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Future Advances and Areas of Future Focus in the Treatment of Sport-Related Concussion

2010; Elsevier BV; Volume: 30; Issue: 1 Linguagem: Inglês

10.1016/j.csm.2010.08.002

1556-228X

Paul McCrory,

Trauma and Emergency Care Studies

The critical issues in the clinical management of sports concussion include confirming the diagnosis, differentiating concussion from other pathologies (particularly structural head injury), and determining when players have recovered so that they can be safely returned to competition. When expressed in this fashion, the management process seems simple. Yet the occurrence and management of this injury provokes more debate and concern than virtually all other sports injuries combined. In the past 3 decades, clinicians have gone from mostly anecdotal strategies to an international consensus–based approach and the early evolution of evidence-based practice, particularly in the area of injury prevention.1McCrory P. Meeuwisse W. Johnston K. et al.Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.Br J Sports Med. 2009; 43: i76-90Crossref PubMed Scopus (465) Google Scholar, 2Cantu R.C. Aubry M. Dvorak J. et al.Overview of concussion consensus statements since 2000.Neurosurg Focus. 2006; 21: E3Crossref PubMed Google Scholar, 3Guskiewicz K.M. Bruce S.L. Cantu R.C. et al.National Athletic Trainers' Association position statement: management of sport-related concussion.J Athl Train. 2004; 39: 280-297PubMed Google Scholar, 4Herring S. Bergfeld J. Boland A. et al.Concussion (mild traumatic brain injury) and the team physician: a consensus statement.Med Sci Sports Exerc. 2006; 38: 395-399Crossref PubMed Scopus (85) Google Scholar, 5Kelly J.P. Rosenberg J.H. The development of guidelines for the management of concussion in sports.J Head Trauma Rehabil. 1998; 13: 53-65Crossref PubMed Scopus (74) Google Scholar We have come far, but the situation in 2011 should be seen as the end of the beginning, not the beginning of the end. The past 2 to 3 years have seen increasing engagement by mainstream neuroscientists in this field, which had previously been dominated by sports team physicians. This change has been useful in bringing a range of expertise (eg, neuropathology, neuroradiology) to the debate. However, it has been disappointing because the interchange has largely taken place in the media rather than through scientific journals. The resultant media interest has caused significant alarm in the minds of the public about putative long-term risks and concern about how an acute injury should be managed, particularly in communities that currently lack access to quality medical resources. Tragic stories of athletes who have not been managed according to current guidelines, or who have failed to fully disclose their injury to team medical staff, resulting in catastrophic outcomes, are regularly aired in the media and, at least in the United States, have caused legislators to propose regulatory measures that restrict medical management of concussion in ways that apply to no other medical condition. When last checked in 2009, 13 US states had bills either before their legislatures or passed related to sports concussion in addition to proposed national legislation. In many cases, the principle of the bills is primarily educative. However, in some states, mandatory preseason cognitive testing and other paradigms are included. The tragedy in this area is the replacement of scientific management by media anecdote. This is ironic given that the focus in sports concussion in the past 3 decades has been the opposite. This paper examines some of the key areas that are likely to be the focus of research in the next few years. From the media perspective, the risk of long-term injury is paramount. However, from the sports perspectives globally, the major concern is how community athletes who may lack the resources available for elite athletes can safely be managed. In many ways, elite sport has been its own worst enemy in this field. The sight of concussed professional athletes returning to play on the day of injury in many sports globally6Pellman E.J. Viano D.C. Casson I.R. et al.Concussion in professional football: players returning to the same game–part 7.Neurosurgery. 