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For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research., Competing Interests: Competing interests: OHA is a Senior Physiotherapist at University Hospitals Dorset NHS Foundation Trust (England) and is Para Football Physiotherapy Lead/Para Football Classification Lead at the Football Association (England). He also works on a consultancy basis with the Football Association as the squad physiotherapist to the England Cerebral Palsy Football squad and teaches a course on the Football Association’s Advanced Trauma and Medical Management in Football course on a consultancy basis. He has a Visiting Senior Lecturer position at the University of Portsmouth, England (unpaid). He sits on several disability sport committees, including Para Football Foundation as Medical Unit Co-Lead (unpaid), the International Federation of Cerebral Palsy Football as Medical and Sports Science Director (unpaid) and the International Blind Sports Association as Medical Committee member (unpaid). He has Associate Editor positions at the British Journal of Sports Medicine (unpaid) and BMJ Open Sports & Exercise Medicine (unpaid). He is also an Institutional Ethics Committee external member for World Rugby (unpaid) and co-chair of the Concussion in Para Sport Group (unpaid). CAB is an Associate Professor of PM&R Journal at Spaulding Rehabilitation Hospital/Harvard Medical School and Chief Medical Officer at Spaulding Rehabilitation Hospital. She receives grant funding from the US Center for Disease Control and Prevention and the US National Institute on Disability, Independent Living, and Rehabilitation Research. She serves on the Board of Directors of the US Olympic & Paralympic Committee (unpaid) as well as on the International Paralympic Committee Medical Committee (unpaid) and the IOC Medical & Scientific Commission (unpaid). She serves as an Associate Editor of the British Journal of Sports Medicine (unpaid) and the PM&R Journal (unpaid). SPB Current or past research funding from the National Institutes of Health; US Centers for Disease Control and Prevention; Department of Defence (DoD)—USA Medical Research Acquisition Activity, National Collegiate Athletic Association (NCAA); National Athletic Trainers’ Association Foundation; NFL/Under Armour/GE; Simbex and ElmindA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medicolegal litigation and received speaker honorarium and travel reimbursements (including Concussion in Sport Group (CISG)) for talks given. He is the coauthor of Biomechanics of Injury (3rd Edition) and has a patent pending on Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source (US Application No 17/164,490). He is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present) and British Journal of Sports Medicine (2008–2019). RCC Senior Advisor NFL Head Neck & Spine Committee NOCSAE and Chair Scientific Advisory Committee Co-Founder, Medical Director Concussion Legacy Foundation Royalties Houghton Mifflin Harcourt Legal Expert Opinion. GAD is a member of the Scientific Committee of the Sixth International Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee; Section Editor, Sport and Rehabilitation, Neurosurgery and has attended meetings organised by sport organisations including NFL, NRL, IIHF, IOC and FIFA; however has not received any payment, research funding or other monies from these groups other than for travel costs. JD is the co-founder and board member of CISG and Senior Advisor to BJSM. RJE is a paid consultant for the NHL and cochair of the NHL/NHLPA Concussion Subcommittee. He is also a paid consultant and chair of the Major League Soccer concussion committee and a consultant to the US Soccer Federation. He previously served as a neuropsychology consultant to Princeton University Athletic Medicine and EyeGuide. He is currently a co-principal investigator (PI) for a grant funded by the NFL (NFL-Long) through Boston Children’s Hospital. He occasionally provides expert testimony in matters related to mild traumatic brain injury (mTBI) and sports concussion and occasionally receives honoraria and travel support/reimbursement for professional meetings. CAE holds external peer-reviewed research funding from Canadian Institutes of Health Research, Canada Foundation for Innovation, IOC Medical and Scientific Committee, NFL Play Smart Play Safe Program and World Rugby. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is an external advisory board member for HitIQ. NF-D International independent FIFA Concussion Advisory Group. GOTS Concussion Committee Innovation and Technology Panel, UK Department for Digital, Culture, Media and Sport. International Consensus Group on Concussion in Sports (CISG), NINDSCDE Sports Concussion CDE Subacute Subgroup (National Institutes of Health). IFAB Concussion Expert Group. Member of Swiss Neurology Society, Swiss Society for Clinical Neurophysiology, European Neuro-Ophthalmology Society and CISG. Editorial Board Member of Journal of Concussion, Journal of Science and Medicine in Football. GF has received travel expenses to attend academic meetings from World Rugby. He has also collaborated on research projects with World Rugby as chief or co-investigator. He is a previous associate editor of the British Journal of Sports Medicine. He has not received any other payments or support from any sporting or commercial bodies. CCG discloses the following: Grants/research support: HitIQ (2022–2023); NIH NINDS (R01 NS110757 2019–2024); NINDS (U54 NS121688 2021-2026); UCLA Brain Injury Research Center, UCLA Steve Tisch BrainSPORT programme, Easton Clinic for Brain Health. Clinical Consultant (provide clinical care to athletes): NBA, NFL-Neurological Care Program, NHL/NHLPA, Los Angeles Lakers Advisory Board (non-compensated): Major League Soccer, NBA and US Soccer Federation. Advisory Board (compensated): Highmark Interactive Medicolegal: One or two cases annually Speaker’s bureau: None. Stock shareholder: Highmark Interactive stock options (2018). Other financial or material support: book royalties—Blackwell/Wiley Publishing: prioritized. Neurological differential diagnosis. KMG has received grant funding from NFL for the NFL LONG study. He also serves on the NCAA Scientific Advisory Board in an unpaid capacity. BH works full time as a paid employee of the NCAA as Senior Vice President, Sport Science Institute, and as Chief Medical Officer. I serve as a volunteer advisory member for: US Football Medical Advisory Panel; CrashCourse by TeachAids; NBJA Youth Health & Wellness Working Group; External Advisory Board, DIAGNOSE CTE (Boston University). I am on the Board of Directors for the US Tennis Association, the Grand Slam Board; the International Tennis Integrity Agency and the Datalys Center. I am chair of the International Tennis Federation Sports Science & Medicine Commission. SAH is co-founder and senior advisor of the Sports Institute at UW Medicine (unpaid). Centers for Disease Control and Prevention and National Center for Injury Prevention and Control Board Pediatric Mild Traumatic Brain Injury Guideline Workgroup (unpaid). CISG (travel support). NCAA Concussion Safety Advisory Group (unpaid). Team Physician, Seattle Mariners. Former Team Physician, Seattle Seahawks. Occasional payment for expert testimony. Travel support for professional meetings. GLI serves as a scientific advisor for NanoDX, Sway Operations and Highmark. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mTBIs (including former athletes) and on the topic of suicide. He has received past research support or funding from several test publishing companies, including ImPACT Applications, CNS Vital Signs and Psychological Assessment Resources (PAR). He receives royalties from the sales of one neuropsychological test (WCST-64). He has received travel support and honorariums for presentations at conferences and meetings. He has received research funding as a PI from the NFL and subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of NFL Players Association Members. He has received research funding from the Wounded Warrior Project. He acknowledges unrestricted philanthropic support from ImPACT Applications, the Mooney-Reed Charitable Foundation, the National Rugby League, Boston Bolts and the Schoen Adams Research Institute at Spaulding Rehabilitation. JK declares the following affiliations: NBA. US Ski and Snowboard. US Olympic & Paralympic Committee. NHL Players’ Association. Major League Soccer Players’ Association. NFL Players’ Association. NeuroSync. Cognivue. JJL receives grant/research support from NIH, DoD and AMSSM. He is a member of the Scientific Advisory Board for Neuronasal, Highmark Innovations and Quadrant Biosciences. Minority stock options in Highmark Innovations and 360 Concussion Care. Expert consultant to NCAA. Consults with NFL and NHL teams on athlete care but does not receive any compensation from these organizations. He is on the Editorial Board of Journal of Head Trauma and Rehabilitation. DM Neuropsychologist and lawyer—legal practice in Medical Law. Legal representation provided to parties in personal injury legal proceedings. Former member of AFL Concussion Working Group—no remuneration. Past legal advisor to Cricket Australia and the AFL. Legal advisor to various professional sporting clubs. Past ARF concussion research funding received through the Florey Institute of Neuroscience & Mental Health. Member of the AFL Grievance Tribunal—no remuneration received. Legal advisor to private schools. Lectures (neuropsychology/law) to education providers—no remuneration. Cricket Victoria—former Director/Chair—no remuneration. Melbourne Grammar School—Audit & Risk Committee Member—no remuneration. CISG Board Member—no remuneration. Travel support to attend the 2022 CISG meeting. Abstained from discussions in the 2022 CISG consensus process in relation to ‘chronic traumatic encephalopathy, neuropathological change and trauatic encephalopathy syndrome'and 'potential long-term sequelae'. MM Sport and exercise medicine physician working in private consulting practice. Shareholder of Olympic Park Sports Medicine Centre in Melbourne. Ex-senior physician at the Hawthorn Football Club (AFL). Ex-Chief Executive Officer of the AFL Doctors Association. Research grants received from the Australian Football League, outside the submitted work. Travel support received from the Australian Football League, FIFA and the IOC to attend and present at international conferences. Member of the Scientific Committee for the Sixth International Conference on Concussion in Sport. Honorary member of the International CISG. Honorary member of the Australian Rugby Union Concussion Advisory Group. Independent Concussion Consultant for World Rugby. GTM discloses grants from the US DoD—TBI Endpoints Development Initiative (Grant no W81XWH-14-2-0176), TRACK-TBI Precision Medicine (Grant no W81XWH-18-2-0042) and TRACK-TBI NETWORK (Grant no W81XWH-15-9-0001); NIHNINDS—TRACK-TBI (Grant no U01NS086090) and the NFL Scientific Advisory Board—TRACK-TBI LONGITUDINAL. US Department of Energy supports GTM for a precision medicine collaboration. One Mind has provided funding for TRACK-TBI patients’ stipends and support to clinical sites. He has received an unrestricted gift from the NFL to the UCSF Foundation to support the research efforts of the TRACK-TBI NETWORK. GTM has also received funding from NeuroTruama Sciences to support TRACK-TBI data curation efforts. Additionally, Abbott Laboratories has provided funding for add-in TRACK-TBI clinical studies. MAM has received research funding to the Medical College of Wisconsin from the National Institutes of Health (NIH), Department of Veterans Affairs, US Centers for Disease Control and Prevention, DoD, NCAA, NFL and Abbott Laboratories. He receives book royalties from Oxford University Press. He serves as a clinical consultant to Milwaukee Bucks, Milwaukee Brewers and Green Bay Packers, and is Co-Director of the NFL Neuropsychology Consultants without compensation. He serves as a consultant for NeuroTrauma Sciences. He receives travel support and speaker honorariums for professional activities. MJM Chair, Ethics Expert Group, WADA (2021–2023) (paid). Member, International Boxing Association, Ethics and Integrity Committee, (2021–2022; resigned October 2022) (paid). Chair, Therapeutic Use Exemption Fairness Committee (2020 to present) (paid). Member, Steering Group, Sex Segregation in Sport, IAAF/World Athletics, (2019–2020) (unpaid). Member, International Ice Hockey Federation, Ethics and Integrity Committee (2019–2021) (paid). Member, IOC Consensus Statement Expert Group on Injuries in Children and Adolescents (2017) (unpaid). Member, Ethics Expert Group, WADA (2016–2021) (unpaid). Member, IOC Consensus Statement Expert Group on Pain Management (2016) (unpaid). WM is employed as the Chief Medical Officer of the NHL. JSP is an Editor of BJSM for which he receives a honorarium. He is an unpaid consultant to the World Rugby Concussion Advisory Group for which he also serves as an Independent Concussion Advisor (fee per consultation). Other unpaid positions include being medical advisor to South African Rugby, Co-chair of the Scientific Committee, 6th International Conference on Concussion in Sport (travel and accommodation subsidised), Board member of the CISG and a Scientific Advisory Board Member of EyeGuide. LKP CASEM Board Member, President-Elect 2022–2023 NIH R34 Grant for EPICC Study (Eye Problems In Concussed Children), Site PI. Speaker at various conferences. CISG member. Expert panellist for the Sixth International Conference on Concussion in Sport (travel and accommodation subsidised). MP declares the following: Consultant, Chief Medical Officer, Major League Soccer. Senior Advisor, NFL Head, Neck & Spine Committee. FA Research Task Force Committee member. UK Concussion Foundation Protocol Forum. US Soccer Medical Advisory Committee. CDC Concussion Consultant. CISG expert panel. NOCSAE Scientific Advisory Committee. IOC Mental Health Working Group. USOPC Mental Health Advisory Committee. Team Physician, US Soccer. Received funding for research; NCAA-CARE-DoD 2.0, ended 2020. He received honoraria and reimbursement for travel for speaking and conferences amended. He has written chapters for UpToDate and received royalties for the Netter’s Sports Medicine textbook. He has provided work as an expert for cases involving concussion, team physician and other sports medicine topics. KJS has received grant funding from the Canadian Institutes of Health Research, NFL Scientific Advisory Board, IOC Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary with funds paid to her institution and not to her personally. She is an Associate Editor of BJSM (unpaid), independent consultant to World Rugby and has received travel and accommodation support for meetings where she has presented. She led and coordinated the writing of the systematic reviews that informed the Sixth International Conference on Concussion in Sport and Amsterdam Consensus Statement, for which she received an educational grant to assist with the administrative costs associated with the writing of the reviews (with funds paid to her institution and not to her personally). She is a member of the AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid position). She works as a physiotherapy consultant and treats athletes of all levels of sport from grassroots to professional. MT is employed full-time as the CEO and Medical Director of ICHIRF—a paid post he has held since April 2015. Hon Medical Adviser to the Professional Riders Insurance Scheme (PRIS)—discretionary Honorarium. Member of the Premier League Head Injury Advisory Group—no remuneration. Director of ICHIRF Ireland—no remuneration. Honorary Medical Adviser to the Concussion Foundation—no remuneration. Member of the expert panel for the Department of Digital, Culture, Media and Sport review into concussion in amateur sport—no remuneration. Attendance at conferences or meetings as a guest speaker—reimbursement of travel expenses, complimentary registration and payment of hotel accommodation and meals by the organising committee. No stocks or options in any concussion-related company. No consultancies, board or editorial positions related to concussion. KOY is Editor-in-Chief of the journal Neuropsychology and receives an editorial stipend from the American Psychological Association. He is an unpaid consulting editor for the journals Archives of Clinical Neuropsychology and Journal of Head Trauma Rehabilitation. He is an unpaid member of the Scientific Advisory Committee for Brain Injury Canada. He is the chair of the Canadian Concussion Network, which is funded by a grant from the Canadian Institutes of Health Research (CIHR) to his institution; he is the principal applicant for the grant but receives no income from it. He is a PI on another grant from CIHR from which he derives no income. He is a co-investigator on research grants from CIHR, the US NIH, Brain Canada Foundation and NFL Scientific Advisory Board; he derives income only from the grant from the NIH. He serves as a member of a CIHR grant review panel for which he receives a small honorarium. He receives book royalties from Guilford Press and Cambridge University Press. He has received travel support and honorarium for presentations to multiple organisations. He serves or has served on the following committees/boards for which he receives honorarium: (1) Independent Data Monitoring Committee, Care for Post-Concussive Symptoms EffecCveness (CARE4PCS-2) Trial, National Institute for Child Health and Human Development; (2) Observational Study Monitoring Board, Approaches and Decisions in Acute Pediatric TBI (ADAPT) Trial, National Institute of Neurological Disorders and Stroke National Research Advisory Council; (3) National Pediatric Rehabilitation Resource Center, Center for Pediatric Rehabilitation: Growing Research, Education, and Sharing Science, Virginia Tech University., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Repetitive head impacts (RHI) from contact sports have been associated with cognitive and neuropsychiatric disorders. However, not all individuals exposed to RHI develop such disorders. This may be explained by the reserve hypothesis. It remains unclear if the reserve hypothesis accounts for the heterogenous symptom presentation in RHI-exposed individuals. Moreover, optimal measurement of reserve in this population is unclear and likely unique from non-athlete populations., Objective: We examined the association between metrics of reserve and cognitive and neuropsychiatric functioning in 89 symptomatic former National Football League players., Methods: Individual-level proxies (e.g., education) defined reserve. We additionally quantified reserve as remaining residual variance in 1) episodic memory and 2) executive functioning performance, after accounting for demographics and brain pathology. Associations between reserve metrics and cognitive and neuropsychiatric functioning were examined., Results: Higher reading ability was associated with better attention/information processing (β=0.25; 95% CI, 0.05-0.46), episodic memory (β=0.27; 95% CI, 0.06-0.48), semantic and phonemic fluency (β=0.24; 95% CI, 0.02-0.46; β=0.38; 95% CI, 0.17-0.59), and behavioral regulation (β=-0.26; 95% CI, -0.48, -0.03) performance. There were no effects for other individual-level proxies. Residual episodic memory variance was associated with better attention/information processing (β=0.45; 95% CI, 0.25, 0.65), executive functioning (β=0.36; 95% CI, 0.15, 0.57), and semantic fluency (β=0.38; 95% CI, 0.17, 0.59) performance. Residual executive functioning variance was associated with better attention/information processing (β=0.44; 95% CI, 0.24, 0.64) and episodic memory (β=0.37; 95% CI, 0.16, 0.58) performance., Conclusion: Traditional reserve proxies (e.g., years of education, occupational attainment) have limitations and may be unsuitable for use in elite athlete samples. Alternative approaches of reserve quantification may prove more suitable for this population.

