). White matter abnormalities characterize the acute stage of sports-related mild traumatic brain injury. Brain Communications, 4(4), fcac208. https://doi.org/10.1093/braincomms/fcac208

• Conclusion: Overall, this study demonstrates that acute mild traumatic brain injury is characterized by specific white matter abnormalities, which are compatible with tract-specific cytotoxic oedema. These potential oedematous changes were absent in our subacute mild traumatic brain injury participants, suggesting that they may normalize within 12 days after injury, although subtle abnormalities may persist in the subacute stage. Future longitudinal studies are needed to elucidate individualized recovery after brain injury.

Pedersen et al. (2020). Quantitative MRI as an imaging marker of concussion: Evidence from studying repeated events. European Journal of Neurology, 27(10). https://doi.org/10.1111/ene.14377

Patricios et al. (2023). Consensus statement on concussion in sport: The 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695–711. https://doi.org/10.1136/bjsports-2023-106898

• This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.

Schneider et al. (2023). Amsterdam 2022 process: A summary of the methodology for the Amsterdam International Consensus on Concussion in Sport. British Journal of Sports Medicine, 57(11), 712–721. https://doi.org/10.1136/bjsports-2022-106663

• The 6th International Conference on Concussion in Sport was held in Amsterdam (27–30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews.

Makdissi & Patricios (2018). Concussion in sport: Best from Berlin, direction from Dublin and gems from gridiron. British Journal of Sports Medicine, 52(14), 903–904. https://doi.org/10.1136/bjsports-2018-099402

• Sports-related concussion (SRC) is one of the most important medical issues in contact and collision sports around the world. The NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocols, published in this edition of the BJSM, represent a comprehensive approach to concussion management in professional sport. The protocols highlight how much the approach to SRC has evolved, particularly since the first International Conference on Concussion in Sport held in Vienna in November 2001. This evolution has been driven largely by concerns (both medical and public) regarding potential short-term and long-term adverse outcomes following SRC, and have been underpinned by evolving concepts from five international consensus meetings, and an explosion of research on SRC over the past decade.

Makdissi et al. (2023). When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review. British Journal of Sports Medicine, 57(12), 822–830. https://doi.org/10.1136/bjsports-2023-106815

• Conclusion: No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC.

Putukian et al. (2023). Clinical recovery from concussion–return to school and sport: A systematic review and meta-analysis. British Journal of Sports Medicine, 57, 798-809. https://doi.org/10.1136/bjsports-2022-106682

• Conclusion: Most athletes have full return to learning by 10 days but take twice as long for a return to sport.

Leddy et al. (2023). Rest and exercise early after sport-related concussion: A systematic review and meta-analysis. British Journal of Sports Medicine, 57, 762-770. https://doi.org/10.1136/bjsports-2022-106676

• Conclusion: Early physical activity, prescribed aerobic exercise and reduced screen time are beneficial following SRC. Strict physical rest until symptom resolution is not effective, and sleep disturbance impairs recovery after SRC.

Schneider et al. (2023). Targeted interventions and their effect on recovery in children, adolescents and adults who have sustained a sport-related concussion: a systematic review. British Journal of Sports Medicine, 57(12), 771–779. https://doi.org/10.1136/bjsports-2022-106685

• Conclusion: Cervicovestibular rehabilitation is recommended for adolescents and adults with dizziness, neck pain and/or headaches for >10 days. Vestibular rehabilitation (for adolescents with dizziness/vestibular impairments >5 days) and active rehabilitation and/or collaborative care (for adolescents with persisting symptoms >30 days) may be of benefit.

Tabor et al. (2023). Role of biomarkers and emerging technologies in defining and assessing neurobiological recovery after sport-related concussion: A systematic review. British Journal of Sports Medicine, 57(12), 789–797. https://doi.org/10.1136/bjsports-2022-106680

• Conclusion: Advanced neuroimaging, fluid-based biomarkers, genetic testing and emerging technologies are valuable research tools for the study of SRC, but there is not sufficient evidence to recommend their use in clinical practice.

Nguyen et al. (2023). Moving forward on the road to recovery after concussion: participant experiences of interdisciplinary intervention for persisting post-concussion symptoms. Disability and Rehabilitation,1-9. https://doi.org/10.1080/09638288.2023.2261374

• Conclusion: Findings highlight current gaps in the acute management of concussion and provide end-user insights into the facilitators and barriers of treatment engagement and response. Responses also highlight the potential positive impact of interdisciplinary treatments. Clinician perspectives should be explored in future research.

Eliason et al. (2023). Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: A systematic review and meta-analysis. British Journal of Sports Medicine, 57, 749-761. https://doi.org/10.1136/bjsports-2022-106656

• Conclusion: Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC.

Symons et al. (2020). The neurological consequences of engaging in Australian collision sports. Journal of Neurotrauma, 37(5), 792–809. https://doi.org/10.1089/neu.2019.6884

• Conclusion: We conclude that although Australia has had an active history of investigating the neurological impact of collision sports participation, further research is clearly needed to better understand these consequences in Australian athletes and how they can be mitigated.

