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Can I get a pound for every time someone says collaboration? Take home messages from the UK Sports Concussion Research Symposium

3 Dec, 16 | by BJSM

By James Murphy

The UK’s first Sports Concussion Research Symposium started with a warm welcome by Velicia Bachtiar (Drake Foundation1) and Dr Simon Kemp (Rugby Football Union (RFU)). Dr Charlotte Cowie (Football Association (FA)) then kicked off official proceedings. This day brought together the concussion and traumatic brain injury communities that in the past have been disconnected. It called for collaboration – a key concept of the day!


Picture credit:

Session 1 – Current UK Sports Concussion Research Landscape

Challenges to Concussion Research (Dr Charlotte Cowie and Professor Keith Stokes)

Factors that hamper research:

  • concussion not a current priority within the sport of your research area
  • funding issues may restrict the size of studies or prevent them from starting in the first place.


Dr Simon Kemp brightly opened by confirming that for the RFU, concussion is the number one medical priority. He confirmed that across sports it is now widely recognised that governing bodies and clubs have a duty to consider the long term health of those playing their game.

To make significant advances in the field, larger projects need to take place, but you:

  • can still ‘do your own thing’
  • should have some commonality with other studies
  • should use common data elements (for comparison and metanalysis purposes).

Opportunities (Academia) – Prof David Menon

We need to ensure we are all talking about the same thing before we start comparing our results. To this end he defined TBI as: “an alteration in brain function, or other evidence of brain pathology, caused by an external force”. (2)

Session 2 – Snapshots of UK Sports Concussion research in progress

In this session researchers presented methodology and some preliminary results from their work.

Results of RECOS programme (Professor Tony Belli, University of Birmingham)

  • Changes in some specific mRNAs may also allow prediction of symptom severity and clinical course.

Football heading produces immediate changes in brain function (Dr Magdalena Letswaart, University of Sterling)

  • Repeated heading of a football affected patient’s cognition and memory over the following 24 hour period – although further work required! (3)

Developing biomarkers for concussion (Dr Etienne Laverse, University College London)

  • Previous research has shown that Neurofibrillation light chain is a marker of subconcussive head injuries – further research planned in rugby players!

Neuroimaging for the evaluation of traumatic brain injury (Professor David Sharp, Imperial College London)

  • David Sharp showed how MRI techniques can show evidence of axonal injury after concussion
  • Do changes in biomarkers precede clinical symptoms?

Investigating the effects of concussion on schoolboy rugby union players: a pilot study of epidemiology and rehabilitation (Dr Éanna Falvey, Sports Surgery Clinic, Dublin)

  • Is exercise below the level at which patients are symptomatic beneficial in their rehabilitation from a concussive injury. This research leads on from studies in America by JJ Leddy et al (4).

The International Concussion and Head Injury Foundation Study LINK (Dr Michael Turner, ICHIRF)

  • This study will compare the incidence and age of onset of depression, suicide and neurodegenerative disorders in retired jockeys versus aged matched controls.

Safer systems for return to play decisions: the promise of integrating neurocognitive testing and neuroimaging (Professor Huw Williams, Univeristy of Exeter)

  • This work by Professor Huw Williams aimed to ensure a safer return to play for athletes. His work is currently looking at the neuroimaging and neurocognitive tests of concussed elite and university rugby players.

Brain health and healthy AgeINg in retired rugby players: The BRAIN study (Valentina Gallo, Queen Mary University London and Professor Neil Pearce, London School of Hygiene and Tropical Medicine)

  • The researchers will compare physical and cognitive capabilities, biomarkers and intermediate neurological endpoints to determine if there are any long term health risks associated with playing rugby.

Session 3 – Breakout

In the middle of the afternoon the delegates split off into groups and discussed many of the key topics in this area: concussion diagnosis, management, surveillance and long term health impacts to name a few. Group facilitators reported back on each group’s discussion.

What were the talking points?

  • A concussion definition could focus on symptoms and signs of the injury as this is what is used in its diagnosis- this should include a reference to traumatic brain injury.
  • For effective concussion surveillance standardised definitions of concussion and methods of diagnosis should be used – we can achieve this through collaboration.
  • We do not yet know the effect of head impacts on long term health.
  • Any head impact could be subconcussive, more work is needed here.
  • Do the physical, cognitive and social benefits of participating in sport outweigh the neurocognitive risk? It is up to each individual to decide and for healthcare professionals to inform players as best as they can.

Symposium summary

Professor Mark Batt closed the day with a summary of key points. His call to action was for research groups to pull together and collaborate! Is it possible to create vast research networks such as ARUK’s Centre for Sport, Exercise and OA, focused purely on concussion? (5) He underlined the amount of funding there is for concussion research in America, and that researchers need access to similar sums in the UK.

