Keeping a clear head

Berlin ICCCS mobilises top medics against concussions

01.11.2016
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IIHF Chief Medical Officer Mark Aubry addresses the 5th International Consensus Conference on Concussion in Sport. Photo: Adam Steiss

BERLIN – The fight against concussions in sport has been pushed to the center of the player safety debate, not just in ice hockey but across the sporting world.

With this in mind the IIHF, in cooperation with medical representatives from FIFA, the International Olympic Committee, World Rugby, and the International Federation for Equestrian Sports (FEI) have worked to develop the Consensus Conference on Concussion in Sport (ICCCS): a two-day conference bringing together many of the world’s foremost experts on sport concussions.

Click here to access the ICCCS Website

“This whole scientific meeting really brings sport and science together, the science and expertise delivers the knowledge that we in sport can use, and our athletes can be the beneficiaries of our knowledge.” said IIHF Chief Medical Officer Dr. Mark Aubry.

If the fight against concussions is a war, then the ICCCS is both a general mobilisation and a strategy meeting. The 5th ICCCS, held this past week in Berlin, drew over 400 medical professionals and scientists.

“This is by far the biggest one we’ve had,” said Aubry. “You have all the leading experts in the field of sport concussions under one roof, either in the audience or among the expert panel.”

Some of the non-medical attendees included leading figures from the international sports world. IIHF President René Fasel, World Rugby chairman Bill Beaumont, and FEI General Secretary Sabrina Ibanez were on hand to greet the audience.

“As a sports federation what we can do is to make special rules to protect our athletes and players, in hockey we have players skating 45 kilometres per hour and weighing over 100 kilos, but we still need the research and evidence to back us up when we make rule changes.” said IIHF President René Fasel.

“It is because of the ICCCS that we have the scientific evidence to make positive changes for a player’s health, such as eliminating checks to the head. The key is to simplify for us non-medical people…trying to find a consensus of concussion that everyone can understand and use is a very difficult task,” he added when addressing the audience.

The ICCCS grew out of this challenge. With so much debate and conflicting viewpoints about concussions, a combined and unified approach was needed.

The idea of a “consensus conference” – where the world’s top medical professionals would gather to present new research and review and discuss established practice – was determined as the best approach. Leading the push was a Scientific and Organizing Committee that included Aubry and FIFA Chief Medical Officer Dr. Jiri Dvorak.

“We learn from each other the specificity of the different sports, which is a big advantage,” said Dvorak. “Just in the four sports of ice hockey, football, equestrian, and rugby, we are representing probably 1 billion professional and amateur athletes around the globe. So it’s important that we are exchanging views and not just talk about concussions but prevention to reduce the general rate of all injuries.”

“Where the scientific evidence was provided the rules have been changed, in ice hockey they addressed hits to the head, in football it was the elbow to head, in rugby the different scrums were adapted and in equestrian the use of helmets and spine protection was implemented. But we can’t stop…we have to continue because there are other issues to address.”

The development of the ICCCS has been an evolutionary process.  Since the first conference, held in 2001 in Vienna, each successive ICCCS has been adapted and refined to the point where it now is the foremost scientific conference in this field.

In Berlin last week, attendees were shown a variety of research about concussions. The subjects ranged from the definition of what a concussion is, to presentations that gave an assessment of the latest technologies and biomarkers (indications in the patient of the degree of a concussion and the efficacy of its treatment) that could aid sideline medical staff to diagnose a concussion near the field of play.

A big advantage of the consensus conference is that it recognizes the inherent complexity of the concussion issue, and how often different conclusions drawn from past research can lead to an unguided, unorganized approach that fails to make real progress in protecting athletes from injury.

Being a scientific conference first and foremost, the ICCCS attendees are a “who’s who” of top medical professionals representing not only sports federations but also hospitals, medical clinics, neuroscience research centers, international brain injury organizations, and some of the world’s foremost medical university programs.

The presenters are all experts in their respective fields, and the material produced for review comes out of a tremendous amount of work by their research teams, who go over vast amounts of scientific papers to get the latest and most important scientific data.

In all, about 18 months of preparation goes into an ICCCS. All the research since the last conference is brought forward, pored over, analyzed, and developed into a systematic review. The review is presented at the scientific meeting along with poster abstracts and oral presentations on the most recent research being done in the field. The conference participants who are also specialists in the field give feedback on the reviews so that a consensus is developed amongst the experts.

The process is scientific, complete, and transparent; and results in a document…the “Consensus Statement on Concussion in Sport”…that will be clinically applicable.

The three major achievements of the ICCCS have been the Pocket Concussion Assessment Tool (CRT), the Sport Concussion Assessment Tool (currently in its third version known as SCAT3), and the Child Sport Concussion Assessment Tool (Child-SCAT3)

These three tools address three different needs:

The CRT tool was developed for parents and coaches. It allows them to recognize when someone might have a concussion and remove them from play so that they can then be medically evaluated. For parents, coaches, and players, the CRT is very important because of its applicability: you don’t have to be medically-trained to use it and is the first safeguard to preventing further injury and getting proper treatment.

Click here to access the Concussion Recognition Tool

The SCAT3 is standardized tool for doctors to use when evaluating injured players for a concussion, the Child-SCAT3 does the same but is adjusted for children aged 5 to 12 years.

Click here to access the Sport Concussion Assessment Tool (SCAT3)

Click here to access the Child-SCAT3

These tools will now be updated to become the SCAT4, CRT and the Child SCAT4. The new SCAT4 , CRT and the Child SCAT4 will be based on new scientific evidence brought out during the Berlin conference.

In order to achieve a unified consensus on how to deal with concussions and create protocols like SCAT that are accepted and used by sports leagues worldwide, it was essential to examine and discuss the latest research.

The evolution of concussions in sport is a precise, laborious, research-based process that requires thousands of man-hours and endless debate, as research teams review notes and studies going as far back as 20 years.

Click here to view a list of all presentations from the 2016 ICCCS

These groups then set about screening all the relevant literature, most dating back decades. In total about 59,000 articles were examined in preparation for the ICCCS, 750 of which were included in the detailed evaluations presented in Berlin.

“On average for a single presentation there were about 10 experts involved,” said Jiri Dvorak. “They had to screen on average 5,000 articles and study each in detail, so that would be about 500 hours per pre-defined question. This research is presented in addition with the expertise and knowledge of the presenters themselves.”

Supplementing the reviews were the presentations of “abstracts”: a one-page summary of emerging research into concussions that has not yet been published. This allows the latest research into concussions to be presented and discussed at the ICCCS.

With the focus on concussions bigger than ever, abstracts play an important part in the formulation of the consensus. There were four times more abstracts presented in Berlin than in the last ICCCS in Zurich 2012.

Following the presentations, typically 5-10 members of the audience would get up and ask questions or give comments on the presentation. These are all taken into account at the end of the ICCCS, when a 35-member expert panel then gathered over the weekend to discuss the conference and formulation the 2016 Consensus.

Once the consensus is developed, it will be put on paper, written, and finalized over the next three months.

“What we want this meeting to be is scientific in nature, based on evidence, in a format that allows presenters time to properly research and prepare to present the evidence,” said Aubry. “Over all we make sure that we follow the rigid scientific guidelines to develop a consensus free from any commercialization, and let the science speak for itself.”

The Consensus Statement on Concussion in Sport from the 5th ICCCS in Berlin will be published in early 2017, and will appear in various medical journals such as the British Journal of Sports Medicine.

ADAM STEISS

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