International concussion guidelines must protect all athletes’ brains, not just professionals’

Imagine that you are the parent of an 11-year-old soccer player who dreams of competing in the Women’s World Cup one day. You want to support her love for the sport while keeping her safe from harm. You are particularly concerned about brain injuries in youth sports, so you look up information about concussion protocols online.

Information published by an international group of experts known as the Concussion in Sport Group (CISG) is reassuring. They meet every several years to write updated consensus statements on concussions. Their guidelines, once called the “bible of concussion treatment recommendations,” informs concussion research, policies, and return-to-play protocols around the world.

Parents, coaches, academics, athletic trainers, physicians, and sports officials across the world rely on the CISG’s concussion statements to protect athletes at all levels of sports.

But the CISG’s guidelines have fallen far short of this goal.

As the group prepares to gather from Oct. 27 to Oct. 29 in Amsterdam to provide its latest recommendations on how to evaluate and manage concussions, now is the time for all who care about safeguarding athletes’ health to call for change. A major overhaul of the group’s processes for crafting guidelines is needed to protect all athletes at risk of brain trauma.

The CISG’s guidelines are based largely on research on professional adult male athletes. The studies cited by the CISG relied on samples that were 88% male. This is, unfortunately, not surprising. A 2022 study led by Christopher D’Lauro, a U.S. Air Force Academy professor of cognitive neuroscience, found that research on concussions among female athletes is sorely lacking. This gender gap is problematic because a growing body of research makes clear that findings from concussion research only in men cannot be assumed to apply to all athletes. But in the CISG’s highly influential international concussion guidelines, girls and women make up barely 10% of the athletes studied. Concerted efforts are needed to remedy this profound inequity and ensure that concussion guidelines for all athletes are fully inclusive of all athletes.

Children and amateur athletes are also not adequately represented in the CISG guidelines, even though they represent the overwhelming majority of athletes at risk for brain trauma. Only a tiny minority of athletes ever go on to play sports at the professional level, yet the prevailing focus of the CISG guidelines remains on professional sports, with a relative lack of attention to children and lifelong amateur athletes who are also at risk of concussion.

That the Concussion in Sport Group has largely excluded women, children, and amateur athletes in its deliberations is linked to another major problem: its ties to adult male professional sports leagues. The CISG is funded by powerful sports organizations, such as the International Federation of Association Football (better known as FIFA) and World Rugby. In fact, an analysis of the most recent CISG concussion statement found that 32 out of 36 expert panelists were affiliated with these organizations in various ways, ranging from employment connections to providing expert witness testimony in legal cases. There is ample evidence that funding from professional sports organizations presents conflicts of interest that are fundamentally in tension with public health objectives to prevent brain injuries.

In particular, the CISG has a troubling history of downplaying evidence that repeated brain trauma can cause chronic traumatic encephalopathy, or CTE. This progressive brain disease is associated with long-term symptoms that can be debilitating, including memory loss, impaired judgment, and personality changes. Australian neurologist Paul McCrory has led the CISG for more than 20 years and has been the lead author of the group’s past four concussion consensus statements, published in 2005, 2009, 2013, and 2017. Yet he has characterized the effects of concussion as “transitory” and once notoriously derided media coverage of CTE as “carry-on and hoo-hah.”

This dismissive attitude has carried directly over into the CISG recommendations. The 2017 concussion statement, led by McCrory, says that “a cause and effect relationship between CTE and concussions or exposure to contact sports has not been established.” In other words, the organization is claiming that no one knows if repeated head injuries have anything to do with symptoms of CTE.

That means that the “bible” of concussion guidance is trailing behind the National Football League, an organization that has a history of denying the risks of concussions. Even so, in 2016, the NFL acknowledged the connection between repeated concussions and long-term neurological disorders such as CTE. Subsequent research has only further reinforced a causal relationship between repeated exposure to head trauma and a heightened risk of developing brain diseases like CTE.

At a bare minimum, the Concussion in Sport Group must align its recommendations with this body of evidence to provide effective guidelines to protect athletes.

The credibility of the CISG was called into further question this year due to academic misconduct. McCrory has faced a bevy of substantiated accusations of plagiarizing and misrepresenting research. As a result, some of his publications have been retracted, and he stood down from the CISG in March 2022. This month, the prestigious British Journal of Sports Medicine announced that it would be retracting nine additional articles by McCrory as the journal continues to investigate dozens of others for additional misconduct.

I want to emphasize two points: First, as researchers Stephen Casper and Adam Finkel have noted, McCrory did not merely copy and paste other researchers’ language (as unethical as that alone would be). He also inaccurately quoted and misrepresented past research in ways that weakened recommendations for the necessary cautions to take after an athlete had experienced loss of consciousness or multiple concussions. As Casper and Finkel observe, such misrepresentations published by the head of the CISG may have “altered the interpretation of concussion science and thus shaped the content of consensus statements on concussion.”

Second, the problem of flawed CISG guidelines cannot simply be fixed by the removal of a single unethical researcher. While McCrory’s academic misconduct has been particularly egregious, he did not operate in a vacuum. For the past several decades, the CISG has been beset by conflicts of interest, has excluded the overwhelming majority of athletes who are not adult male professionals in its recommendations, and has downplayed the causal relationship between repeated head trauma and the risks of long-term neurological disorders like CTE. The result: guidelines that place athletes at greater risk of harm whenever they step out onto the playing field, court, or rink.

This month’s meeting of the Concussion in Sport Group in Amsterdam needs to be an opportunity to entirely overhaul the process by which these concussion guidelines are written. In a 2021 commentary, an interdisciplinary team of colleagues and I made several specific recommendations for a new approach to developing international consensus statements on concussion in sport. We believe that the authors of concussion guidelines should not be limited to sports medicine physicians with links to professional sports. Instead, the perspectives of pediatricians, public health experts, ethicists, athletes — some of whom have experienced concussions — and caregivers should all be included. The guidelines should be drafted in an open process with procedural transparency that includes explaining any potential conflicts of interest. Journalists should be invited to report on the proceedings and share them with the public. The journals that publish the CISG guidelines should invite independent experts to provide open and rigorous peer review.

All athletes — not just professional athletes — deserve a truly inclusive, independent, and transparent process by which to craft the guidelines on which their brains depend. The status quo is continuing to fail athletes at every level, from NFL stars like Tua Tagovailoa to 11-year-old children dreaming of competing in the World Cup one day. Every athlete of every age, gender, skill level, and experience has something in common: they only get one brain that must last them throughout their lives. It is high time that we have an international concussion group that prioritizes that all-important goal.

Kathleen Bachynski is an assistant professor of public health at Muhlenberg College and author of “No Game for Boys to Play: The History of Youth Football and the Origins of a Public Health Crisis” (University of North Carolina Press, 2019). She is a volunteer member of the professional advisory board of Pink Concussions, a nonprofit organization that advocates for more research on concussions among girls and women.