A great day, if you have any of the answers to the questions above, feel free to pen a blog on them, and get in touch with those currently undertaking this important research!


The Drake Foundation – ‘About us’ – Accessed 24/11/16

Position statement: definition of traumatic brain injury. Menon DK, Schwab K, Wright DW, Maas AI Arch Phys Med Rehabil 2010;91: 1637-40.

Thomas G. Di Virgilio, Angus Hunter, Lindsay Wilson, William Stewart, Stuart Goodall, Glyn Howatson, David I. Donaldson, Magdalena Ietswaart, Evidence for Acute Electrophysiological and Cognitive Changes Following Routine Soccer Heading, EBioMedicine, Volume 13, November 2016, Pages 66-71, ISSN 2352-3964,

John J. Leddy, John G. Baker, Barry Willer, Active Rehabilitation of Concussion and Post-concussion Syndrome, Physical Medicine and Rehabilitation Clinics of North America, Volume 27, Issue 2, May 2016, Pages 437-454, ISSN 1047-9651,


James Murphy has completed four years of medicine at Newcastle University and is currently intercalating on the MSc Sports and Exercise Medicine course at the University of Nottingham. 

Safety in youth rugby: education is not the answer to the concussion crisis

19 Sep, 16 | by BJSM

By Adam White @AdJWhite, Dr. Tim Gamble, and John Batten @JBatz85 

Injury worries

Despite the potential health benefits from participating in the sport, rugby is under increasing scrutiny as a result of the high number of injuries experienced by youth participants. We know, for example, that injury rates in rugby union for participants under 21 years of age can be as high as 128.9 injuries per 1000 playing hours, with a mean injury incidence rate of 26.7 per 1000 playing hours. The tackle is often to blame, causing sixty-three per cent of all injuries in one study on school rugby.


Concussion has received particular attention due to the potential long-term impacts (e.g., chronic traumatic encephalopathy) it may have upon brain functioning. Indeed, a systematic review of concussion in youth sport, stated that rugby had the highest risk of concussion compared to sports such as Field Hockey and American Football. In fact, one recently published study in Sweden shows many of the damaging social outcomes of concussion. Concerned about the potential damage the tackle may be having on children, we and the Sport Collision Injury Collective recently wrote to the British government urging them to ban tackling in rugby in school sport.

The HEADCASE programme

The Rugby Football Union’s response to safety concerns in their sport is through the delivery of educational initiatives. Specifically, the online HEADCASE programme provides key stakeholders with information about recognising concussion and managing injured players (i.e., secondary prevention). Delivered through an online, interactive web platform, it is freely available for players, coaches, officials, parents, teachers, first-aiders and spectators to complete. This potentially represents an improvement to player-safety, with the rugby authorities (the Rugby Football Union, World Rugby etc.) leaders in the management of brain trauma in sport. However, the following sections highlight some concerns about the effectiveness and delivery of this health-focused educational programme.

Voluntary participation

Globally, some rugby authorities require their coaches and teachers take either annual or biannual training to coach the sport. The Rugby Football Union, however, has no mandate for coaches to have undertaken HEADCASE training – although any individuals seeking to undertake a new coaching or refereeing qualification (which is also not mandatory to coach or officiate) are required to complete the programme before attending a course. Yet, this neglects the vast population of coaches who have completed their qualifications before the introduction of the HEADCASE programme, or those coaches and officials who do not seek qualifications at all. Furthermore, coaches and officials in England who have completed the training will only have to do so once, with no immediate plans to make it a yearly requirement like rugby governing bodies in the southern hemisphere.

Lack of evaluation

There is poor evaluation of educational initiatives aimed at reducing injury in sport. Only two rugby programmes (BokSmart and RugbySmart) complete all four elements of Van Mechelen’s Model of Injury Prevention (i.e., establishing the extent of the injury problem, establishing the aetiology and mechanisms of sports injury, introducing a preventative measure, assessing its effectiveness by repeating the process) to establish intervention effectiveness. Subsequently, researchers have asserted: ‘There is a dearth of evidence to support the effectiveness of such programmes’. Additionally, a recent BJSM systematic review found the concussion prevention benefits of technique training and practice time restrictions may be limited to a specific sub-set (i.e., 11-15 year olds) of the at-risk athletic population.