Importance: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease; understanding ALS risk factors is a critical public health issue., Objectives: To evaluate the incidence of and mortality from ALS in National Football League (NFL) athletes and to describe characteristics associated with ALS within this cohort., Design, Setting, and Participants: This population-based cohort study included all 19 423 NFL athletes who debuted between 1960 and 2019 and played 1 or more professional game. It was conducted between October 3, 2020, and July 19, 2021., Exposure: Participation in the NFL, including playing 1 or more professional games., Main Outcomes and Measures: Cases of ALS and death information were identified based on public records from NFL statistics aggregators, news reports, obituaries, and National Death Index results. The standardized incidence ratio and the standardized mortality ratio were calculated based on data acquired from surveillance studies of ALS accounting for age, sex, and race. Secondary analyses examined the association of body mass index, NFL career duration, race, birth location, and markers of fame, using a nested case-control design, matching athletes with ALS to athletes without ALS, by NFL debut year., Results: A total of 19 423 male former and current NFL players (age range, 23-78 years) were included in this cohort study and were followed up for a cumulative 493 168 years (mean [SD] follow-up, 30.6 [13.7] years). Thirty-eight players received a diagnosis of ALS, and 28 died during the study time frame, representing a significantly higher incidence of ALS diagnosis (standardized incidence ratio, 3.59; 95% CI, 2.58-4.93) and mortality (standardized mortality ratio, 3.94; 95% CI, 2.62-5.69) among NFL players compared with the US male population, adjusting for age and race. Among NFL athletes, nested-case-control analyses found that those who received a diagnosis of ALS had significantly longer careers (mean [SD] duration, 7.0 [3.9] years) than athletes without ALS (mean [SD] duration, 4.5 [3.6] years; odds ratio, 1.2; 95% CI, 1.1-1.3). There were no differences in ALS status based on proxies of NFL fame, body mass index, position played, birth location, or race., Conclusions and Relevance: The age-, sex-, and race-adjusted incidence of and mortality from ALS among all NFL players who debuted between 1960 and 2019 were nearly 4 times as high as those of the general population. Athletes with a diagnosis of ALS had longer NFL careers than those without ALS, suggesting an association between NFL duration of play and ALS. The identification of these risk factors for ALS helps to inform the study of pathophysiological mechanisms responsible for this fatal neurodegenerative disease.

