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Cantu, Robert C.

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Neurosurgery 64(5):p 786-787, May 2009. | DOI: 10.1227/01.NEU.0000348539.13887.D3

It has been estimated by PubMed Central that more refereed publications on sports-related concussion have appeared since the year 2000 than in all the previous years combined. Since 2000, three international concussion-in-sport consensus statements have been published: 1. the Vienna statement of 2001 (3); 2. the Prague statement of 2004 (6); and now the consensus statement on concussion in sport from the 3rd International Conference on concussion in Sport held in Zurich, November 2008. Extensive documents on concussion have also emerged from the NATA (the National Athletic Trainers' Association position statement, published in 2004 (4) and the ACSM (A Consensus Statement on Concussion and the Team Physician, which appeared in 2006) (5). In addition, entire issues of the Clinical Journal of Sport Medicine (July 2001) (2) and the Journal of Athletic Training (October 2001) (1) have been devoted to the subject.

A consensus statement obviously is just that, a consensus that is often not unanimous. Whenever writing groups are assembled from diverse organizations as well as from diverse personal and professional backgrounds, organizational or personal bias may be present, no matter how much expertise is brought to the table. As a member of the writing groups of all three international concussion consensus statements as well as the NATA and ACSM publications, I can attest to this first hand.

Starting in November 2001 in Vienna the first of three international consensus statements supported and organized by the International Ice Hockey Federation (IIHF), Federation International de Football Association (FIFA), International Olympic Committee (IOC), and for Prague in 2004 and Zurich in 2008 also the International Rugby Board (IRB) have been held. The Vienna conference was convened with the stated objective of providing recommendations for the improvement of the safety and health of athletes who suffer concussive injuries in ice hockey, soccer, and other sports. At the conclusion of the conference, a small group of experts was given the mandate to draft a document that was subsequently published concurrently in early 2002 in the British Journal of Sports Medicine, the Clinical Journal of Sport Medicine, and Physician and Sports Medicine (4). The meeting organizers and participants planned to have periodic future meetings to update the document in light of subsequent knowledge. This next happened in Prague in 2004 with the outcome paper published jointly in the same three journals (6), and now most recently in Zurich in November, 2008.

The Zurich meeting chose a strategy of a formal consensus meeting based on the NIH model. The core organizing group and author group included Paul McCrory (Neurologist and Director, Centre for Health, Exercise & Sports Medicine, University of Melbourne, Parkville, Australia), Willem Meeuwisse (Sports Physician, Sport Medicine Centre, Faculty of Kinesiology, and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Canada), Karen Johnston (Neurosurgeon and Director, Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Canada), Jiri Devorak (Neurologist and Director, FIFA Medical Assessment and Research Center and Schulthess Clinic, Zurich, Switzerland), Mark Aubry (Chief Medical Officer, International Ice Hockey Federation and Hockey Canada, Co-Director Ottawa Sport Medicine Centre, Ottawa, Canada), Mick Molloy (Chief Medical Officer, International Rugby Board, Dublin, Ireland), and myself. The consensus panelists in addition to the authors included Steven Broglio (Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois), Gavin Davis (Cabrini Medical Centre, Victoria, Australia), Randall Dick (Associate Director of Research for the National Collegiate Athletic Association Injury Surveillance System), Ruben Echemendia (Psychological and Neurobehavioral Associates, Inc., State College, Pennsylvania), Gerard Gioia (Children's National Medical Center, Washington DC), Kevin Guskiewicz (Department of Exercise andience, The Univeristy of North Carolina at Chapel Hill, Chapel Hill, North Carolina), Stan Herring (Medical Director of the Spine Center at Harborview Medical Center and Clinical Professor at the University of Washington, Seattle, Washington), Grant Iverson (Department of Psychiatry, University of British Columbia, Vancouver, Canada), James Kelly (Chicago Neurological Institute, Northwestern University's School of Medicine and the Loyola University Medical School, Chicago, Illinois), James Kissick (Palladium Sport Medicine Centre, Ontario, Canada), Michael Makdissi (School of Physiotherapy, University of Melbourne, Melbourne, Australia), Michael McCrea (Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin), Alain Ptito (Montreal Neurological Institute and Hospital, Montreal, Canada), Laura Purcell (Division of Emergency Medicine, University of Western Ontario, Ontario, Canada), and Margot Putukian (Director of Athletic Medicine, University Health Services, Princeton University, Princeton, New Jersey). This document is being jointly published in 9 journals including American Journal of Sports Medicine, British Journal of Sports Medicine (with review papers), Clinical Journal of Sport Medicine, Journal of Athletic Training, Journal of Clinical Neuroscience, Journal of Clinical Sports Medicine, Journal of Science and Medicine in Sport, Neurosurgery, Physician and Sports Medicine, Physical Medicine & Rehabilitation, Neurosurgery, and Scandinavian Journal of Science & Medicine in Sport.

The consensus statement (see Supplementary Digital Content 1, on concussion in Sport – the 3rd International Conference on Concussion in Sport held in Zurich November 2008 reaffirms, where necessary revises including deletions such as the complex and simple definitions of concussion found in the Prague document, and enhances the Vienna and Prague documents with updates based on current science. This document also includes a revised validated sideline concussion assessment tool, SCAT (see Supplementary Digital Content 2,, and Supplementary Digital Content 3,, that combines and consolidates information from the Sideline Evaluation for Concussion-Colorado Head Injury Foundation, Inc., Management of Concussion Sports Palm Card-American Academy of Neurology and Brain Injury Association, Standardized Assessment of Concussion, Sideline Concussion Check-UPMC, Thinksafe, Sports Medicine New Zealand, Inc. and the Brain Injury Association, McGill Abbreviated Concussion Evaluation, National Hockey League Physician Evaluation Form, The UK Jockey Club Assessment of Concussion, and Maddocks questions. I believe the Zurich document is state of the art for all scientists, clinicians, and educators involved with concussion.

I strongly recommend to all these disciplines a thorough reading of this document and believe it is an invaluable resource for all interested in sports-related concussion.

Robert C. Cantu

Concord, MA


1. Anonymous: Concussion in Athletes. J Athl Train 36:213–348, 2001.
2. Anonymous: Concussion in Sport. Clin J Sportsmed 11:139–209, 2001.
3. Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Johnston K, Kelly J, Lovell M, McCrory P, Meeuwisse W, Schamasch P: Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med 36:6–10, 2002.
4. Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, Valovich McLeod TC: National Athletic Trainers' Association position statement: management of sport-related concussion. J Athl Train 39:280–297, 2004.
5. Herring SA, Bergfeld JA, Boland A, Boyajian-O'Neill LA, Cantu RC, Hershman E: Concussion (mild traumatic brain injury) and the team physician: a consensus statement. Med Sci Sports Exerc 38:395–399, 2006.
6. McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Kelly J, Lovell M, Schamasch P: Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 39:196–204, 2005 (copublished in Clin J Sport Med 15:48–56, 2005; Phys Sportsmed 33:29–44, 2005).

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