Education and injury prevention

Unless sporting bodies evaluate the effectiveness of their training, the impact upon injury prevention is unknown. However, evidence from the health and safety literature suggests that when implementing controls to manage risk, educational interventions are somewhat limited in effectiveness. Specifically, the Hierarchy of Control asserts that elimination of a risk is the most effective way of management, with personal protective equipment being the least effective, and administrative controls (i.e. education) the second least effective. Thus, altering the structure of an activity (substitution) or eliminating the mechanism – in this case tackling –  are likely to be much more effective interventions for the prevention of injuries than educational initiatives. Exemplifying this, law amendments in youth Ice Hockey (i.e., removing the body check) resulted in a reduction of injuries and concussions.

The way forward

Injury prevention must be the priority when considering the current concussion crisis in sport.  However, if the Rugby Football Union is committed to education about tertiary care of brain trauma at this stage, programmes should specify mandatory annual participation for the rugby workforce, with comprehensive evaluations of their effectiveness simultaneously undertaken. Although unlikely to be as effective as altering the structure of the sport (e.g., moving from contact rugby to touch rugby in schools), such changes may help to reduce the risk of concussion in youth rugby, while maintaining the cardiovascular and psychosocial health benefits offered by participation.

Conflicts of interest: None to be declared.


Adam White [] @AdJWhite, is a doctoral researcher at the University of Winchester and founding member of the Sport Collision Injury Collective. He also sits on the committee of the England Rugby Football Schools Union.

Dr. Tim Gamble [] is a Senior Lecturer in Psychology at the University of Winchester. His main research interest is investigating risk and protective equipment, specifically the unintended consequences of safety equipment provision.

John Batten [] @JBatz85 is a senior lecturer in the Department of Sport and Exercise at The University of Winchester where he is currently programme leader for the BSc/MSci (Hons) Sport and Exercise Science.

#RSNlive16: Rugby Science Network 2016 Conference (September 13th and 14th, 2016)

19 Aug, 16 | by BJSM

Tackling. Concussion. Doping. Rugby is a sport which has had to confront some big topics in the public domain over the past few years, and has persistently shown significant commitment to ensuring the welfare of its participants, be it through research, education, or otherwise.

RSN live picture

As a collision sport, injuries are unavoidable – and so there has been much in the form of injury research in the game, with the RFU in England, the NZRU in New Zealand and the SARU in South Africa in particular, providing examples of high quality surveillance research over the past few years. World Rugby, the governing body, deserve much credit for clear and effective leadership – and have been at the forefront of ensuring player welfare through taking account of this research and enforcing rule changes, most notable when it comes to dangerous tackles and the scrum.

With its inclusion in the Olympics however, and with more lucrative prizes, nations and teams have been searching for the marginal gains of sporting performance, which as a result has provided a great bulk of research, some of which has been published in the BJSM.

As such, rugby medicine has a high quality and diverse range of research topics – the vast majority of which are applicable to both team, and individual sports – and may be of interest to the majority of the BJSM readership. Interested in knowing more?

The University of Bath, who have been at the forefront of rugby medicine through their work with the RFU, have organised a two-day conference, on September 13th & 14th, at which much of this research will be presented. Topics include: injury prevention; dietary supplementation; skill development; long-term player welfare; and concussion – which will be brought to life by a fantastic array of speakers including Prof Ross Tucker, Prof Graeme Close, and Dr Martin Hagglund amongst others.

Whilst tickets are available online, if you can’t make it in person, they will be live-streaming the talks for free via their website, with even an opportunity to join in the conversation through the usual social media channels via #RSNlive16. BJSM+ will be tweeting from the event and helping to widen the conversation – we look forward to engaging with the SEM community on a wide range of issues.

Can’t wait? Here are some seminal #RugbyMedicine papers to whet your appetite:

We look forward to your contribution to #RSNlive2016

Undergrad intro to Sports Medicine in Ireland, #SEMSEP by @FSEM_IRL: Concussion seminar highlights, and upcoming courses

30 Dec, 15 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine  a BJSM blog series

Fiachra Maguire @Fiachra_Maguire

The Faculty of Sports and Exercise Medicine in Ireland (@FSEM_IRL) began their 3rd successive Structured Educational Programme (#SEMSEP) this past November. The #SEMSEP is comprised of 4 half-day seminars on current topics. Two seminars took place in 2015 (the first on Concussions and the second on Cardiology in Sport).

concussions coverWhat can you expect from this education? As one example, we summarize the highlights from the 2015 session on concussions

Concussions have recently been a top focus for sports physicians and the general public alike. Following the rugby world cup, but prior to an upcoming Hollywood film, and an international consensus conference on concussion, @FSEM_IRL began their educational programme on this topic.