Study Design: Literature-based review., Objective: We sought to evaluate clinical and case studies related to return to play (RTP) after cervical spine injuries in elite American football athletes and to formulate guidelines to help health care practitioners manage these conditions., Summary of Background Data: American football athletes are at unique risk of cervical spine injury and appropriate case-by-case management of cervical spine injuries is necessary for these athletes. Despite this need, no standardized guidelines exist for RTP after cervical spine injury., Methods: Observational or case-based articles relating to RTP after cervical spine injury in American football athletes were curated from PubMed/EMBASE databases. Primary literature published before December 1, 2019 involving National Football League (NFL) or National Collegiate Athletic Association (NCAA) athletes met inclusion criteria., Results: The data acquisition process yielded 28 studies addressing cervical spine injuries and RTP in American football athletes. Stingers/burners were the most common injury and placed athletes at higher risk of a more severe re-injury. Transient quadriplegia, cervical stenosis, cervical disc herniation (CDH), and cervical fractures have a more significant impact on the long-term health and career longevity of the American football athlete. As such, the literature offers some guidance for management of these athletes, including average time for RTP in patients treated nonoperatively, thresholds involving cervical stenosis, and postoperative recommendations after spinal decompression and/or fusion surgery., Conclusion: Elite American football athletes are at high risk for cervical spine injury due to the nature of their sport. The decision to allow these athletes to return to play should involve an understanding of the average RTP time, the potential risks of recurrence or re-injury, and individual characteristics such as position played and pathology on imaging.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Professional American football players incur thousands of repetitive head impacts (RHIs) throughout their lifetime. The long-term consequences of RHI are not well characterized, but may include olfactory dysfunction. RHI has been associated with changes to brain regions involved in olfaction, and olfactory impairment is common after traumatic brain injury. Olfactory dysfunction is a frequent early sequelae of neurodegenerative diseases (e.g., Alzheimer's disease), and RHI is associated with the neurodegenerative disease, chronic traumatic encephalopathy (CTE). We examined olfaction, and its association with clinical measures, in former National Football League (NFL) players. Ninety-five former NFL players (ages 40-69) and 28 same-age controls completed a neuropsychological and neuropsychiatric evaluation as part of a National Institutes of Health-funded study. The Brief Smell Identification Test (B-SIT) assessed olfaction. Principal component analysis generated a four-factor structure of the clinical measures: behavioral/mood, psychomotor speed/executive function, and verbal and visual memory. Former NFL players had worse B-SIT scores relative to controls (p = 0.0096). A B-SIT cutoff of 11 had the greatest accuracy (c-statistic = 0.61) and specificity (79%) for discriminating former NFL players from controls. In the former NFL players, lower B-SIT scores correlated with greater behavioral/mood impairment (p = 0.0254) and worse psychomotor speed/executive functioning (p = 0.0464) after controlling for age and education. Former NFL players exhibited lower olfactory test scores relative to controls, and poorer olfactory test performance was associated with worse neuropsychological and neuropsychiatric functioning. Future work that uses more-comprehensive tests of olfaction and structural and functioning neuroimaging may improve understanding on the association between RHI and olfaction.