2005; 56 ([discussion: 90–2]): 79-90PubMed Google Scholar gives the public the wrong perception of the seriousness of this injury. Although it is broadly accepted that all athletes, regardless of their level of participation, should be managed using the same return-to-play paradigm, elite teams have far greater resources such as access to emergent neuroimaging, immediate neuropsychological assessment, as well as high-level expertise in concussion evaluation, which in turn means that the accurate assessment of recovery can occur in shorter time frames. However, the public never sees the back-office assessment, simply the rapid return of a concussed athlete to the field of play. The public assumes that similar rapid return is possible at lesser levels of competition. This lack of understanding makes the need for community education much more urgent, so that athletes, coaches, parents, trainers, and others involved in athlete care become aware of the significance of the injury and its appropriate management. The basic management principles, namely full clinical and cognitive recovery before consideration of return to play, should be followed. This approach is supported by the major published guidelines such as the American Academy of Neurology, US Team Physician Consensus Statement, US National Athletic Trainers Association Position Statement, and the Zurich Consensus statement.1McCrory P. Meeuwisse W. Johnston K. et al.Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.Br J Sports Med. 2009; 43: i76-90Crossref PubMed Scopus (465) Google Scholar, 3Guskiewicz K.M. Bruce S.L. Cantu R.C. et al.National Athletic Trainers' Association position statement: management of sport-related concussion.J Athl Train. 2004; 39: 280-297PubMed Google Scholar, 4Herring S. Bergfeld J. Boland A. et al.Concussion (mild traumatic brain injury) and the team physician: a consensus statement.Med Sci Sports Exerc. 2006; 38: 395-399Crossref PubMed Scopus (85) Google Scholar, 5Kelly J.P. Rosenberg J.H. The development of guidelines for the management of concussion in sports.J Head Trauma Rehabil. 1998; 13: 53-65Crossref PubMed Scopus (74) Google Scholar There is published evidence that some professional American football players are able to return to play on the same day without a risk of concussion recurrence or sequelae.6Pellman E.J. Viano D.C. Casson I.R. et al.Concussion in professional football: players returning to the same game–part 7.Neurosurgery. 2005; 56 ([discussion: 90–2]): 79-90PubMed Google Scholar However, there are also data showing that, at the collegiate and high school level, some athletes allowed to return to play on the same day show neuropsychological deficits that may not be evident on the sidelines, and are more likely to have delayed onset of symptoms.7Guskiewicz K.M. McCrea M. Marshall S.W. et al.Cumulative effects associated with recurrent concussion in collegiate football players.JAMA. 2003; 290: 2549-2555Crossref PubMed Scopus (1192) Google Scholar, 8Lovell M. Collins M. Bradley J. Return to play following sports-related concussion.Clin Sports Med. 2004; 23 (ix): 421-441Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar This disparity in outcomes between elite and college/high school athletes highlights a key area in the debate, namely that any concussion management strategy needs to be tailored by age and possibly level of performance. A 'one-size-fits-all strategy may not be possible unless one takes the ultraconservative view and simply has a policy of no return to play on the same day. Increasingly, research and clinical focus will be directed at managing different age groups with safe and appropriate guidelines. In many cases, this may involve no return on the day of injury, a strategy that may create concern, particularly at US collegiate levels. Mental health issues (such as depression) have been reported as a long-term consequence of sports-related concussion, occurring in approximately 11%, with a possible association with recurrent concussion.9Guskiewicz K.M. Marshall S.W. Bailes J. et al.Recurrent concussion and risk of depression in retired professional football players.Med Sci Sports Exerc. 2007; 39: 903-909Crossref PubMed Scopus (640) Google Scholar It is important to examine the wider perspective, because depression and anxiety symptoms occur in 15% to 60% of patients following traumatic brain injury from any cause.10Rao V. Bertrand M. Rosenberg P. et al.Predictors of new-onset depression after mild traumatic brain injury.J Neuropsychiatry Clin Neurosci. 2010; 22 (Winter): 100-104Crossref PubMed Scopus (42) Google Scholar, 11Fann J.R. Hart T. Schomer K.G. Treatment for depression after traumatic brain injury: a systematic review.J Neurotrauma. 2009; 26: 2383-2402Crossref PubMed Scopus (228) Google Scholar, 12Silver J.M. McAllister T.W. Arciniegas D.B. Depression and cognitive complaints following mild traumatic brain injury.Am J Psychiatry. 