Revised international guidelines, protocols and tools for sport-related concussion


Ottawa, Ontario — Thursday June 15, 2023

Dr. Roger Zemek, CHEO Research Institute Senior Scientist and CHEO Emergency physician, part of multiple systematic reviews and tool updates

A new set of protocols, tools and recommendations for clinicians and sports organizations to help better identify and manage sports-related concussions were published in a series of papers in the British Journal of Sports Medicine on June 14, 2023. The key recommendations were the outcome of the International Conference on Concussion in Sport held last October in Amsterdam. Dr. Roger Zemek, a leading concussion expert in Canada, Senior Scientist at the CHEO Research Institute, and CHEO Emergency physician, was among the 100 expert researchers and clinicians from around the world who synthesized the new scientific evidence and updated sport-concussion recommendations and tools.

“Concussion protocols are rapidly evolving, and these updated recommendations are intended to support sporting organizations and clinicians alike to better treat sport-related concussion.  The updated tools will help parents, coaches, and teachers to recognize potential concussions,” said Dr. Zemek, Professor and Clinical Research Chair in Pediatric Concussion at the University of Ottawa and co-lead of the Living Guideline for Pediatric Concussion.

The Statement includes a series of new and updated age-appropriate tools for clinicians and sports organizations to help them better identify and manage sports related concussion in the short and longer term. Dr. Zemek was directly involved in the new Concussion Recognition Tool (CRT6), the Sport Concussion Assessment Tool (SCAT6), and the Child Sport Concussion Assessment Tool (ChildSCAT6), as well as the systematic reviews for acute evaluation and prevention.
The Statement features new evidence-based strategies for returning to active sport and education after concussion; early exercise and treatment recommendations; approaches to prevention; targeted rehabilitation; and a call for a working group to be set up to guide further research on the potential long-term effects of concussion on health.

“With this update, there are finally some evidence-based recommendations on concussion prevention for older athletes, but there remains limited evidence on the optimal prevention and management of sport-related concussion for 5- to 12-year-olds,” added Dr. Zemek. “I look forward to spearheading new and continued research at CHEO as we lead cutting-edge pediatric concussion research.”

Overview of the Consensus Statement on Concussion in Sport (provided by British Journal of Sports Medicine):

The latest Consensus Statement on Concussion in Sport includes:

  • New and updated age-appropriate tools to aid identification and management of condition
  • New versions of return to active sport and education strategies
  • Stronger evidence for benefits of light intensity exercise within first 48 hours to aid recovery
  • New targeted approach to rehabilitation
  • Call for interdisciplinary working group to guide research into potential long-term effects

Among the key recommendations:


  • Policy or rule changes to minimize collisions, such as disallowing body checking in ice hockey—a defensive move in which the player tries to separate the puck from his/her opponent
  • Neuromuscular training—aerobic, balance, strength, agility exercises +/-neck-specific components—in warm ups
  • Mouthguard use in ice hockey (all ages)
  • Implementing laws and protocols, such as mandatory removal from play after actual or suspected concussion; healthcare professional clearance to return to play; and education of coaches, parents, and athletes on the signs and symptoms of concussion
  • Early interventions
  • Strict rest isn’t recommended. There’s now stronger evidence that light intensity physical activity, such as routine activities of daily living, and aerobic exercise, such as walking and stationary cycling, can aid recovery, as can limiting screen time during the first 48 hours.


  • For those experiencing dizziness, neck pain and/or headaches for more than 10 days, the Statement recommends cervico-vestibular rehabilitation—physiotherapy exercises to reduce symptoms and improve function.
  • Rehabilitation should be targeted to the needs of the individual.

Persisting symptoms 

  • Multidisciplinary team assessment to identify the types, pattern, and severity of symptoms and any other contributory factors is advised for those with symptoms lasting more than 4 weeks.


  • Advanced neuroimaging, biomarkers (chemical signals from nerves or blood vessels), genetic tests, and other emerging technologies to assess recovery are useful for research into the diagnosis, outlook, and recovery from sports related concussion. But as yet, they are some way off from being used in clinical practice, says the Statement.

Return to education and sport

  • Academic support may be needed for some athletes in the form of a return to learn strategy: this can include modified school attendance, limiting screen time, avoiding any contact sports or game play, extra time to complete assignments/homework or tests.
  • Light intensity activity in the early phases of the return to sport strategy is now recommended, with full sports participation usually occurring within 1 month of injury.
  • But it’s best to manage athletes on an individual basis, accounting for specific factors that may affect their recovery, such as a history of migraine, anxiety, and social factors.

Potential long-term effects

  • The Statement notes the “increasing societal concern about possible problems with later in life brain health in former athletes, such as mental health problems, cognitive impairment and neurological diseases.”
  • Studies tracking the mental health of people over time (cohort studies) have found that former amateur and professional athletes don’t seem to be at heightened risk of depression or suicidality later in life.
  • Similarly, no heightened risk of neurological disease has been reported in former amateur athletes in these types of study. But some studies of former professional athletes have reported an association between playing professional American football and professional soccer and neurological disease in later life.
  • But the studies to date on the links between early sports participation and later life dementia and neurological disease are limited because they haven’t been able to adjust for a range of potentially highly influential factors, says the Statement.
  • It recommends setting up an interdisciplinary working group to guide appropriate research into the potential long-term effects of concussion on health.

Evidence gaps still to be filled

  • There’s limited evidence on the management of sports related concussion in 5-12 year olds and in para sport athletes, who are known to be at heightened risk of sports related concussion.
  • And little research on concussion exists for certain regions of the world, diverse cultural contexts, sex and genders.

This news item includes content from the official news release issued by the British Medical Journal. Read the complete news release here.
Media contacts:
Jennifer Ruff
Director of Communications
CHEO Research Institute
(613) 261-3979
[email protected]

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