Background/aim: Despite concussion education being increasingly mandated by states and sports leagues, there has been limited evaluation of what education is in fact effective. The National Collegiate Athletic Association (NCAA) currently mandates that institutions provide concussion education, without specifying content or delivery. The present study evaluated the effectiveness of this general mandate, as enacted for male collegiate ice hockey teams within one conference of competition., Methods: In a prospective cohort design, 146 players from 6 male collegiate ice hockey teams in one Division 1 conference completed written surveys before and after receiving their institution-determined concussion education. Knowledge, attitudes, perceived norms and behavioural intention were assessed using validated measures. Education content and delivery was assessed by open-ended responses and consultation with team athletic trainers., Results: All teams received concussion education material; however, content and delivery varied. Rates of material recall differed by delivery format. Considering all teams together, there were no significant improvements in knowledge and only a very small decrease in intention to continue playing while experiencing symptoms of a concussion. Pre-education and post-education, there were significant between-team differences in attitudes towards concussion reporting and behavioural intention., Conclusions: The NCAA's general education mandate was divergently enacted; it did not significantly change the constructs of interest nor did it mitigate the pre-education team differences in these constructs. Existing educational materials should be evaluated, theory and evidence-driven materials developed, and mandates extended to, at a minimum, recommend materials found to be effective in changing concussion-reporting behaviour.

