Concussion consensus claim more con, less sense

At the time, I had no idea how prophetic that headline would be.

Back then, I chronicled the statements of various expert bodies that had been drafted in response to the growing concern with concussion and how different they were from each other.

In 1997, the American Academy of Neurology (AAN) published guidelines that included a grading scale of mild to severe. The Vienna Consensus Statement from the Concussion in Sports Group (CISG), four years later, urged abandonment of grading scales. Nonetheless, AAN did not update its guidelines, minus grading scales, until 2013.

In 2004, the National Athletic Trainers’ Association (NATA) issued guidelines that, contrary to Vienna, neither prohibited return-to-play (RTP) on the same day nor required physician evaluation. Not until March of 2014 did the NATA issue an updated position statement that banned same day RTP and mandated physician referral.

Also in 2004, the CISG reconvened in Prague. The Prague Consensus Statement differed from Vienna’s by backing off an endorsement of universal baseline testing.

Zurich was the site for the next “international” CISG meeting in 2007. There, changes were made again in the final consensus statement, allowing same day return-to-play in adults and returning to a 2001 opinion, recommending universal baseline testing in high-risk sports.

The fourth CISG meeting was held in 2012, once again, in Prague. And, once again, the pendulum swung. The “consensus” was that same-day RTP was out and so was the endorsement of universal baseline testing.

The fifth and most recent CISG gathering was held in October 2016 in Berlin and it resulted in a statement published in the British Journal of Sports Medicine (BJSM) in April of the following year that took a little different tack — perhaps because so many other expert bodies, including the AAN and the NATA were now on the same page with the CISG. So was nearly every major sports organization in the world from the IOC and FIFA to the NFL, NCAA, and NHL to virtually every state high school athletic association.

Mimicking the three "Rs" of elementary education — reading, ‘riting, and ‘rithmetic — the authors of the statement came up with 11 Rs of their own when it comes to managing conclusion: recognize, remove, re-evaluate, rest, rehabilitation, refer, recover, return to sport, reconsider, residual effects and risk reduction.

While the conference was held in Europe and brought together concussion experts from around the world, its resultant consensus statement had a distinctively North American flavor with 16 of the 38 authors being from the United States and seven from Canada. However, for the fourth consecutive time, the lead author of the statement was the same Australian.

Neurologist Dr. Paul McCrory was a physician for a rugby team in the Australian Football League (AFL) and had been with the CISG from its inception, one of the 10 co-authors of the original statement in 1997. From 2004 on, though, he had chaired the group and was credited with being the lead author of its statements. By 2001, he was also serving as an editor for the prestigious British Journal of Sports Medicine, and remained in that post until 2008.

As his influence grew, he had also become the primary concussion consultant for the entire AFL — and a vocal skeptic of the connection between collision sports and chronic traumatic encephalopathy (CTE). I am sure that made for an interesting dynamic between McCrory and another of the co-authors of all five CISG statements, neurosurgeon Dr. Robert Cantu of Boston University, where the bulk of the research on CTE has been performed.

In fact, the most recent statement, when covering residual effects, controversially claimed, “A cause-and-effect relationship has not yet been demonstrated between CTE and sports related concussion or exposure to contact sports. As such, the notion that repeated concussion or subconcussive impacts cause CTE remains unknown.”

While some of the claims regarding the incidence of CTE coming out of BU may be exaggerated, there is no doubt regarding its association with years of playing a collision sport.

As the evidence out of Boston University since 2016 has mounted, I have wondered how the next CISG statement would read regarding cause and effect for the dreaded neurodegenerative condition.

The group was scheduled to re-convene in 2020. However, COVID-19 prompted postponement in consecutive years — now, until October of this year in Amsterdam.

However, McCrory will not be among those deliberating. On March 5, facing allegations of multiple instances of plagiarism, including at least one to which he admitted, McCrory resigned from the CISG. Last week, the AFL announced he was no longer affiliated with the league and told the Guardian Australia that a complete review of its concussion policies — that had been based on McCrory’s advice and supposed research — was underway.

Furthermore, the Guardian Australia also discovered last week that McCrory had voluntarily accepted disciplinary action imposed upon him in May 2018 by the Medical Board of Australia, placing significant limits on his medical license that remain in effect.

Between now and the meeting this fall in Amsterdam, the leadership of the CISG will need to be reconstituted. Meanwhile, will other sports governing bodies follow the AFL’s lead and re-examine the validity and efficacy of their concussion-related policies? In the course of any such review, those bodies should focus on the fact that head trauma remains a serious issue, requiring continued vigilance. The management protocols currently in effect have been well-established and based on peer reviewed research, independent of any alleged misconduct by McCrory, and there should be no effort to relax them.

John Doherty is a licensed athletic trainer and physical therapist. This column reflects solely his opinion. Reach him at jdoherty@comhs.org. Follow him on Twitter @JDohertyATCPT.