Dr. John Ryan (@ryanjtw), Associate Professor in Emergency Medicine and Leinster Rugby team doctor, began the morning by describing his experience running a concussion clinic and return-to-play for athletes. Professor Michael Molloy spoke from personal and clinical perspective in rugby, highlighting the change in the biomechanics at the ruck and greater transfer of force. He also echoed calls for weight/size based stratification of players versus age based approach and the potential for jersey design where a delineation exists between the area considered a high tackle, in order to minimise the risk of head injury.

Dr. Adrian McGoldrick, CMO of the Irish Turf Club, spoke from his extensive experience in horse racing. He described atypical head injuries resulting from a torsional (twisting) force being exerted using the case of an ejected jockey. Commenting on the potential relationship with regards Chronic Traumatic Encephalopathy (CTE), he noted the absence of a large group of former jockeys presenting with characteristic symptoms despite the highest reported incidence in the literature.

A short discussion followed where Medical Director of the IRFU, Dr. Rod McLoughlin, addressed a common misunderstanding of the Head Injury Assessment protocol. He described the ‘sports issue’ of recognizing a suspected head injury and removing the player from play. Whilst SCAT3, mobile applications and potential pitch side biomarkers can be useful in acquiring that suspicion, they should not be used to justify a return to play or out-rule an existing suspicion. The ‘medical issue’ of diagnosis and management of a player who has suffered a head injury can proceed later.

The post coffee-break session began with Dr. Colin Doherty (@gastaut) introducing a new Dublin based Concussion Research Interest Group. Dr. Eugene Wallace provided a description of the neuro-metabolic cascade following concussion and the concerns over ‘test-retest reliability’ in existing biomarkers. He reminded the audience of the many confounding factors within the former NFL players as a study cohort, not least common opioid use and rates of depression/poor literacy. Dr. Niall Pender, touched on the potential psychosocial factors in concussion and suggested a changed in vernacular. The use of the term ‘mild Traumatic Brain Injury’ in place of concussion has it’s advantages, not least, a previously established relationship with dementia. Dr. Matthew Campbell (@mattcampbelltcd) revisited the fundamental physiology, considering the delicate relationship between vascular supply to the brain, the blood brain barrier and the potential role of claudin-5 protein. Professor Jim Meaney concluded the afternoon with a review of the medical imaging technologies with a potential to be utilised in concussion.

The session was a fantastic educational tool for all levels of healthcare professional and students. In providing clear, up-to-date, expert led information; @FSEM_IRL is pre-eminently working towards some of the recommendations set out by Mrazik et al.’s recent review of concussion education in the fresh edition of the BJSM.

Looking forward to the 2016 Educational Programme

The high caliber of instruction and discussion will continue into the seminars we have lined up for 2016:

  • Exercise Promotion, 30th January
  • The Paediatric Athlete, 16th April

All sessions take place on Saturday mornings in the Royal College of Surgeons in Ireland, Stephen’s Green. They are aimed at doctors, physiotherapists, healthcare professionals. Importantly there is a heavily discounted rate for students!

This programme is an accessible gateway to sport and exercise medicine (SEM) for undergraduates and covers topics not encountered on clinical rotation or during lectures. For those with an interest in SEM, the #SEMSEP represents a fantastic opportunity to network and springboard into a rewarding career path. For others, it provides a novel context in which to consider your regular clinical presentations and pathologies. Consider this your call to action…

For further information; see the linked flyer or tweet @FSEM_IRL



Fiachra Maguire (@Fiachra_Maguire) is usually an undergraduate medical student at Trinity College Dublin, Ireland. He is currently undertaking an intercalated MSc in Biomedical Science and has a healthy interest in Sports and Exercise Medicine. Founder of the new TCD Sports and Exercise Medicine Society (@TrinitySEMS), he is also an ambassador for @MoveEatTreat

Dr. Liam West (@Liam_West) coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

Further Reading

McCrory, P. et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 47, 250–258 (2013).

Doug King, Matt Brughelli, Patria Hume & Conor Gissane. Assessment, Management and Knowledge of Sport-Related Concussion: Systematic Review. Sports Medicine 44, 449–471 (2014).

Giza, C. C. et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 80, 2250–2257 (2013).

Cottler, L. B. et al. Injury, pain, and prescription opioid use among former National Football League (NFL) players. Drug and Alcohol Dependence 116, 188–194 (2011).


Time for football team doctors to have the immediate benefit of TV footage use to help with the concussion decision: Let’s help team doctors not look foolish

6 Sep, 15 | by BJSM

By Thor Einar Andersen, MD, PhD – Chief Medical Officer, the Football Association of Norway

ConcussionRemindereOn Sunday August 30, in the Norwegian Football Premier League local derby, the goalkeeper for Mjøndalen IF fell to the ground unconscious after being hit in the face by a ball shot from a short distance. TV images, both live and in slow motion from all angles, captured the incident graphically. All TV viewers could see that the goalie had lost consciousness for a few seconds as he lay on the pitch convulsing.