Return-to-play and retirement decisions after concussion are often difficult and complex. The complexity of these decisions may be influenced by many factors, including the number, proximity, and severity of previous concussions; gender; age; sport played; exposure to head impacts; and predisposing or pre-existing conditions. These circumstances and conditions can confound the decisions concerning return to play and retirement. Clinicians should carefully weigh how these circumstances and conditions influence quality of life and how they interact with the effects of concussion. Furthermore, clinicians should consider past and potential exposures to both subconcussive and concussive impacts during the athlete's lifetime when deliberating a return to play or retirement. The purpose of this overview is to highlight and discuss these issues as they factor into the return-to-play and retirement decisions after a concussive injury in an effort to provide clinicians with evidence-based information that can be used in the decision-making process., (Copyright © 2011 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background: Sudden deaths of young competitive athletes are highly visible events that have a substantial effect on families and communities. Recent attention has focused predominantly on cardiovascular causes, and less on traumatic organ damage., Objective: To define the clinical profile, epidemiology, and frequency of trauma-related deaths in young US athletes., Methods: We analyzed the 30-year US National Registry of Sudden Death in Young Athletes (1980-2009) by using systematic identification and tracking strategies., Results: Of 1827 deaths of athletes aged 21 years or younger, 261 (14%) were caused by trauma-related injuries, usually involving the head and/or neck (mean: 16 ± 2 years; 90% male) in 22 sports. The highest number of events in a single year was 16 (1986), with an average of 9 per year throughout 30 years. The mortality rate was 0.11 in 100 000 participations (95% confidence interval: 0.08-0.15). The largest number of deaths was in football (148 [57%]), including 17 high school athletes who sustained concussions shortly before fatal head trauma ("second-impact syndrome"). Football deaths were more frequent in defensive players, although the single most common position involved was running back (61% of offensive players)., Conclusions: In a large community-based national registry, sudden deaths caused by blunt trauma in young athletes aged 21 years or younger were relatively uncommon with 16 or fewer per year, about fourfold less than cardiovascular deaths. These fatalities were most frequent in football, and an important proportion of deaths after head blows in high school football were associated with a recent history of symptomatic concussion., (Copyright © 2011 by the American Academy of Pediatrics.)

