IOC Concussion Conference Amsterdam 2022

The podium at CISG meeting in Amsterdam — Dr. Jacklyn Caccese of Ohio State University presenting

What is the definition of a concussion?

If you are wondering whether this is a rhetorical question, would it confuse you still more to know this is how the IOC Concussion in Sport Group (CISG) Consensus Conference in Concussion began in Amsterdam?

Would it concern you that this is still an open question for one of the more vexing problems we deal with in sports medicine? Even among the panel of world experts gathered to bring together the most recent update of consensus statement for concussion in sport?

I think the answer is — yes. Yes to the confusion, yes to the concern.

I had never been to an IOC CISG meeting. As many of the journal’s readers will know, there have heretofore been several meetings with a consensus statement as their output: 2001 Vienna was the first, 2016 Berlin was the most recent.

CISG was set for a meeting to take place in Paris in the autumn of 2020, but we all know what occurred in that year’s spring.  And so the 6th meeting was rescheduled for 2022 and for a new venue: Amsterdam.

I have just returned home from Amsterdam and wanted to collect my thoughts to give you the reader a brief rundown.

These meetings have become huge, and I am not merely referring to the number of participants (hundreds).  The worldwide press recognizes the importance of the CISG and its influence on global sports.  Over the past year the press has been following closely the story of the previous leader, and now discredited academician, Paul McCrory. And……..immediately prior to the gathering in Amsterdam, the news broke that America’s NIH formally acknowledges the causal link between concussion and chronic traumatic encephalopathy (CTE). 

That’s a lot.

The CISG will come out with its 6th concussion statement, which well guide clinicians globally in their care of concussed athletes over the next four years. We all look forward to this output.  Much of what was shared on the podium, at least in its detail, is embargoed until the official output is published.  That output is largely a series of systematic reviews, and the original science that was presented on the Amsterdam stage was, out of necessity, and as requested by the CISG presenters, to stay among those present.  We were asked not tweet or otherwise post on social media the granular scientific detail because it is yet to be published.

But the general impressions I would want to share with you follow.  Briefly:

1. there is still so much more we DON’T KNOW than what we know.  In truth, a great deal of deliberation took place over the actual definition of what a concussion is.  
2. This really is about ‘concussion in sport.’ I think appropriately, the scientific committee emphasizes that.  The CISG group began in 2001 — that time span seems a lifetime ago.  It was a much more casual gathering at that point, with a much smaller of stakeholders and scientists of interest assembling and producing a statement that would have had limited importance at that time.  The influence and meaning of the consensus statement has grown hugely over time.  Many people in our world care for concussions that occur outside of the sporting arena.  Many people in our world need to guide our patients about questions involving the effect of long term exposure to sub-concussive blows.  I think CISG rightly emphasizes their scientifically rigorous approach is focused on concussion in sport.  The world may look to it for other answers, but I think the group itself would state its purview is limited.  Concussions in the workplace, the effect of thousands of head hits over a lifetime — these are important concerns, but CISG may not be able to address them or answer the relevant questions.
3. It is extraordinary how little we know about the kids. By some measures, less than 1% of the world’s concussion scientific literature — the landscape which CISG surveys — involves children ages 5 – 12.  A clarion call from CISG is the need for more focused studies of this population by 2026 and the next round of consensus. 
4. The group recognizes the enormity of the task.  The amount of literature it has sifted through to arrive at an assessment of the current science is over 80,000 studies.  The pace at which the literature is being published is growing.  It is unclear what this means in specifics, but there are suggestions that updates may need to come more frequently than every four years.  Open questions include:  how this may be financed?  Who will supply the manpower?
5. Much, much more work needs to be done on assessing the long-term effects of concussion and understanding questions such as when an athlete may want to consider retirement.  When is ‘enough enough’?  This has been true for some time, and the concern predates the timely statement by the NIH.
6. Finally, there is one scientific statement I think I can share with you, because the strength of the science is Level 1 evidence, and the recommendations grounded in that science represent a major shift in current approaches to the management of concussion.  That statement — ‘exercise is medicine.’  Regarding the treatment and therapy for the injured, exercise should be a mainstay.  It should be sub-symptom exacerbating, ideally supervised, and most especially avoiding the occasion of potential head injury.  But there is Level 1 evidence now to support subsymptom aerobic exercise.  The interested reader can go to this CJSM 2021 article by Leddy and his group to learn more about that practical management.

I am eager to read the output of the CISG when it is published, and I am already looking forward four years ahead:  to the next European city and the next round of the CISG. Whether it’s the World Cup or the Olympics, the four year clock is the timepiece for global sports.  Four years now represents a similar benchmark for concussion and sports medicine.