Immediately the incident occurred, the team doctor raced from the bench but he could not have seen the incident properly from his sideline spot. He grabbed his emergency kit bag and ran onto the pitch with the team physiotherapist to assess the player. This took 10-15 seconds.

By then the player was still lying flat, but conscious and somewhat dizzy. The goalie stood up, responded adequately to Maddocks’ standard questions about the state of the game, had normal balance testing and so two minutes after the impact the doctor allowed the player to continue.

The doctor returned to the bench, of course concerned whether his decision was correct or not, but a decision had been taken and match continued. About 15 minutes later, the goalkeeper was substituted. During that time he had reacted uncharacteristically poorly to playing situations and one of those reactions resulted allowed a goal. Back at the team bench the goalie told the doctor that he could not remember anything of his last fifteen minutes of play.

Whose responsibility is to view TV footage?

Is the team doctor to blame for an insufficient medical assessment under stressful condition? Or, would TV footage of the head impact, shown to the doctor in the technical area immediately after coming off the pitch, have helped him make a more appropriate medical decision.

In response to many concussions not having been treated according to widely accepted international concussion guidelines (See BJSM Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012) during the FIFA World Cup in Brazil in summer 2014, the UEFA medical Committee implemented a new procedure last year to deal with suspected concussion. The new procedure was appended to the Laws of the Game and Guidelines for Referees. In the event of a suspected concussion, the referee may stop the game for up to three minutes to let the team doctor assess the injured player. Only the team doctor (ie, NOT the manager) can communicate his or her decision to the referee and allow the player to continue playing if that is appropriate.

This new procedure certainly helps team doctors in top-level football making better medical decisions to the benefit of player’s health. However, giving the team doctors the opportunity to study TV recordings of suspected concussion incident in the technical area under less stressful conditions after the initial assessment will help the team doctor to reconsider the medical decision and may prevent the doctor from appearing foolish because of a lack of information — information that is freely available to all those watching at home.


Thor Einar Andersen is the Chief Medical Officer, the Football Association of Norway; Associate professor, MD, PhD; Consultant in Physical and Rehabilitation Medicine & Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences


Conference Highlights from the Concussion in Sport conference at the Sports Surgery Clinic in Dublin

21 Aug, 15 | by BJSM

By Steffan Griffin (@lifestylemedic) and Dr. Sean Carmody (@seancarmody1)

You may have seen @BJSMPlus – our conference twitter handle feeding various clinical pearls from events around the world – going into overdrive at the recent ‘Concussion: Diagnosis and Rehabilitation’ conference at the Sports Surgery Clinic in Dublin early last month #sscConcussion

This fantastic event, expertly organised by Colm Fuller and the rest of the team at SSC not only provided teaching from some of the world’s premier concussion experts, but also raised some intriguing questions and stimulated some great debate. Additionally, the conference provided an ideal opportunity to launch the innovative Post Concussion Rehabilitation Pathway that aims to improve the recovery process in concussed athletes.

In case you missed out – below are some highlights and impactful tweets – enjoy! All of the day’s stats are easily accessible via the 2012 Zurich Consensus Document, a must-read:

The Athlete’s Perspective Ruby Walsh

concussion 1


It was, perhaps, appropriate that a conference on Concussion was opened by horse-racing legend, Ruby Walsh. As Prof Paul McCrory and Dr Michael Turner later informed us, horse racing is the most high risk sport for developing concussions. During his talk, Ruby ignited a theme which was to recur throughout the day – “Concussion is not a new story and the media storm does not mean it’s a new issue, it’s simply in the news more often”.

Concussion Management – New Ideas and Global Consensus Professor Paul McCrory PhD

  • We need to resort to scientific evidence and not media speculation when considering all aspects of a concussion – a culture of fear exists which may be unfounded.
  • An example of this is the issue of suicide amongst NFL footballers in the USA – “Rate of suicide in 3049 retired NFL footballers (who played > 5 seasons) is 40% of age-matched non-footballers” – meaning that sport may confer a protective effect!
  • At the moment – scans don’t rule in concussion, only rule out more serious pathologies
  • Second Impact Syndrome should be called Single Impact Syndrome- there doesn’t have to be a second impact
  • Examples of how concussions can be prevented include: coaching (eg tackle technique in collision sports), neck muscle strengthening, and rule changes (eg NFL rule banning hits with the crown of the helmet).
  • Mouth guards have no role in preventing concussion.
  • Our understanding of the pathogenesis of concussion is still very rudimentary. Do we know all of the causative pathways? Do NSAIDs put you at increased risk?
  • The Mild/Moderate/Severe classification of concussion is inadequate in comparison to most other conditions. Breast cancer, for example, is classified according to clinical features, histological findings, hormonal receptor status and evidence of metastases- concussion has a long way to go.
  • Concussion has a wide and varied profile, with aspects stretching across many different clinical realms – it means that there is unlikely to be a single diagnostic test.