Purpose: To identify the effects of infractions sustained during participation in youth ice hockey on biomechanical measures of head impact severity., Methods: Sixteen adolescent Bantam-aged male ice hockey players (age = 14.0 +/- 0.5 yr, height = 171.3 +/- 4.5 cm, mass = 63.7 +/- 6.6 kg) were equipped with accelerometer-instrumented helmets to collect biomechanical measures relating to head impacts (linear acceleration, rotational acceleration, and Head Impact Technology severity profile (HITsp)) sustained while participating in ice hockey. Single-camera video footage from 54 games was synchronized with the head impact data, and all viewable collisions (n = 665) were evaluated as resulting from a legal collision or an infraction. Infractions were further categorized into boarding or charging, checking from behind, and elbowing or intentional head contact. Statistical analyses included random-intercepts general linear mixed models., Results: Infractions were observed in 17.3% (115/665) of all body collisions. Overall, collisions involving infractions had higher linear accelerations (P = 0.012) and HITsp (P = 0.021) than collisions with no infraction. Specifically, elbowing, head contact, and high sticking infractions resulted in greater linear acceleration (P = 0.005) and HITsp (P = 0.010) than collisions with no infraction. A strong trend for higher rotational accelerations in this infraction type compared with legal collisions was also present (P = 0.059)., Conclusions: Infractions result in higher measures of head impact severity than noninfraction collisions. Athletes and coaches should conform to playing rules, and officials should enforce more stringently existing rules and assess more severe penalties to participants who purposefully attempt to foul an opponent at the youth ice hockey level.

Data from the National Center for Sports Injury show that changes in rules and equipment have made interscholastic sports safer in recent decades, but the record for 1982-1997 shows that there is still room for improvement. The paper presents sport-specific considerations and examines several general safety recommendations that should be followed. (SM)

ObjectiveSystematic review of possible long-term effects of sports-related concussion in retired athletes.Data sourcesTen electronic databases.Study selectionOriginal research; incidence, risk factors or causation related to long-term mental health or neurological problems; individuals who have suffered a concussion; retired athletes as the subjects and possible long-term sequelae defined as >10 years after the injury.Data extractionStudy population, exposure/outcome measures, clinical data, neurological examination findings, cognitive assessment, neuroimaging findings and neuropathology results. Risk of bias and level of evidence were evaluated by two authors.ResultsFollowing review of 3819 studies, 47 met inclusion criteria. Some former athletes have depression and cognitive deficits later in life, and there is an association between these deficits and multiple prior concussions. Former athletes are not at increased risk for death by suicide (two studies). Former high school American football players do not appear to be at increased risk for later life neurodegenerative diseases (two studies). Some retired professional American football players may be at increased risk for diminishment in cognitive functioning or mild cognitive impairment (several studies), and neurodegenerative diseases (one study). Neuroimaging studies show modest evidence of macrostructural, microstructural, functional and neurochemical changes in some athletes.ConclusionMultiple concussions appear to be a risk factor for cognitive impairment and mental health problems in some individuals. More research is needed to better understand the prevalence of chronic traumatic encephalopathy and other neurological conditions and diseases, and the extent to which they are related to concussions and/or repetitive neurotrauma sustained in sports.

Background/aim: To evaluate the association of genetic polymorphisms APOE, APOE G-219T promoter, microtubule associated protein(MAPT)/tau exon 6 Ser53Pro, MAPT/tau Hist47Tyr, IL-6572 G/C and IL-6RAsp358Ala with the risk of concussion in college athletes.Methods: A 23-centre prospective cohort study of 1056 college athletes with genotyping was completed between August 2003 and December 2012. All athletes completed baseline medical and concussion questionnaires, and post-concussion data were collected for athletes with a documented concussion.Results: The study cohort consisted of 1056 athletes of mean±SD age 19.7±1.5 years, 89.3% male, 59.4% Caucasian, 35.0% African-American, 5.6% other race. The athletes participated in American football, soccer, basketball, softball, men's wrestling and club rugby. A total of 133 (12.1% prevalence) concussions occurred during an average surveillance of 3 years per athlete. We observed a significant positive association between IL-6R CC (p=0.001) and a negative association between APOE4 (p=0.03) and the risk of concussion. Unadjusted and adjusted logistic regression analysis showed a significant association between IL-6R CC and concussion (OR 3.48; 95% CI 1.58 to 7.65; p=0.002) and between the APOE4 allele and concussion (OR 0.61; 95% CI 0.38 to 0.96; p=0.04), which persisted after adjustment for confounders.Conclusions: IL-6R CC was associated with a three times greater concussion risk and APOE4 with a 40% lower risk. [ABSTRACT FROM AUTHOR]

Objective: To test a helmetless-tackling behavioral intervention for reducing head impacts in National Collegiate Athletic Association Division I football players. Design: Randomized controlled clinical trial. Setting: Football field. Patients or Other Participants: Fifty collegiate football players (intervention = 25, control = 25). Intervention(s): The intervention group participated in a 5- minute tackling drill without their helmets and shoulder pads twice per week in the preseason and once per week through the season. During this time, the control group performed noncontact football skills. Main Outcome Measure(s): Frequency of head impacts was recorded by an impact sensor for each athlete-exposure (AE). Data were tested with a 2 x 3 (group and time) repeated-measures analysis of variance. Significant interactions and main effects (P < .05) were followed with t tests. Results: Head impacts/AE decreased for the intervention group compared with the control group by the end of the season (9.99 ± 6.10 versus 13.84 ± 7.27, respectively). The intervention group had 30% fewer impacts/AE than the control group by season's end (9.99 ± 6.10 versus 14.32 ± 8.45, respectively). Conclusion: A helmetless-tackling training intervention reduced head impacts in collegiate football players within 1 season. [ABSTRACT FROM AUTHOR]