2009; 166: 653-661Crossref PubMed Scopus (204) Google Scholar, 13Menzel J.C. Depression in the elderly after traumatic brain injury: a systematic review.Brain Inj. 2008; 22: 375-380Crossref PubMed Scopus (36) Google Scholar Neuroimaging studies using functional magnetic resonance imaging and other neuroimaging modalities suggest that a depressed mood following brain injury may reflect an underlying pathophysiologic abnormality consistent with a limbic-frontal model of depression.14Fleminger S. Long-term psychiatric disorders after traumatic brain injury.Eur J Anaesthesiol Suppl. 2008; 42: 123-130Crossref PubMed Scopus (120) Google Scholar, 15Chen J.K. Johnston K.M. Petrides M. et al.Neural substrates of symptoms of depression following concussion in male athletes with persisting postconcussion symptoms.Arch Gen Psychiatry. 2008; 65: 81-89Crossref PubMed Scopus (201) Google Scholar Although this issue highlights the need to be vigilant for all mental health problems in all current and retired athletes, it seems that sport per se is not the concern here, but rather the presence of a traumatic brain injury, which in itself carries an inherent risk of depression, suicide, and other mental health issues. In addition to awareness, psychological approaches may have potential applications in this injury and remain an underused resource in sports medicine.16Bloom G. Horton A. McCrory P. et al.Sport psychology and concussion: new impacts to explore.Br J Sports Med. 2004; 38: 519-521Crossref PubMed Scopus (65) Google Scholar, 17Weiss M.R. Gill D.L. What goes around comes around: re-emerging themes in sport and exercise psychology.Res Q Exerc Sport. 2005; 76: S71-S87Crossref PubMed Google Scholar Caregivers are also encouraged to evaluate for affective symptoms such as depression, not only in the concussed athlete but also in healthy athletes during preparticipation screenings to prevent future problems.18Johnston K. Bloom G. Ramsay J. et al.Current concepts in concussion rehabilitation.Curr Sports Med Rep. 2004; 3: 316-323Crossref PubMed Google Scholar Recent cross-sectional descriptive epidemiologic studies have suggested an association between repeated sports concussions during a career and late-life cognitive impairment.19Guskiewicz K.M. Marshall S.W. Bailes J. et al.Association between recurrent concussion and late-life cognitive impairment in retired professional football players.Neurosurgery. 2005; 57 ([discussion: 726]): 719-726Crossref PubMed Google Scholar Similarly, case reports have noted anecdotal cases in which possible neuropathologic evidence of chronic traumatic encephalopathy was observed in retired football players as well as other sportsmen, such as boxers.20Omalu B.I. DeKosky S.T. Hamilton R.L. et al.Chronic traumatic encephalopathy in a national football league player: part II.Neurosurgery. 2006; 59 ([discussion: 1092–3]): 1086-1092Crossref PubMed Scopus (18) Google Scholar, 21Omalu B.I. DeKosky S.T. Minster R.L. et al.Chronic traumatic encephalopathy in a National Football League player.Neurosurgery. 2005; 57 ([discussion: 134]): 128-134Crossref PubMed Scopus (660) Google Scholar, 22Cantu R.C. Chronic traumatic encephalopathy in the National Football League.Neurosurgery. 2007; 61: 223-225Crossref PubMed Scopus (65) Google Scholar, 23Casson I.R. Pellman E.J. Viano D.C. Chronic traumatic encephalopathy in a National Football League player.Neurosurgery. 2006; 59: E1152Crossref PubMed Scopus (15) Google Scholar, 24McKee A.C. Cantu R.C. Nowinski C.J. et al.Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury.J Neuropathol Exp Neurol. 2009; 68: 709-735Crossref PubMed Scopus (1536) Google Scholar Major methodological flaws exist in these observational studies, and the putative associations may be spurious. Much of the debate in this regard has been in the media rather than in the scientific literature, and many of the cases proposed are easily explained by mechanisms other than participation in sport, with or without recognized head injury. Even the recent cases reported with neuropathologic features (such as tau positive neurofibrillary tangles) have other possible causes and, of more concern, differ in their microscopic features from the older cases of punch-drunk syndrome (which also have β amyloid deposition) in boxers, which were the basis for the current understanding of this condition.25Corsellis J.A. Bruton C.J. Freeman-Browne D. The aftermath of boxing.Psychol Med. 1973; 3: 270-303Crossref PubMed Scopus (649) Google Scholar, 26Roberts A.H. Brain damage in boxers: a study of the prevalence of traumatic encephalopathy among ex-professional boxers. Pitman, London1969Google Scholar, 27Roberts G.W. Allsop D. Bruton C. The occult aftermath of boxing.J Neurol Neurosurg Psychiatr. 