concussion 2

Taking a Targeted Approach to Concussion Rehabilitation Professor Willem Meeuwisse MD, PhD

  • Normal recovery is dependent on age – an important factor to consider with young athletes.
  • Much of the early management of concussion features reassurance and education.
  • What comprises the ‘difficult’ concussion patient?
    • Persistent symptoms
    • Multiple concussions
    • Concussions with diminishing force
    • Seizures
    • Structural brain injury
    • Paediatric injury
    • Multiple co-morbidities

concussion 3

  • Dix-Hallpike test & Walk-whilst-talk test can be used to assess the potentially concussed athlete – whilst the latter may be used as a management tool


Long Term Monitoring of the Retired Athlete Dr Michael Turner

  • Consensus statements must be taken with a pinch of salt – evidence constantly evolving and many of the recommendations are based on the ‘I just know’ principle.

concussion 5

  • Jockeys are the athletes at greatest risk of developing a concussion. In professional racing a jockey falls off a horse in 1 out of 16 rides, compared to amateur racing where jockeys fall off once every 8 rides. The difference relates to skill level. One jockey dies every 250,000 rides.

Analysis of CSF Biomarkers in Concussion Dr Sanna Neselius MD, PhD

concussion 6

  • Concussions may lead to an increased risk for chronic injuries.
  • Several concussions will lead to delayed recovery.
  • Neurofilament light (NFL) which although varies with time-of-day may correlate with amount of head trauma.
  • NFL may have more of a role to play in delayed recovery than in the initial assessment period.
  • Subdural haematoma is the most common sports-related intracranial bleeding.


A Physiological Approach to Assessment and Treatment of Concussion and mTBI Professor Barry Willer PhD

  • Return to Play can happen when the athlete can exercise fully without exacerbation of symptoms.
  • Issue with return-to-play (RTP) guidelines – return when ‘asymptomatic’ – but when are athletes, let alone controls, fully without symptoms?
  • No evidence to support ‘radical rest’, simply academic suggestion – deconditioning may even confer risks to the athlete.
  • Role for exercise testing followed by graded exercise protocol (%HRmax) in getting athletes asymptomatic faster, thus potentially accelerating RTP?
  • Poor exercise tolerance in the acute phase post concussion may be a marker of poor prognosis.


All papers available at



Dr Sean Carmody is a junior doctor working in the South Thames deanery. He tweets regularly on topics related to sports medicine and performance @seancarmody1.

Is the abuse of medication the next major concern in sports medicine?

28 Jul, 15 | by BJSM

By Dr Sean Carmody

“Also, be aware of the pills you take. If you take sleeping pills to overcome jet lag, before you know it, you’ll be taking them every night. When your arm is sore and you’re given medication for it, throw that bottle away. Those pills will give you a painful, persistent ulcer. Be aware of what you put in your body.”

Pete Sampras, Letter to My Younger Self, June 29th 2015

americanfootballIn August 2013, sports medicine made headlines around the world as the NFL reached a settlement to contribute $765 million to provide medical help to more than 18,000 former players who may have been affected by concussion. It catapulted the condition into the public conscience, and drove the governing bodies of the world’s most popular sports to enforce policy change to protect the health of their athletes.

With all the scrutiny on concussion over the last few years, the use and sometimes abuse of medications in sport is an issue that has often been overlooked. This could be about to change as eight retired NFL players are suing the league for unethically providing them with pain medications throughout their career. They allege that these medications were taken without prescription or knowledge of side effects, and were used to mask serious injuries. The individuals filing the lawsuit are now believed to suffer from renal failure, dependency and chronic pain among other ailments, as a result of medical mismanagement during their playing careers.

The allegations being made in this lawsuit are supported in the literature. A 2011 paper in the journal Drug and Alcohol Dependence concluded that NFL players who misused opioids during their career were most likely to misuse in later life. Interestingly, misuse of opioids in this population was associated with more chronic pain, undiagnosed concussions and alcohol abuse.