Objective: Chronic Traumatic Encephalopathy (CTE) is a neurodegenerative disease associated with repetitive brain trauma (RBT). Initially described in boxers, CTE has now been found in other contact sport athletes with a history of RBT. In recent years, there has been tremendous media attention regarding CTE, primarily because of the deaths of high profile American football players who were found to have CTE upon neuropathological examination. However, the study of CTE remains in its infancy. This review focuses on research from the Centre for the Study of Traumatic Encephalopathy (CSTE) at Boston University. Methods: This study reviews the formation of the CSTE, major CSTE publications and current ongoing research projects at the CSTE. Results: The neuropathology of CTE has been well-described. Current research focuses on: methods of diagnosing the disease during life (including the development of biomarkers), examination of CTE risk factors (including genetic susceptibility and head impact exposure variables); description of the clinical presentation of CTE; development of research diagnostic criteria for Traumatic Encephalopathy Syndrome; and assessment of mechanism and pathogenesis. Conclusions: Current research at the BU CSTE is aimed at increasing understanding of the long-term consequences of repetitive head impacts and attempting to begin to answer several of the unanswered questions regarding CTE. [ABSTRACT FROM AUTHOR]

Background The onfield assessment of concussion in the adult athlete is challenging, given the elusiveness of injury, the sensitivity and specificity of the sideline assessment tools and the evolving nature of concussive injury. This paper reviews the evidence related to the onfield assessment and considers questions related to same day return to play, what to do when no physician is available onsite, as well as the benefit of remote notification of potential concussive events. Objective To review the evidence regarding the onfield assessment of concussion in the adult athlete. Additional key issues to consider include same day return to play for the adult athlete with concussion, what to do in a community setting when no doctor is present and whether there is any benefit with remote notification of potential concussive events that occur on the playing field. Data Sources Systematic literature review of concussion assessment and management. PubMed, MEDLINE, Psych Info and Cochrane Library databases were reviewed using the MeSH key words concussion and mild traumatic brain injury combined with athletic injuries. Each was refined by adding the key words 'adult', 'sideline assessment', 'onfield assessment' and 'return to play'. Results For the MEDLINE search, using 'concussion' and 'athletic injuries' as key words, there were 880 results, and refining by 'adult' there were 292 results. When 'traumatic brain injury' and 'athletic injuries' were combined, there were 210 results. When refining by 'adult', there were 89 results. Many of these results overlapped. Following an initial review, these articles form the basis of the discussion. Conclusions The onfield evaluation of sport-related concussion is often a challenge, given the elusiveness and variability of presentation, difficulty in making a timely diagnosis, specificity and sensitivity of the sideline assessment tools and the reliance on symptoms. Despite these challenges, the sideline evaluation is based on recognition of injury, assessment of symptoms, cognitive and cranial nerve function and balance. Serial assessments are often necessary and, since signs and symptoms may be delayed, erring on the side of caution (keeping an athlete out of participation when there is any suspicion for injury) is important. A standardised assessment of concussion is useful in the assessment of the athlete with suspected concussion but should not take the place of the clinician's judgement. [ABSTRACT FROM AUTHOR]

The article discusses the pathophysiology of spinal cord injury (SCI), as well as guidelines for returning to contact sports following cervical SCI. Following cervical SCI, athletes can generally return to contact sports if they are already asymptomatic with full range of motion (ROM). They should also have regained their pre-injury neck strength. Imaging should also show that the athletes do not have functional stenosis.

Chronic traumatic encephalopathy (CTE) has been linked to participation in contact sports such as boxing and American football. CTE results in a progressive decline of memory and cognition, as well as depression, suicidal behavior, poor impulse control, aggressiveness, parkinsonism, and, eventually, dementia. In some individuals, it is associated with motor neuron disease, referred to as chronic traumatic encephalomyelopathy, which appears clinically similar to amyotrophic lateral sclerosis. Results of neuropathologic research has shown that CTE may be more common in former contact sports athletes than previously believed. It is believed that repetitive brain trauma, with or possibly without symptomatic concussion, is responsible for neurodegenerative changes highlighted by accumulations of hyperphosphorylated tau and TDP‐43 proteins. Given the millions of youth, high school, collegiate, and professional athletes participating in contact sports that involve repetitive brain trauma, as well as military personnel exposed to repeated brain trauma from blast and other injuries in the military, CTE represents an important public health issue. Focused and intensive study of the risk factors and in vivo diagnosis of CTE will potentially allow for methods to prevent and treat these diseases. Research also will provide policy makers with the scientific knowledge to make appropriate guidelines regarding the prevention and treatment of brain trauma in all levels of athletic involvement as well as the military theater. [ABSTRACT FROM AUTHOR]

