5th International Consensus Conference on Concussion in Sport
Berlin, Germany. 27-28 October 2016
A summary from Sport and Exercise Physician Dr David Bolzonello
"The main value was reassurance that we here in Melbourne are using best practice principles and that we do manage our athletes well."
Australians were well represented from all our key sports and four of the seven sessions were moderated by Australians, Sport and Exercise Physicians Michael Makdissi, Martin Raftery, and Paul McCrory, who is also a neurologist, and Gavin Davis, Neurosurgeon.
The format for the event was 7 key topics explored over 7 sessions.
The seven topics were:
- Concussion Definition and Sideline Screening
- Sport Concussion Assessment Tool ( SCAT) and Post-injury assessment
- Advanced or Novel testing and treatment
- Physiologic Recovery - Return to play modifiers
- Childhood concussion
- Persistent Post concussive Symptoms and Long Term Sequelae
- Risk Reduction.
A leader of each working group presented a review of the most recent scientific papers in each topic. Some 2000+ papers were assessed and culled using key words/criteria in each group to sometimes only 15 papers.
A summary of evidence in each area was presented to the forum. Each session included scientific presentations on that session topic and attendees from the floor added comments, suggestions or even disagreements. These comments were recorded and over the next two days the leaders met to write up the new International consensus position statement. It is due for publication in the British Journal of Sports Medicine in the first third of next year.
What did I learn?
The definition of concussion is largely agreed upon by experts, although there is no uniform definition in the scientific literature. There was agreement on a definition as "change in brain function due to a transfer of energy to the brain and its associated structures".
No definition proposed a prognosis for recovery, and no symptom is specific to concussion.
Sideline assessment can be very difficult for clinicians as they do not have the benefit of multiple camera angles and slow motion whilst they are testing the player and making decisions. Often, commentators and spectators have a better picture of the impact, and the injured player's response to that impact, than do the staff in the playing arena. Access to tools such as Hawkeye video review are helping doctors to see what the commentators have seen, and be able to respond accordingly.
The SCAT remains a very important tool and will be refined in its next iteration.
Universities are looking for a single marker of diagnosis or recovery, be it by scans or blood test which will simplify management.
Recovery was discussed, women it seems recover more slowly than men and may be more susceptible.
Not all symptoms are due to brain injury e.g. headache and balance disturbance are likely due to injury to the neck and/or the vestibular structures of the inner ear. It was a surprise to me that this fact seemed to be presented as new discovery.
Persistent symptoms may in part be due to altered mood state and anxiety from the diagnosis itself, and it was noted that too much medical attention can create an expectation of poor recovery, as may occur in back pain.
There is no magic bullet in terms of testing or treatment as yet. Clinical assessment using the full gamut of history, examination and special tests such as MRI and neuropsychological testing, remains the mainstay of management.
Children do not need to rest totally before resuming activity. Low level activity aids recovery and shortens recovery time as compared to those who totally rested. Engaging the school in the recovery process is very important. How long they should remain out of competition was not fully explored but will be considered in the position statement.
Long term sequelae, specifically Chronic Traumatic Encephalopathy (CTE) remains the most contentious issue in this area of medicine, with believers and sceptics.
The consensus is that the condition probably exists but current evidence based on retrospective reviews and post-mortem changes is flawed as the contributions of factors such as past alcohol, illicit and performance enhancing drug use are unknown.
Risk reduction centred on issues such as rule changes, rule enforcement, general and neck specific conditioning and protective equipment.
Overall I am glad I received an AFL nomination to be invited and enjoyed the collegiality and discussion with clinicians from around the world. The main value was reassurance that we here in Melbourne are using best practice principles and that we do manage our athletes well. As always, continuous improvement comes from doing things well for each and every patient and keeping abreast of the knowledge.