This is not exclusively a problem of American sports. Research published in the British Journal of Sports Medicine highlighted the alarming incidence of medication abuse at major football tournaments, which has not declined despite several preventative campaigns. Nearly half of all players at the 2010 World Cup took some sort of medication and more than one-third of the players were prescribed at least one NSAID before a match, regardless of whether or not they went on to feature in the match. Worryingly, in a similar vein to the NFL players mentioned earlier, a large proportion of the medication prescribed was for players who had not fully recovered from injury or may have received “prophylactic pain-treatment”. This is in spite of the fact that NSAIDs, in particular, may adversely affect the healing of muscular and bone injuries. Furthermore, the players could potentially have consumed over-the-counter medications without the physicians’ knowledge and, hence, the actual intake reported in studies might be underestimated.

The high use of medication is not purely limited to ball-based sports; similar use of medication was reported at the Sydney Olympics in 2000. Moreover, a study in the American Journal of Sports Medicine found that while medication use wasn’t as prevalent in track and field compared to team sports, nearly half of all athletes (44%) studied had taken at least one medication. Cycling has long been plagued by doping scandals, and there is anecdotal evidence to suggest that medication abuse exists within the sport. Significantly, a 2010 study found that using paracetamol increased pain tolerance, and consequently, improved time-trial time in cycling, suggesting that there may be a performance-enhancing effect of taking pain medications too. Nevertheless, long term abuse of medications by athletes is not without its side-effects, as former cyclist Jesus Manzano noted, with particular reference to anti-depressants;

“Prozac cuts the appetite, keeps you in another world, a world where you’re not afraid of what you’re doing… It takes you to a world where you don’t ask any more questions, especially you don’t ask your doctor any questions… Then one day it all stops and you become dramatically depressed. Look at Pantani, Vandenbroucke and all the others we don’t even talk about. There are numerous other cyclists and former cyclists that are addicted to cocaine, heroin and other medications. It’s not just in the world of cycling”

The growing evidence of medication abuse in sport is disconcerting, and its rise is showing no signs of abating. It appears that the long-term health of athletes is being gambled for the sake of the team’s short-term gain. While further longitudinal studies are needed to clarify the long-term effects of medication use in athletes from other sports, there exists enough compelling evidence to act definitively now. It should not take another $765 million pay out for governing bodies to sit up and take notice.


Dr Sean Carmody is a junior doctor working in the South Thames deanery. He tweets regularly on topics related to sports medicine and performance @seancarmody1.


Almekinders LC. Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies. Sports Med. 1999;28:383-388.

Bailey S, O’Connor PJ. NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol 115: 892–899, 2013

Corrigan B, Kazlauskas R. Medication Use in Athletes Selected for Doping Control at the Sydney Olympics (2000). Clin J Sport Med 2003;13:33-40.

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FSEM Supports Concussion Guidelines for the Education Sector

30 Jun, 15 | by BJSM

fsem_v_Variation_1The Faculty of Sport and Exercise Medicine UK (FSEM) is supporting new Concussion Guidelines for the Education Sector, produced by the Forum on Concussion in Sport and Physical Education in conjunction with the Sport and Recreational Alliance.

The guidelines have been created in order to alleviate parental concerns around the safety of school sport and to ensure a consistent and suitable management protocol is available to those working with children in the education sector.

Endorsed by an independent expert panel of Sport and Exercise Medicine, Neurology and Health specialists, the guidelines have a clear message on how to handle a suspected concussion in school aged-children and above, including the dangers of returning to play too soon. Concussion can occur during any physical activity and these simple guidelines will help those working in education to follow the four principles of concussion management:


Dr Mike England, Fellow of the FSEM, Community Rugby Medical Director of the Rugby Football Union and Facilitator of the guidelines comments: This has been a ground breaking initiative, with sport, education and health coming together to address a very important issue. We hope teachers will find these guidelines useful, as it is imperative that those working in the education sector know how to recognise concussion and take action. If I had to pick out one key message it would be if in doubt sit them out.”

Dr Roderick Jaques, President of the FSEM comments: “We identified the education sector as a priority area through our call for a national consensus on the prevention, assessment and management of concussion. We are now delighted to see the launch of concussion guidelines to help teachers, school staff, coaches, parents and carers to be aware of the danger signs and how a suspected concussion should be managed in the absence of a trained medical professional.”

The FSEM called for a national best practice consensus on concussion, for all sectors where concussion is encountered, last year and has been working with the UK National Sporting Bodies and Medical Royal Colleges. Easy to follow guidelines, like this, could be developed to deliver UK wide concussion guidelines applicable to anyone handling a suspected concussion.

