Consensus statement Br J Sports Med: first published as 10.1136/bjsports-2020-103696 on 9 April 2021. Downloaded from Concussion in para sport: the first position statement of the Concussion in Para Sport (CIPS) Group Richard Weiler ,1,2,3 Cheri Blauwet ,4,5 David Clarke,6 Kristine Dalton ,7 Wayne Derman ,8,9 Kristina Fagher ,10 Vincent Gouttebarge ,1,11 James Kissick ,12,13 Kenneth Lee ,14 Jan Lexell ,10 Peter Van de Vliet ,15 Evert Verhagen ,1 Nick Webborn ,16 Osman Hassan Ahmed 3,17,18 ► Additional supplemental ABSTRACT Alpine Skiing, Para Ice Hockey and Para Snow- material is published online Concussion is a frequent injury in many sports and is also boarding, demonstrate the need for this discussion only. To view, please visit the 1 2 journal online (http:// dx. doi. common in para athletes. However, there is a paucity and debate. At the Rio 2016 Summer Paralympic org/ 10. 1136/ bjsports- 2020- of concussion research related to para sport, and prior Games, no concussions were reported by team 103696). International Concussion in Sport (CIS) consensus papers physicians in the injury reporting survey, despite have not substantively addressed this population. To several incidents across different sports where For numbered affiliations see remedy this and to improve concussion care provided end of article. athletes were observed to suffer a blow to the head, to para athletes, the concussion in para sport (CIPS) followed by unsteady gait and reports of significant 3 Correspondence to multidisciplinary expert group was created. This group injuries to the head and face. Recently, a study Professor Evert Verhagen, analysed and discussed in- depth para athlete- specific of clinicians working at the 2015 Cerebral Palsy Department of Public issues within the established key clinical domains of (CP) Football World Championships showed that and Occupational Health, the current (2017) consensus statement on CIS. Due clinicians’ overall knowledge around concussion Amsterdam UMC, Amsterdam, to the onset of the COVID-19 pandemic, the group Noord Holland, The Netherlands; was sound, but their methods for recognition and 4 e. verhagen@ amsterdamumc. nl held all meetings by video conferencing. The existing management were highly variable. Study partic- Sport Concussion Assessment Tool 5 (SCAT5) for the ipants recognised an urgent need for expert clin- Accepted 4 March 2021 immediate on- field and office- based off- field assessment ical guidance specific to this population of athletes. of concussion was evaluated as part of this process, Aside from a wider need for concussion education, to identify any para athlete- specific concerns. Regular clinicians face difficulties when applying existing preparticipation and periodic health examinations are concussion assessment and management guidelines essential to determine a baseline reference point for to para athletes. concussion symptoms but pose additional challenges Various terminology has been used within para for the interpreting clinician. Further considerations sport and our paper will align with the Para sport for concussion management for the para athlete are translation of the International Olympic Committee required within the remove, rest, reconsider and refer (IOC) consensus on the recording and reporting of http://bjsm.bmj.com/ consensus statement framework. Considering return data for injury and illness in sport.5 Accordingly ‘a to sport (RTS), the 2017 CIS consensus statement has para athlete is the International Paralympic Commit- limitations when considering the RTS of the para athlete. tee’s term for a sportsperson with an impairment Case- by- case decision making related to RTS following and these terms will be used in this consensus state- concussion is imperative for para athletes. Additional ment as they apply to all athletes with impairment challenges exist for the evaluation and management of partaking in sport.’ The World Health Organization concussion in para athletes. There is a need for greater (WHO) defines disability as ‘any restriction or lack on September 29, 2021 by guest. Protected copyright. understanding of existing knowledge gaps and attitudes of ability to perform an activity in the manner or towards concussion among athlete medical staff, coaches within the range considered normal for a human and para athletes. Future research should investigate being,’ wherein disability is considered the result of the use and performance of common assessment tools 5–7 in the para athlete population to better guide their an impairment. clinical application and inform potential modifications. While tools assessing brain function (eg, Sport Concussion prevention strategies and sport- specific rule Concussion Assessment Tool 5 (SCAT5) and neuro- changes, such as