1990; 53: 373-378Crossref PubMed Scopus (407) Google Scholar At the present time, the classification and neuropathologic understanding of this condition still needs resolution. One particular concern is raised by clinicians is that, if this condition is a potential risk for all athletes (even reported in footballers never diagnosed with concussion during their career), then why are there not more cases of retired footballers with dementia? Sports such as Australian football have a risk of concussion 15 times that of American football, yet long-term follow-up studies do not show similar findings.28McCrory P. 2002 Refshauge Lecture. When to retire after concussion?.J Sci Med Sport. 2002; 5: 169-182Abstract Full Text PDF PubMed Google Scholar, 29McCrory P.R. Berkovic S.F. Cordner S.M. Deaths due to brain injury among footballers in Victoria, 1968-1999.Med J Aust. 2000; 172: 217-219PubMed Google Scholar More importantly, prospective cohort studies using neuropsychological assessment in athletes have been available since the late 1980s, and these published studies do not conclusively support evidence of deteriorating cognitive function during an athletic career following recurrent concussions. However, they do suggest that having 1 concussion may increase the risk and/or severity of subsequent concussions.30Iverson G.L. Brooks B.L. Lovell M.R. et al.No cumulative effects for one or two previous concussions.Br J Sports Med. 2006; 40: 72-75Crossref PubMed Scopus (169) Google Scholar, 31Collins M.W. Lovell M.R. Iverson G.L. et al.Cumulative effects of concussion in high school athletes.Neurosurgery. 2002; 51 ([discussion: 1180–1]): 1175-1179Crossref PubMed Scopus (331) Google Scholar, 32Guskiewicz K.M. McCrea M. Marshall S.W. et al.Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study.JAMA. 2003; 290: 2549-2555Crossref PubMed Scopus (465) Google Scholar In many ways, this parallels the debate about the small percentage of boxers who seem disproportionately affected by chronic traumatic encephalopathy. However, most boxers, many of whom have had substantial head trauma during their careers, remain unaffected.33McCrory P. Zazryn T. Cameron P. The evidence for chronic traumatic encephalopathy in boxing.Sports Med. 2007; 37: 467-476Crossref PubMed Scopus (90) Google Scholar The data from the original work by Corsellis and Roberts25Corsellis J.A. Bruton C.J. Freeman-Browne D. The aftermath of boxing.Psychol Med. 1973; 3: 270-303Crossref PubMed Scopus (649) Google Scholar, 26Roberts A.H. Brain damage in boxers: a study of the prevalence of traumatic encephalopathy among ex-professional boxers. Pitman, London1969Google Scholar suggest that extremes of head injury exposure are a risk factor for chronic traumatic encephalopathy in boxers. However, such levels are simply not seen in other sports. It seems that there is likely to be an alternative explanation, such as a particular genetic factor that puts these athletes at greater risk. The significance of apolipoprotein (Apo) E ε4, ApoE promoter gene, tau polymerase, and other genetic markers in the risk of sports concussion or injury outcome is unclear at this time.34Kristman V.L. Tator C.H. Kreiger N. et al.Does the apolipoprotein epsilon 4 allele predispose varsity athletes to concussion? A prospective cohort study.Clin J Sport Med. 2008; 18: 322-328Crossref PubMed Scopus (71) Google Scholar, 35Terrell T.R. Bostick R.M. Abramson R. et al.APOE, APOE promoter, and Tau genotypes and risk for concussion in college athletes.Clin J Sport Med. 2008; 18: 10-17Crossref PubMed Scopus (90) Google Scholar, 36Jordan B. Relkin N. Ravdin L. Apolipoprotein E epsilon 4 associated with chronic traumatic brain injury in boxing.J Am Med Assoc. 1997; 278: 136-140Crossref PubMed Google Scholar Additional concerns are the role of risk-taking behavior, alcohol use, and drug use by elite athletes, which in turn may have adverse neuropathologic consequences.37Peretti-Watel P. Guagliardo V. Verger P. et al.Sporting activity and drug use: alcohol, cigarette and cannabis use among elite student athletes.Addiction. 2003; 98: 1249-1256Crossref PubMed Scopus (110) Google Scholar, 38Dietze P.M. Fitzgerald J.L. Jenkinson R.A. Drinking by professional Australian Football League (AFL) players: prevalence and correlates of risk.Med J Aust. 2008; 189: 479-483PubMed Google Scholar At this time, the frequency or risk, if any, of long-term consequences of sports concussion are unknown. However, ongoing monitoring during and after an athletic career is a reasonable approach. Clinicians need to be mindful of the potential for long-term problems in the management of all athletes. It was accepted by the Zurich international consensus group that the adult athlete evaluation and management recommendations could be applied to children and adolescents down to the age of 10 years with a few important differences.1McCrory P. Meeuwisse W. Johnston K. et al.Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.Br J Sports Med. 2009; 43: i76-90Crossref PubMed Scopus (465) Google Scholar Younger than that age, children report different concussion symptoms than adults and require age-appropriate symptom checklists as a part of the assessment. When assessing the child or adolescent athlete with a concussion, the health care professional needs to consider input from parents, teachers, and other school personnel.39Purcell L. Carson J. Sport-related concussion in pediatric athletes.Clin Pediatr (Phila). 2008; 47: 106-113Crossref PubMed Scopus (33) Google Scholar, 40Lee L.K. Controversies in the sequelae of pediatric mild traumatic brain injury.Pediatr Emerg Care. 2007; 23 ([quiz: 584–6]): 580-583Crossref PubMed Scopus (44) Google Scholar, 41Schnadower D. Vazquez H. Lee J. et al.Controversies in the evaluation and management of minor blunt head trauma in children.Curr Opin Pediatr. 2007; 19: 258-264Crossref PubMed Scopus (66) Google Scholar, 42Wozniak J.R. Krach L. Ward E. et al.Neurocognitive and neuroimaging correlates of pediatric traumatic brain injury: a diffusion tensor imaging (DTI) study.Arch Clin Neuropsychol. 2007; 22: 555-568Crossref PubMed Scopus (236) Google Scholar Although neuropsychological assessment is widely used following symptom resolution in adult concussion, its timing differs in children, because it may be used to assist planning for school and home management while the patient is still symptomatic. If cognitive testing is performed, then it must be developmentally sensitive through the late teen years. It is particularly important to consider the use of trained neuropsychologists to interpret data, particularly in children with learning disorders and/or attention-deficit hyperactivity disorder who may need more sophisticated assessment strategies.39Purcell L. Carson J. Sport-related concussion in pediatric athletes.Clin Pediatr (Phila). 2008; 47: 106-113Crossref PubMed Scopus (33) Google Scholar, 43Gioia G. Janusz J. Gilstein K. et al.Neuropsychological management of concussion in children and adolescents: effects of age and gender on ImPACT [abstract].Br J Sports Med. 2004; 38: 657Google Scholar, 44McCrory P. Collie A. Anderson V. et al.Can the authors manage sport related concussion in children the same as in adults?.Br J Sports Med. 2004; 38: 516-519Crossref PubMed Scopus (176) Google Scholar Because of the different physiologic response, longer recovery after concussion, and specific risks (eg, diffuse cerebral swelling) related to head impact during childhood and adolescence, a more conservative return-to-play approach is usually recommended for children and adolescents. It is not appropriate for a child or adolescent athlete with concussion to return to play on the same day as the injury, regardless of the level of athletic performance. Consideration of rule changes to reduce the head injury risk may be appropriate if a specific mechanism is implicated. An example of this is in football (soccer), for which published studies show that upper limb to head contact in heading contests accounted for approximately 50% of concussions.45Andersen T. Arnason A. Engebretsen L. et al.Mechanism of head injuries in elite football.Br J Sports Med. 2004; 38: 690-696Crossref PubMed Scopus (131) Google Scholar By penalizing such contact and enforcing the rules, the risk of injury has been substantially reduced.46Dvorak J. Give Hippocrates a jersey: promoting health through football/sport.Br J Sports Med. 2009; 43: 317-322Crossref PubMed Scopus (19) Google Scholar, 47Blatter J.S. Dvorak J. Football for health - prevention is better than cure.Scand J Med Sci Sports. 2010; 20: vCrossref PubMed Scopus (5) Google Scholar There is no good clinical evidence that currently available protective equipment (especially soft-shell helmets) prevents concussion. However, mouthguards have a definite role in preventing dental and orofacial injury.48Benson B.W. Hamilton G.M. Meeuwisse W.H. et al.Is protective equipment useful in preventing concussion? A systematic review of the literature.Br J Sports Med. 2009; 43: i56-i67Crossref PubMed Scopus (158) Google Scholar, 49McIntosh A.S. McCrory P. Finch C.F. et al.Does padded headgear prevent head injury in rugby union football?.Med Sci Sports Exerc. 2009; 41: 306-313Crossref PubMed Scopus (83) Google Scholar For skiing and snowboarding, there are several studies to suggest that helmets provide protection against soft tissue head (not brain) and facial injury. Hence, they may be recommended for participants in alpine sports.50Hagel B.E. Pless I.B. Goulet C. et al.Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study.BMJ. 2005; 330: 281Crossref PubMed Scopus (145) Google Scholar, 51McCrory P. The role of helmets in skiing and snowboarding.Br J Sports Med. 2002; 36: 314Crossref PubMed Scopus (27) Google Scholar, 52Sulheim S. Holme I. Ekeland A. et al.Helmet use and risk of head injuries in alpine skiers and snowboarders.JAMA. 2006; 295: 919-924Crossref PubMed Scopus (209) Google Scholar In specific sports such as cycling, motor sports, and equestrian sports, protective helmets may prevent other forms of head injury (eg, skull fracture) that are related to falling on hard surfaces. These may be important injury prevention issues for those sports.53Delaney J.S. Al-Kashmiri A. Drummond R. et al.The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players.Br J Sports Med. 2008; 42 ([discussion: 115]): 110-115Crossref PubMed Scopus (66) Google Scholar, 54Viano D.C. Pellman E.J. Withnall C. et al.Concussion in professional football: performance of newer helmets in reconstructed game impacts–part 13.Neurosurgery. 2006; 59 ([discussion: 591–606]): 591-606Crossref PubMed Scopus (75) Google Scholar, 55Finch C. Braham R. McIntosh A. et al.Should football players wear custom fitted mouthguards? Results from a group randomised controlled trial.Inj Prev. 2005; 11: 242-246Crossref PubMed Scopus (88) Google Scholar, 56McIntosh A. McCrory P. The dynamics of concussive head impacts in rugby and Australian Rules football.Med Sci Sports Exerc. 2000; 32: 1980-1985Crossref PubMed Scopus (121) Google Scholar, 57McIntosh A. McCrory P. Impact energy attenuation performance of football headgear.Br J Sports Med. 2000; 34: 337-342Crossref PubMed Scopus (86) Google Scholar, 58McIntosh A. McCrory P. Effectiveness of headgear in a pilot study of under 15 rugby union football.Br J Sports Med. 2001; 35: 167-170Crossref PubMed Scopus (98) Google Scholar, 59McIntosh A. McCrory P. Finch C. et al.Rugby headgear study. The University of New South Wales, Sydney2005Google Scholar Because the ability to reduce the effects of concussive injury after the event is minimal, the education of athletes, colleagues, and the general public is a mainstay of progress in this field. All people involved in athlete care, including referees, administrators, parents, coaches, as well as the athletes themselves, must be educated regarding the importance of injury and the principles of safe return to play. However, in spite of the efforts by sports to promulgate such information, evidence that these educational strategies are effectively reaching their target groups is lacking.60Sullivan S.J. Bourne L. Choie S. et al.Understanding of sport concussion by the parents of young rugby players: a pilot study.Clin J Sport Med. 2009; 19: 228-230Crossref PubMed Scopus (47) Google Scholar, 61Sullivan S.J. Schneiders A.G. McCrory P. et al.Physiotherapists' use of information in identifying a concussion: an extended Delphi approach.Br J Sports Med. 2008; 42 ([discussion: 177]): 175-177Crossref PubMed Scopus (5) Google Scholar, 62Sye G. Sullivan S.J. McCrory P. High school rugby players' understanding of concussion and return to play guidelines.Br J Sports Med. 2006; 40: 1003-1005Crossref PubMed Scopus (131) Google Scholar, 63Valovich McLeod T.C. Schwartz C. Bay R.C. Sport-related concussion misunderstandings among youth coaches.Clin J Sport Med. 2007; 17: 140-142Crossref PubMed Scopus (135) Google Scholar Methods to improve education, including Web-based resources, are important in delivering the message and providing peer support.64Ahmed O.H. Sullivan S.J. Schneiders A.G. et al.iSupport: do social networking sites have a role to play in concussion awareness?.Disabil Rehabil. 2010; 32: 1877-1883Crossref PubMed Scopus (78) Google Scholar, 65Provvidenza C.F. Johnston K.M. Knowledge transfer principles as applied to sport concussion education.Br J Sports Med. 2009; 43: i68-i75Crossref PubMed Scopus (75) Google Scholar In addition, enlightened bodies, such as Fédération Internationale de Football Association (FIFA), the International Olympic Committee, the International Rugby Board, and the International Ice Hockey Federation, are to be congratulated for their support because their efforts reach a global audience. There are several areas of focus at the present time that require resolution. The role of the Concussion in Sport group as an international forum for research exchange and in the development of consensus guidelines cannot be underestimated. In specific countries, such as the US, local guidelines have had a similarly important role in educating medical staff but have yet to translate into mainstream community education. The engagement of mainstream neuroscience is important, but, rather than conducting the debate through the media, the issues raised need to be tested by scientific peer review. We must remember that the plural of anecdotes is not data.