View the Concussion Guidelines for the Education Sector at

Also see related BJSM material:

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Full text free online. (downloaded >100 k times)

Guest blog by @DrJohnOrchard. On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinicians’ hands



Scotland’s concussion guidelines highlight the need for a UK wide approach

4 Jun, 15 | by BJSM

News Release – The Faculty of Sport and Exercise Medicine

sealThe Faculty of Sport and Exercise Medicine UK (FSEM) welcomes the launch of Scottish Sport Concussion Guidelines for the general public and for grassroots sports participants, where specialists in Sports and Exercise Medicine are not available to manage concussed players. The FSEM would like to see similar guidelines produced, not just for sport, but to improve recognition, assessment and management of all concussions in the UK.

Dr Roderick Jaques, President of the Faculty of Sport and Exercise Medicine UK comments:

Concussion is recognised to be one of the most challenging of injuries to diagnose, assess and manage. Best practice clinical pathways from injury to return to play, work or school for a concussed person, outside of the elite sports setting, are not always easily accessible in the UK.

“The Faculty of Sport and Exercise Medicine fully supports the new Scottish guidelines for the recognition, assessment and management of concussion. We would like to see great initiatives like this developed to deliver UK wide concussion guidelines applicable to anyone handling a suspected concussion.”

Sport Scotland, the Scottish National Sporting Bodies, Medical Royal Colleges and the Scottish CMO have produced the guidelines that are intended to provide information on how to recognise sports concussion and on how sports concussion should be managed from the time of injury through to a safe return to play.

The guidelines stress that, at all levels and in all sports, if an athlete is suspected of having a concussion, they must be immediately removed from play.

Any player with a second concussion within 12 months, a history of multiple concussions, player with unusual symptoms or prolonged recovery should be assessed and managed by health care providers (multidisciplinary) with experience in sports-related concussions.

The overriding message is that ALL concussions are serious and if in doubt, sit them out!

The FSEM recognised the need for a national best practice consensus on concussion last year and has been working with a group including UK National Sporting Bodies and Medical Royal Colleges. The group would like to see consistent best practice, recognition, management guidelines and care pathways adopted from ground level up, across all sectors in the UK and by all health and allied professional groups, where concussion is encountered.

Can animals help limit concussions?

7 Feb, 15 | by BJSM

Gregory D. Myer, Director of Research in Sports Medicine at Cincinnati Children’s Hospital Medical Center. Recently wrote a fantastic – and very popular- article for “The Opinion Pages” of the New York Times on the concussion crisis. Below, we highlight a few key paragraphs and link to related BJSM publications. 

CINCINNATI — THE N.F.L. playoffs start tomorrow. During the regular season, the conversation about traumatic brain injuries in sports among doctors, players, league officials, politicians and parents seemed to gain in volume and intensity with each passing week. New revelations from retired N.F.L. players who announced that they had the progressive neurodegenerative brain disease chronic traumatic encephalopathy, or C.T.E., helped fuel these discussions.

The key to beating the concussion crisis lies in dealing with what’s happening inside the skull, not outside of it. Because the brain doesn’t fill the skull, there’s room for it to rattle, be bruised or sheared, not just with every collision but with every sudden stop and even start —a phenomenon sometimes described as “brain slosh.” For athletes in contact sports, brain slosh has long been seen as inherent and unavoidable. But to make progress against concussions, we have to give priority in future research to minimizing brain slosh during game play. This means that we need sports leagues, policy makers and health care providers to emphasize primary prevention instead of damage control…

… Newer helmets don’t seem to make much of a difference, either. Studies appearing in the British Journal of Sports Medicine and the American Academy of Pediatrics found nearly identical rates of sports-related concussions among different helmet brands and models, including older helmets and new. Why? Think about shipping fragile porcelain — do we use steel or titanium containers, or Bubble Wrap? The same principle applies when protecting the brain. Helmets fulfill their primary purpose of preventing skull fractures and lacerations, but they do not reduce concussions. It is the delicate brain within the skull that is damaged because it does not fit snugly. Athletes would benefit from a tighter fit for the brain — a Bubble Wrap effect — during play, but what are the factors within our control that might provide that effect? We have some leads….

Read the full NY Times article HERE.

See related BJSM articles/blogs/podcasts

Clara Karton et al. The evaluation of speed skating helmet performance through peak linear and rotational accelerations. 2014.

Brian W Benson et al. What are the most effective risk-reduction strategies in sport concussion? 2014.

Kimberly G HarmonJonathan A Drezner et al. American Medical Society for Sports Medicine position statement: concussion in sport. 2013.

Shameemah Abrahams et al. Risk factors for sports concussion: an evidence-based systematic review.2014.

BJSM Podcast: Kim Harmon on managing concussion 

BJSM Blog: James Thing – Paediatric concussion…….must try harder!


Gregory D. Myer is the Director of Research in Sports Medicine at Cincinnati Children’s Hospital Medical Center.

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