Context: Lack of empirical data on recovery time following sport-related concussion hampers clinical decision making about return to play after injury. Objective: To prospectively measure immediate effects and natural recovery course relating to symptoms, cognitive functioning, and postural stability following sport-related concussion. Design, Setting, and Participants: Prospective cohort study of 1631 football players from 15 US colleges. All players underwent preseason baseline testing on concussion assessment measures in 1999, 2000, and 2001. Ninety-four players with concussion (based on American Academy of Neurology criteria) and 56 noninjured controls underwent assessment of symptoms, cognitive functioning, and postural stability immediately, 3 hours, and 1, 2, 3, 5, 7, and 90 days after injury. Main Outcome Measures: Scores on the Graded Symptom Checklist (GSC), Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and a neuropsychological test battery. Results: No player with concussion was excluded from participation; 79 players with concussion (84%) completed the protocol through day 90. Players with concussion exhibited more severe symptoms (mean GSC score 20.93 [95% confidence interval {CI}, 15.65-26.21] points higher than that of controls), cognitive impairment (mean SAC score 2.94 [95% CI, 1.50-4.38] points lower than that of controls), and balance problems (mean BESS score 5.81 [95% CI, –0.67 to 12.30] points higher than that of controls) immediately after concussion. On average, symptoms gradually resolved by day 7 (GSC mean difference, 0.33; 95% CI, -1.41 to 2.06), cognitive functioning improved to baseline levels within 5 to 7 days (day 7 SAC mean difference, -0.03; 95% CI, -1.33 to 1.26), and balance deficits dissipated within 3 to 5 days after injury (day 5 BESS mean difference, -0.31; 95% CI, -3.02 to 2.40). Mild impairments in cognitive processing and verbal memory evident on neuropsychological testing 2 days after concussion resolved by day 7. There were no significant differences in symptoms or functional impairments in the concussion and control groups 90 days after concussion. Conclusions: Collegiate football players may require several days for recovery of symptoms, cognitive dysfunction, and postural instability after concussion. Further research is required to determine factors that predict variability in recovery time after concussion. Standardized measurement of postconcussive symptoms, cognitive functioning, and postural stability may enhance clinical management of athletes recovering from concussion. [ABSTRACT FROM AUTHOR]

Since the 1920s, it has been known that the repetitive brain trauma associated with boxing may produce a progressive neurological deterioration, originally termed “dementia pugilistica” and more recently, chronic traumatic encephalopathy (CTE). We review the 47 cases of neuropathologically verified CTE recorded in the literature and document the detailed findings of CTE in 3 professional athletes: one football player and 2 boxers. Clinically, CTE is associated with memory disturbances, behavioral and personality changes, Parkinsonism, and speech and gait abnormalities. Neuropathologically, CTE is characterized by atrophy of the cerebral hemispheres, medial temporal lobe, thalamus, mammillary bodies, and brainstem, with ventricular dilatation and a fenestrated cavum septum pellucidum. Microscopically, there are extensive tau-immunoreactive neurofibrillary tangles, astrocytic tangles, and spindle-shaped and threadlike neurites throughout the brain. The neurofibrillary degeneration of CTE is distinguished from other tauopathies by preferential involvement of the superficial cortical layers, irregular, patchy distribution in the frontal and temporal cortices, propensity for sulcal depths, prominent perivascular, periventricular and subpial distribution, and marked accumulation of tau-immunoreactive astrocytes. Deposition of beta amyloid, most commonly as diffuse plaques, occurs in fewer than half the cases. CTE is a neuropathologically distinct, slowly progressive tauopathy with a clear environmental etiology.

The article presents an abstract of the paper "The Value Added of Neurocognitive Testing After Sports-Related Concussion," by D. A. Van Kampen, M. R. Lovell, J. E. Pardini, M. W. Collins and F. H. Fu. A commentary for this paper was also provided. Here, the author states that the researchers presented a valid conclusion when they determine that the sensitivity of detecting post concussion abnormalities increases when using neurocognitive testing, compared to just using symptoms checklist. However, he added that some areas of this study still needs further exploration.

Objective: This study aimed to evaluate whether preseason concussion knowledge and reporting intention predicted in-season concussion reporting behavior. Design: Prospective cohort study. Setting: Collegiate athletic facility of each participating team. Participants: National Collegiate Athletic Association Division I men's ice hockey players in 1 conference of competition (n = 116). Independent Variables: Intention to report symptoms of a "minor" concussion and concussion knowledge were assessed at preseason. Main Outcome Measures: Postseason recall of non-report of postimpact symptoms. Results: Preseason concussion knowledge was not significantly associated with in-season reporting behavior. Intention to report concussion symptoms was significantly related to in-season reporting behavior. There was a significant interaction between the number of different symptoms experienced and both preseason reporting intention and in-season reporting behavior. Conclusions: Evaluations of concussion education programs tend to measure concussion knowledge. The present findings suggest that reporting intention may be more strongly predictive of reporting behavior than concussion knowledge and should be included in evaluations of concussion effectiveness. New concussion education initiatives should consider targeting psychosocial constructs that increase reporting intention. Clinical Relevance: Sports medicine clinicians who are involved in evaluating concussion education programs should measure constructs other than just concussion knowledge. Intention, to report symptoms or to continue play while experiencing symptoms of a concussion, seems to be an important and feasible construct to include as part of proximal evaluations of education effectiveness. [ABSTRACT FROM AUTHOR]

The article discusses a study examining the effectiveness of the Sport Legacy Institute Community Educator (SLICE) curriculum on recognition and appropriate response to concussions, for student athletes. The SLICE concussions education program was conducted, which provided interactive demonstration, discussions, and case studies of athletes. Evaluation of the outcomes revealed that there was a significant improvement in the concussion knowledge quiz after the presentation.