In November 2001, the first international symposium on concussion in sport was held in Vienna, Austria to provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in sports. More recently, the second international symposium on concussion in sport was held in November 2004 in Prague, Czech Republic. The results were recently published in the British Journal of Sports Medicine 2005; 39:196-204 and can be downloaded here.

Their paper, issued following the conference, revised and updated the Vienna consensus recommendations which were developed after the first symposium.

One of the striking recommendations was with regard to concussion management after acute injury. The new report stated that when a player shows any symptoms or signs of concussion, the player should not be allowed to return to play in the current game or practice; the player should not be left alone and regular monitoring for deterioration is essential over the initial few hours after injury. The player should be medically evaluated after the injury and return to play must follow a medically supervised stepwise process. A player should never return to play while symptomatic. “When in doubt, sit them out!”

Return to play after a concussion follows a stepwise process:

1) No activity, complete rest. Once asymptomatic, proceed to level two.
2) Light aerobic exercise such as walking or stationary cycling, no resistance training.
3) Sport specific exercise- for example, skating in hockey, running in soccer; progressive addition or resistant training at steps three or four.
4) Non-contact training drills.
5) Full contact training after medical clearance.
6) Game play.

The study recommended that with this step progression, the athlete should continue to proceed to the next level if symptomatic at the current level. If any post-concussion symptoms occur, the patient should drop back to the previous asymptomatic level and try to progress again after 24 hours.