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The consensus definition of concussion was only agreed in 20011 which means that concussion has just turned 18. It must, therefore, be viewed as an unruly teenager, rebellious and changing, but finally beginning to mature. Along the way, there has been a book, a film, extensive litigation and legislation, millions of words written in the media, thousands of peer-reviewed articles, more consensus meetings, more books and the threat of still more litigation. Hardly a week goes by without another story about concussion hitting the headlines and the centre of the concussion maelstrom is the USA.
In terms of global participation, volleyball leads the field with 998 million participants, followed by basketball (400 m), soccer (242 m), badminton (200 m) and tennis (60 m). Not the strongest line-up for sports involving concussion and in the USA, the list is only slightly skewed—basketball (30.3 m), baseball (29.3 m), soccer (13.6 m) volleyball (10.7 m), American Football (8.9 m) and ice hockey (3.1 m). There are doctors around the globe who are involved with sport and never see a case of sport-related concussion from 1 year to the next.
Sport related concussion in the USA
Although participation may generate concussion, it is viewing popularity that generates interest and controversy, and, in the USA, the pageant winners are American Football, basketball, baseball, ice hockey and golf (in that order). The only country in the world to legislate the management of any medical condition is the USA and that condition is concussion. Every state of the union now has its own version of the original Zackery Lystedt Law2 with varying emphasis on removal from play, return to play and education relating to concussion. It is therefore logical that the American Medical Society for Sports Medicine (AMSSM) would turn its attention, once again, to this medical minefield.
The USA has over 1.0 million doctors (2013) and a doctor/patient ratio of 2.568 per 1000 patients (WHO 2013), so it is reasonable to have a set of guidelines for American doctors treating the 1.3–3.8 million sports-related concussions that occur in the USA annually. As the largest membership organisation representing sports medicine physicians in North America, AMSSM is perfectly placed to provide advice and guidance to the people who are expected to manage every stage of the concussion spectrum. It has also been able to assemble a formidable line up of experts to update the original 2013 iteration of their position statement3 and translate the information from the 2016 Berlin Consensus4 into a user-friendly document that is focused on the sports that are popular in the USA. The document covers prevention, sideline assessment, management, return to sport, disqualification from sport, return to learn, delayed recovery and the long-term risks in a balanced and impartial way. By using a Strength-of-Recommendation Taxonomy (SORT), and with over 125 references, the paper enables the reader to measure the strength and value of each recommendation and to update their clinical ‘best practice’ (despite the lack of definitive outcome data).
Global recommendations for sport-related concussion
By contrast, the sports outside the USA that generate the most concussion are those involving horses (equestrian events and horse racing), Australian Rules football, rugby union, rugby league and soccer - followed by skiing, motor sports, martial arts, cricket and, far behind the rest, boxing. It is therefore not surprising that numerous other organisations or national associations have issued guidance on concussion:
UK Faculty of Sport and Exercise Medicine—Position Statement on Concussion https://www.fsem.ac.uk/position_statement/concussion-management/
World Rugby—concussion management https://playerwelfare.worldrugby.org/concussion
Sports Concussion South Africa http://www.sportsconcussion.co.za/about-concussion/overview-of-concussion/
Australia—the management of concussion in the AFL—Australian Football League http://www.aflcommunityclub.com.au/fileadmin/user_upload/Health_Fitness/2017_Community_Concu
Sports Medicine Australia—Concussion in Sport Policy https://sma.org.au/sma-site-content/uploads/2018/03/Concussion-Policy-2018.pdf
Concussion management in combat sports—consensus statement https://bjsm.bmj.com/content/bjsports/early/2018/07/26/bjsports-2017-098799.full.pdf
The AMSSM Position Statement on Concussion in Sport provides the most up-to-date assessment of current thinking and clinical practice in a contentious area that is fraught with pitfalls and booby traps. Professor Kimberly Harmon and the AMSSM working group have focused on their own area of influence and they are to be roundly commended, and the document widely recommended.
Footnotes
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.