In the sports literature, the effects of traumatic biomechanical forces on the brain have traditionally been referred to as a concussion. In this Guideline, the term concussion/mTBI will be used to maintain consistency within this document. A sport-related concussion/mTBI is a traumatic brain injury that may be caused by either a direct blow to the head, face, neck or elsewhere on the body as an indirect force being transmitted to the head during sports activity. A sport-related concussion/mTBI can result in a range of clinical signs and symptoms that may or may not involve a loss of consciousness. While the injury may result in neuropathological changes, the acute clinical signs and reported symptoms largely reflect a functional disturbance rather than a structural injury. Sport-related concussion/mTBIs often present without neurological signs, and can cause a variety of symptoms making the injury complex and potentially difficult to assess and manage. Due to rapidly changing clinical signs and symptoms in the acute phase, sport-related concussion/mTBIs are considered to be among the most complex injuries in sports medicine to diagnose, assess and manage.¹ Sport-related concussion/ mTBIs can occur in any population playing sport. A concussion/mTBI injury is more likely to occur when the force or impact suffered is not anticipated by the athlete. Concussion/mTBI’s are more likely to occur in contact sports, with the highest incidences (excluding combat sports) being in soccer, football, ice hockey, rugby and basketball.^2,3 However, nonsport- related concussion/mTBI’s also occur in athletes, and can impact their return-to-sport as well. The majority of sport concussion/mTBI symptoms in adults resolve within 10-14 days, although the recovery time frame may be longer in children and adolescents.^1,3-5 For more information on the management of concussion/mTBI in children and adolescents aged 5-18 years please see the ONF Guidelines for Pediatric Concussion.

Accurate diagnosis, management, and return-to-sport decisions are essential at all levels of participation (i.e., amateur to professional) and for all types of sport. Experts unanimously agree that any player suspected of having experienced a concussion/mTBI should be immediately removed from play, must not return to the game or practice and should be referred for Medical Assessment.^2,6

Concussion/mTBI can be recognized in the community by all sport stakeholders including athletes, parents, coaches, officials, teachers, trainers, and licensed healthcare providers, however a formal diagnosis should be made by a physician following a thorough medical assessment. Athletes with a sport-related concussion/mTBI may require onsite (on-field) medical assessments by emergency medical professionals for a more severe head injury, cervical or spine injury, or loss of consciousness.

In cases in which a concussion/mTBI is suspected without a more severe head or spine injury, a player should be removed from the field of play and a sideline assessment can be performed. The Concussion in Sport Group has created a revised Sport Concussion Assessment Tool (SCAT5 and the Concussion Recognition Tool 5, presented in Appendix 3.1 and Appendix 3.2 respectively)³ to aid with this; these tools can also be used during sideline evaluation and include information that can be handed to the athlete. If a player shows any of the signs or symptoms of a concussion/mTBI outlined in Table A, concussion/mTBI should be suspected and a referral for a comprehensive evaluation and medical assessment is required.^1,4,6

Athletes diagnosed with a concussion/mTBI should be provided with education about the signs and symptoms of concussion/ mTBI, strategies about how to manage initial symptoms, guidance on how to gradually return to school, work, and sport, and risks of returning to sport before a concussion/mTBI has resolved and without medical clearance.6 Historically, most consensus statements and guidelines have recommended that concussed athletes rest until they are symptom-free, and prescribed physical and cognitive rest had been a mainstay of care in this population. However, there is currently insufficient evidence that that prescribing complete rest is beneficial for recovery. Therefore, after a brief period of rest during the acute phase (24-48 hours) after injury, patients should be encouraged to become gradually and progressively more active while not increasing symptoms. In fact the term relative rest is more appropriate as patients may partake in activity in the initial stages as long as symptoms do not worsen. A reasonable approach involves the gradual return to daily tasks, school, and light physical activity in a way that does not result in a significant exacerbation of symptoms. Vigorous exertion or return to contact sport should be avoided while athletes are recovering.¹

Most athletes who sustain a sport-related concussion/mTBI will make a complete recovery in 1-4 weeks after injury. However, athletes who do not recover within this time frame may benefit from a referral to a physician with experience in concussion/ mTBI in a medically-supervised interdisciplinary concussion clinic that has access to professionals with licensed training in mTBI. Individualized medical and rehabilitative care will be provided for the athlete and medical clearance is required before the athlete can return-to-sport.⁶ The Buffalo Concussion Treadmill Test (Appendix 3.3) can be used to investigate exercise tolerance in people with persistent symptoms.

Healthcare professionals should counsel amateur athletes with a history of multiple concussion/mTBIs and subjective persistent neurobehavioural impairments about the risk of further concussion/mTBIs, prolonged symptoms and slower recoveries. Return-to-sport and retirement decision-making in patients with persistent symptoms and multiple concussion/ mTBIs requires an individualized approach within an interdisciplinary healthcare team. This may involve a clinical neuropsychologist with certified training in the administration of comprehensive neuropsychological testing, consideration for neuroimaging, and a physician with experience in sport concussion/mTBI management. Considerations for retirement from play: multiple concussion/mTBIs >3, increasing duration of symptoms, subsequent concussion/mTBIs requiring lesser force, inability to return to full-time school or work.^7,8

It should be noted that sport-related concussion/mTBI represents one area of study in the mTBI field. Given that the current guideline is not specific to sport-related injuries, the information and guidance included herein for acute and subacute management is limited. Thus, readers interested in further guidance on the assessment and management of concussion/ mTBIs in this specific patient population should consult the latest Consensus Statement on Concussion in Sport: the Fifth International Conference on Concussion in Sport held in Berlin, October 2016¹, American Academy of Neurology Evidence-based Guideline for Clinicians: Evaluation and Management of Concussion in Sports⁷, the Concussion Management Guidelines for Certified Athletic Therapists in Quebec⁹, or the Canadian Guideline on Concussion in Sport.⁶ Many sports organizations also formally provide specific guidance and recommendations that are unique to their sport and parallel the principles of existing guidelines; this information can provide further clarity and assistance when making decisions about how to proceed with progressive return to an activity/sport (see resource links in Appendix F). Further, as discussed above, differences exist between the nature of injuries sustained during sport compared with other types of injuries. Therefore, the application of clinical guidance for sport-related concussion/mTBI may not be appropriate for patients who have sustained other types of injuries.

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