Purpose of the statement: ▸ To provide an evidence-based, best practises summary to assist physicians with the evaluation and management of sports concussion.▸ To establish the level of evidence, knowledge gaps and areas requiring additional research.Importance of an AMSSM statement: ▸ Sports medicine physicians are frequently involved in the care of patients with sports concussion.▸ Sports medicine physicians are specifically trained to provide care along the continuum of sports concussion from the acute injury to return-to-play (RTP) decisions.▸ The care of athletes with sports concussion is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion. Competence should be determined by training and experience, not dictated by specialty.▸ While this statement is directed towards sports medicine physicians, it may also assist other physicians and healthcare professionals in the care of patients with sports concussion.Definition: ▸ Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process. Concussion is a subset of mild traumatic brain injury (MTBI) which is generally self-limited and at the less-severe end of the brain injury spectrum.Pathophysiology: ▸ Animal and human studies support the concept of postconcussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell.▸ Experimental evidence suggests the concussed brain is less responsive to usual neural activation and when premature cognitive or physical activity occurs before complete recovery the brain may be vulnerable to prolonged dysfunction.Incidence: ▸ It is estimated that as many as 3.8 million concussions occur in the USA per year during competitive sports and recreational activities; however, as many as 50% of the concussions may go unreported.▸ Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer and basketball.Risk factors for sport-related concussion: ▸ A history of concussion is associated with a higher risk of sustaining another concussion.▸ A greater number, severity and duration of symptoms after a concussion are predictors of a prolonged recovery.▸ In sports with similar playing rules, the reported incidence of concussion is higher in female athletes than in male athletes.▸ Certain sports, positions and individual playing styles have a greater risk of concussion.▸ Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury.▸ Preinjury mood disorders, learning disorders, attention-deficit disorders (ADD/ADHD) and migraine headaches complicate diagnosis and management of a concussion.Diagnosis of concussion: ▸ Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion.▸ Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations.▸ Standardised assessment tools provide a helpful structure for the evaluation of concussion, although limited validation of these assessment tools is available.‘Sideline’ evaluation and management: ▸ Any athlete suspected of having a concussion should be stopped from playing and assessed by a licenced healthcare provider trained in the evaluation and management of concussions.▸ Recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (including orientation, past and immediate memory, new learning and concentration), balance tests and further neurological physical examination.▸ While standardised sideline tests are a useful framework for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined. Their practical usefulness with or without an individual baseline test is also largely unknown.▸ Balance disturbance is a specific indicator of a concussion, but not very sensitive. Balance testing on the sideline may be substantially different than baseline tests because of differences in shoe/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injury.▸ Imaging is reserved for athletes where intracerebral bleeding is suspected.▸ There is no same day RTP for an athlete diagnosed with a concussion.▸ Athletes suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status.Neuropsychological testing: ▸ Neuropsychological (NP) tests are an objective measure of brain–behaviour relationships and are more sensitive for subtle cognitive impairment than clinical exam.▸ Most concussions can be managed appropriately without the use of NP testing.▸ Computerised neuropsychological (CNP) testing should be interpreted by healthcare professionals trained and familiar with the type of test and the individual test limitations, including a knowledgeable assessment of the reliable change index, baseline variability and false-positive and false-negative rates.▸ Paper and pencil NP tests can be more comprehensive, test different domains and assess for other conditions which may masquerade as or complicate assessment of concussion.▸ NP testing should be used only as part of a comprehensive concussion management strategy and should not be used in isolation.▸ The ideal timing, frequency and type of NP testing have not been determined.▸ In some cases, properly administered and interpreted NP testing provides...

Background—: The incidence and cause of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy often reported as the most common cause. Methods and Results—: A database of all National Collegiate Athletic Association deaths (2003–2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4 242 519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16 508 AY) followed by medical causes (147, 29%, 1:28 861 AY). The most common medical cause of death was SCD (79, 15%, 1:53 703 AY). Males were at higher risk than females 1:37 790 AY versus 1:121 593 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9–5.5; P <0.00001), and black athletes were at higher risk than white athletes 1:21491 AY versus 1:68 354 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9–5.2; P <0.00001). The incidence of SCD in Division 1 male basketball athletes was 1:5200 AY. The most common findings at autopsy were autopsy-negative sudden unexplained death in 16 (25%), and definitive evidence for hypertrophic cardiomyopathy was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%), whereas the percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs. Conclusions—: The rate of SCD in National Collegiate Athletic Association athletes is high, with males, black athletes, and basketball players at substantially higher risk. The most common finding at autopsy is autopsy-negative sudden unexplained death. Media reports are more likely to capture high-profile deaths, and insurance claims are not a reliable method for case identification.

Background—: The true incidence of sudden cardiac death (SCD) in US athletes is unknown. Current estimates are based largely on case identification through public media reports and estimated participation rates. The purpose of this study was to more precisely estimate the incidence of SCD in National Collegiate Athletic Association (NCAA) student-athletes and assess the accuracy of traditional methods for collecting data on SCD. Methods and Results—: From January 2004 through December 2008, all cases of sudden death in NCAA student-athletes were identified by use of an NCAA database, weekly systematic search of public media reports, and catastrophic insurance claims. During the 5-year period, there were 273 deaths and a total of 1 969 663 athlete participant-years. Of these 273 deaths, 187 (68%) were due to nonmedical or traumatic causes, 80 (29%) to medical causes, and 6 (2%) to unknown causes. Cardiovascular-related sudden death was the leading cause of death in 45 (56%) of 80 medical cases, and represented 75% of sudden deaths during exertion. The incidence of SCD was 1:43 770 participants per year. Among NCAA Division I male basketball players, the rate of SCD was 1:3100 per year. Thirty-nine (87%) of the 45 cardiac cases were identified in the NCAA database, only 25 (56%) by use of public media reports, and 9 (20%) from catastrophic claims data. Conclusions—: SCD is the leading medical cause of death and death during exercise in NCAA student-athletes. Current methods of data collection underestimate the risk of SCD. Accurate assessment of SCD incidence is necessary to shape appropriate health policy decisions and develop effective strategies for prevention.

Sport-related concussion (SRC) is a common injury in recreational and organised sport. Over the past 30 years, there has been significant progress in our scientific understanding of SRC, which in turn has driven the development of clinical guidelines for diagnosis, assessment and management of SRC. In addition to a growing need for knowledgeable healthcare professionals to provide evidence-based care for athletes with SRC, media attention and legislation have created awareness and, in some cases, fear about many issues and unknowns surrounding SRC. The American Medical Society for Sports Medicine (AMSSM) formed a writing group to review the existing literature on SRC, update its previous position statement, and to address current evidence and knowledge gaps regarding SRC. The absence of definitive outcomes-based data is challenging and requires relying on the best available evidence integrated with clinical experience and patient values. This statement reviews the definition, pathophysiology and epidemiology of SRC, the diagnosis and management of both acute and persistent concussion symptoms, the short-term and long-term risks of SRC and repetitive head impact exposure, SRC prevention strategies, and potential future directions for SRC research. The AMSSM is committed to best clinical practices, evidence-based research and educational initiatives that positively impact the health and safety of athletes.