Concussion Recognition Tool

HealthDay News — The new 2012 Zurich Consensus statement on sports concussion and its management is now available online in the British Journal of Sports Medicine.

“[T]he science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis,” statement author Paul McCroy, PhD, from the Florey Institute of Neuroscience and Mental Health in Heidelberg, Australia, and colleagues reported.

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The revised and updated statement incorporates discussions from the fourth International Conference on Concussion in Sport, held November 2012 in Zurich, and outlines signs and symptoms of acute concussion, guidance for on-field or sideline concussion evaluation, and return-to-play protocol.

Concussion should be suspected not only in players who experiences “a direct blow to the head, face and neck,” but also those who sustain an injury, “elsewhere on the body with an ‘impulsive’ force transmitted to the head,” according to the statement.

Signs and symptoms include a range of domains, the authors emphasized, including clinical symptoms, physical signs, cognitive impairment, neurobehavioural features and sleep disturbance.

“If any one or more of these components are present, a concussion should be suspected and the appropriate management strategy instituted,” they wrote.

The authors recommend the following five steps for on-field or sideline evaluation of any player in whom a concussion is suspected:

  1. Evaluation by a physician or other licensed healthcare provider using standard emergency management principles, with special attention to excluding a cervical spine injury
  2. Determination of the player’s disposition in a timely manner by a healthcare provider, or removal and urgent referral to a physician
  3. Administration of essential first aid and assessment of the concussive injury using sideline assessment tools, including the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool version 3 (SCAT3), and/or the Child SCAT3 card for those aged 5 to 12 years, whose symptoms may be different from adults
  4. Observation for deterioration in the initial few hours following injury, during which the player should not be left alone
  5. Prohibition of the player to return to play on the day of injury.

Patients who are evaluated in the ER or doctor’s office as the first point of contact after injury should undergo a comprehensive medical history and detailed neurological examination, determination of improvement or deterioration since the time of injury, and determination of whether further emergent neurological imaging is necessary.

Concussion management is typically physical and cognitive rest followed by a graded program of exertion before return to play (see Table 1).

Table 1. Graduated return to play protocol

Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage
1. No activity Symptom limited physical and cognitive rest Recovery
2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity <70% maximum permitted heart rate No resistance training Increase HR
3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities Add movement
4. Non-contact training drills Progression to more complex training drills, eg, passing drills in football and ice hockey May start progressive resistance training Exercise, coordination and cognitive load
5. Full-contact practice Following medical clearance participate in normal training activities Restore confidence and assess functional skills by coaching staff
6. Return to play Normal game play
Source: McCrory P et al. Br J Sports Med. 2013;47:250-258 doi:10.1136/bjsports-2013-092313

A more conservative approach to return to play is recommended for children and adolescents.

“Further research to evaluate the long-term outcome of rest, and the optimal amount and type of rest, is needed. In the absence of evidence-based recommendations, a sensible approach involves the gradual return to school and social activities (prior to contact sports) in a manner that does not result in a significant exacerbation of symptoms,” the researchers added.

Other topics covered in the statement include the role of modifying factors (gender, loss of consciousness, concomitant depression) in management, and concussion prevention strategies (protective equipment, rule change, risk compensation, etc).

There is currently no clinical evidence showing the benefit of protective equipment for preventing concussion, although mouth guards prevent dental and orofacial injury, the authors concluded. Helmets do provide protection in alpine sports and in sports where participants could fall on hard surfaces. Risk compensation must be considered with regards to the use of protective equipment, since this use may result in more dangerous playing technique.

“Identifying the needs, learning styles and preferred learning strategies of target audiences, coupled with evaluation, should be a piece of the overall concussion education puzzle to have an impact on enhancing knowledge and awareness,” the researchers wrote.


  1. McCrory P et al. Br J Sports Med. 2013;47:250-258 doi:10.1136/bjsports-2013-092313.