in Para Alpine Skiing and Cerebral Palsy cognitive tests) are widely acknowledged to be Football, also should be carefully considered to reduce helpful following concussion, these tools are neither the occurrence of concussion in para athletes. validated nor applicable in some respects within a © Author(s) (or their para sport population. Significant differences were employer(s)) 2021. Re- use shown between baseline SCAT3 scores for footbal- permitted under CC BY- NC. No lers with and without impairment.8 These differ- commercial re- use. See rights ences, among others, need to be recognised and and permissions. Published INTRODUCTION by BMJ. Concussion prevention, recognition, assessment considered, in order to create concussion guidelines and management have been topics of much discus- that are specific to the wide variety of impairments To cite: Weiler R, sion and debate across all major global sports, noted in the growing number of athletes living Blauwet C, Clarke D, et al. Br J Sports Med Epub ahead including para Sports. Injury surveillance data from with impairment. Within previous iterations of the of print: [please include Day the most recent summer and winter paralympic consensus statements from the Concussion in Sport Month Year]. doi:10.1136/ games, showing high rates of injuries to the head Group (CISG),9 there has been no consideration of bjsports-2020-103696 and face in football 5- a- side (blind football), Para the specific issues faced by para athletes, which may Weiler R, et al. Br J Sports Med 2021;0:1–9. doi:10.1136/bjsports-2020-103696 1 Consensus statement Br J Sports Med: first published as 10.1136/bjsports-2020-103696 on 9 April 2021. Downloaded from reflect the lack of concussion- related research that focuses on itself to make, or exclude, the diagnosis of concussion in a para para athletes. Despite a paucity of research, the concussion issues athlete, and a para athlete may have a concussion even if their faced by para athletes and their support staff are of concern and SCAT5 is deemed to be ‘normal’. If the clinician has concerns therefore specific recommendations for standards of care are regarding the assessment or return to play (RTP) progression, needed. they should err on the side of caution when making decisions. In the para athlete population, the importance of clinicians performing routine baseline periodic preparticipation examina- METHODS tions (PPE) is emphasised in order to establish a point of refer- The aim of the Concussion in Para Sport (CIPS) group was to ence for the assessment of concussion symptoms in the future develop specific recommendations and guidance related to (and also more generally for subsequent injury or illness). This para athletes and their attending medical professionals in the should include consideration of para athletes’ baseline cogni- event that a para athlete sustains a suspected concussion. The tive function and their visual or physical abilities. Paradoxically, Concussion Recognition tool 5 (CRT5), SCAT5 and the CIS while SCAT5 baseline testing cannot be mandated for para 2017 consensus statement lack any specific guidance focusing athletes (due to the lack of validity in general populations and on the para athlete. Our analysis will focus on the SCAT5, which an even greater variability of baseline scores between different can be used by physicians and licensed healthcare professionals disability groups), the clinician attending to a para athlete with a for athletes aged 13 years or older and encompasses immediate suspected concussion has a much greater need to have a compre- on field assessment and office based off-field assessment of hensive understanding of a para athlete’s preinjury cognitive suspected concussion. function and abilities in order to make a diagnosis of concus- An initial multidisciplinary panel of experts was selected who sion and manage the athlete more effectively. Additionally, it are academically and/or clinically experienced in para sport or is recommended that a team clinician with prior knowledge of concussion in both para and non-para athletes. This group was the athlete is involved in the acute assessment of the potentially expanded to include clinicians, researchers, para athletes with concussed athlete. The feasibility of this may be limited in some experience of concussion and other experts with experience in sport contexts, depending on the sport specific rules, (eg, team this field. Initially, a face-to- face meeting was planned for May clinicians may not be permitted access to the field of play) and 2020, however, owing to the COVID-19 pandemic, this was some teams may not travel with the support of a team physician, adapted to a video conference split over two consecutive after- physiotherapist or athletic