For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27–30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete’s perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.

To evaluate the safety and effectiveness of subsymptom threshold exercise training for the treatment of post-concussion syndrome (PCS). Prospective case series. University Sports Medicine Concussion Clinic. Twelve refractory patients with PCS (6 athletes and 6 nonathletes). Treadmill test to symptom exacerbation threshold (ST) before and after 2 to 3 weeks of baseline. Subjects then exercised 5 to 6 days per week at 80% ST heart rate (HR) until voluntary peak exertion without symptom exacerbation. Treadmill testing was repeated every 3 weeks. Adverse reactions to exercise, PCS symptoms, HR, systolic blood pressure (SBP), achievement of maximal exertion, and return to work/sport. Pretreatment, ST occurred at low exercise HR (147 + or - 27 bpm) and SBP (142 + or - 6 mm Hg). After treatment, subjects exercised longer (9.75 + or - 6.38 minutes to 18.67 + or - 2.53 minutes, P = .001) and achieved peak HR (179 + or - 17 bpm) and SBP (156 + or - 13 mm Hg), both P < .001 versus pretreatment, without symptom exacerbation. Time series analysis showed significant change in rate of symptom reduction for all subjects and reduced mean symptom number in 8/11. Rate of PCS symptom improvement was related to peak exercise HR (r = -0.55, P = .04). Athletes recovered faster than nonathletes (25 + or - 8.7 vs 74.8 + or - 27.2 days, P = .01). No adverse events were reported. Athletes returned to sport and nonathletes to work. Treatment with controlled exercise is a safe program that appears to improve PCS symptoms when compared with a no-treatment baseline. A randomized controlled study is warranted.

Objective To synthesise the evidence regarding the risks and benefits of physical activity (PA), prescribed aerobic exercise treatment, rest, cognitive activity and sleep during the first 14 days after sport-related concussion (SRC). Design Meta-analysis was performed for PA/prescribed exercise interventions and a narrative synthesis for rest, cognitive activity and sleep. Risk of bias (ROB) was determined using the Scottish Intercollegiate Guidelines Network and quality assessed using Grading of Recommendations, Assessment, Development and Evaluations. Data sources MEDLINE, Embase, APA PsycInfo, Cochrane Central Register of Controlled Trials, CINAHL Plus and SPORTDiscus. Searches were conducted in October 2019 and updated in March 2022. Eligibility criteria Original research articles with sport-related mechanism of injury in >50% of study sample and that evaluated how PA, prescribed exercise, rest, cognitive activity and/or sleep impact recovery following SRC. Reviews, conference proceedings, commentaries, editorials, case series, animal studies and articles published before 1 January 2001 were excluded. Results 46 studies were included and 34 had acceptable/low ROB. Prescribed exercise was assessed in 21 studies, PA in 15 studies (6 PA/exercise studies also assessed cognitive activity), 2 assessed cognitive activity only and 9 assessed sleep. In a meta-analysis of seven studies, PA and prescribed exercise improved recovery by a mean of −4.64 days (95% CI −6.69, –2.59). After SRC, early return to light PA (initial 2 days), prescribed aerobic exercise treatment (days 2–14) and reduced screen use (initial 2 days) safely facilitate recovery. Early prescribed aerobic exercise also reduces delayed recovery, and sleep disturbance is associated with slower recovery. Conclusion Early PA, prescribed aerobic exercise and reduced screen time are beneficial following SRC. Strict physical rest until symptom resolution is not effective, and sleep disturbance impairs recovery after SRC. PROSPERO registration number CRD42020158928.

Context: Prolonged symptoms after concussion are called post-concussion syndrome (PCS), which is a controversial disorder with a wide differential diagnosis. Evidence Acquisition: MEDLINE and PubMed searches were conducted for the years 1966 to 2011 using the search terms brain concussion/ complications OR brain concussion/ diagnosis OR brain concussion/ therapy AND sports OR athletic injuries. Secondary search terms included post-concussion syndrome, trauma, symptoms, metabolic, sports medicine, cognitive behavioral therapy, treatment and rehabilitation. Additional articles were identified from the bibliographies of recent reviews. Results: Of 564 studies that fulfilled preliminary search criteria, 119 focused on the diagnosis, pathophysiology, and treatment/rehabilitation of concussion and PCS and formed the basis of this review. Rest is the primary treatment for the acute symptoms of concussion. Ongoing symptoms are either a prolonged version of the concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual dysfunction, or some combination of conditions. The pathophysiology of ongoing symptoms from the original concussion injury may reflect multiple causes: anatomic, neurometabolic, and physiologic. Conclusions: Treatment approaches depend on the clinician’s ability to differentiate among the various conditions associated with PCS. Early education, cognitive behavioral therapy, and aerobic exercise therapy have shown efficacy in certain patients but have limitations of study design. An algorithm is presented to aid clinicians in the evaluation and treatment of concussion and PCS and in the return-to-activity decision.