Reyes et al. (2020). An investigation of factors associated with head impact exposure in professional male and female Australian football players. The American Journal of Sports Medicine, 48(6), 1485–1495. https://doi.org/10.1177/0363546520912416

• Conclusion: Playing situations in which players have limited control of the football are a common cause of impacts. Male players sustained a greater exposure to HAEs compared with female players. Female players, however, sustained higher exposure to HAEs than male players during certain skill executions, possibly reflecting differences in skill development. These findings can therefore inform match and skill development in the emerging professional women’s competition of Australian football.

Brennan et al. (2017). Accelerometers for the assessment of concussion in male athletes: A systematic review and meta-analysis. Sports Medicine, 47(3), 469–478. https://doi.org/10.1007/s40279-016-0582-1

• Conclusion: Head impact monitoring through accelerometery has been shown to be useful with regard to characterising the kinematic load to the head associated with concussion. Future research with improved clinical outcome measures and head kinematic data may improve accuracy when evaluating concussion, and may assist with both interpretation of biomechanical data and the development and utilisation of implementation strategies for the technology.

Iverson et al. (2023). Examining later-in-life health risks associated with sport-related concussion and repetitive head impacts: A systematic review of case-control and cohort studies. British Journal of Sports Medicine, 57, 810-824. https://doi.org/10.1136/bjsports-2023-106890

• Conclusion: Evidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors.

Makovec-Knight et al. (2023). Padded headgear in junior and youth Australian football: Player insights from a national survey. Clinical Journal of Sport Medicine, 33(3), 252–257. https://doi.org/10.1097/JSM.0000000000001075

• Conclusion: Club headgear (HG) culture, older age and being female were prominent variables associated with voluntary HG use. Players reported believing that HG offers protection. The rate of voluntary and mandated HG use identified is at odds with current scientific evidence that does not support HG as effective concussion prevention.

Makovec-Knight et al. (2021). Soft-shell headgear, concussion and injury prevention in youth team collision sports: A systematic review. BMJ Open, 11(6), e044320. https://bmjopen.bmj.com/content/11/6/e044320    

• Conclusion: HG use was not associated with reduced rates of SRC or superficial head injury in youth soccer and rugby. The possibility of increased injury risk to all body regions for rugby HG users was raised. The need for research specific to youth and female athletes was highlighted.

Makovec-Knight et al. (2022). The association of padded headgear with concussion and injury risk in junior Australian football: A prospective cohort study. Journal of Science and Medicine in Sport, 25(4), 312–320. https://doi.org/10.1016/j.jsams.2021.11.043

• Conclusion: Headgear use was not associated with reduced risk of suspected sports-related concussion, non-sports-related concussion head injury or injuries to other body regions. There was no difference in the rate of suspected sports-related concussion in female compared to male players, however, rates of non-sports-related concussion head injury and injuries to other body regions were higher in male players.

Willmott et al. (2022). A pilot case crossover study of the use of padded headgear in junior Australian football. Concussion, 7(4). https://doi.org/10.2217/cnc-2022-0005

• Conclusion: Use of HG in junior football was not associated with injury or head contact rate. Associations between HG use and body contact may differ across sexes.

White et al. (2016). Australian Football League concussion guidelines: What do community players think? BMJ Open Sport & Exercise Medicine, 2(1). https://doi.org/10.1136/bmjsem-2016-000169

• Conclusion: Players generally understand that the AFL concussion guidelines protect their long-term welfare. However, their desire to play at all costs and help their team win is a common barrier to reporting concussion and adhering to guidelines. Leagues should take a lead role by mandating and enforcing the use of the guidelines and educating coaches, game day medical providers and players. The return-to-play component of the guidelines is complex and needs further consideration in the context of community sport.

Davis et al. (2020). Concussion guidelines in national and international professional and elite sports. Neurosurgery, 87(2), 418–425. https://doi.org/10.1093/neuros/nyaa057

• Conclusion: We conclude that the Berlin recommendations have been included in concussion protocols/guidelines by all the sporting bodies, with consistency in the essential components of the recommendations, whilst also allowing for sport- and regional-specific variations. Education at the elite, community, and junior levels remains an ongoing challenge, and future iterations of guidelines may consider multiple language versions, and community- and junior-level guidelines.

White et al. (2014). Knowledge about sports-related concussion: Is the message getting through to coaches and trainers? British Journal of Sports Medicine, 48(2), 119–124. https://doi.org/10.1136/bjsports-2013-092785

• Conclusion: The key messages from published concussion management guidelines have not reached community sports coaches and sports trainers. This needs to be redressed to maximise the safety of all of those involved in community sport.

Newton et al. (2014). Intention to use sport concussion guidelines among community-level coaches and sports trainers. Journal of Science and Medicine in Sport, 17(5), 469–473. https://doi.org/10.1016/j.jsams.2013.10.240

• Conclusion: Programmes aimed at increasing the intended use of sport concussion guidelines should focus on enhancing self-efficacy and leveraging personal norms. Increasing coaches’ familiarity and experience in using the concussion guidelines would also be warranted, as would finding ways to overcome the perceived time and resource constraints identified among Australian football personnel.