A new consensus? Change in the air as concussion conference begins | Concussion in sport

You may not know that the sixth International Consensus Conference on Concussion in Sport is being held in Amsterdam this week. You may never even have heard of the Concussion in Sport Group who are organising it, but if you play rugby, football, ice hockey or any number of other contact or collision sports, then the decisions taken there will affect you.

The work of the conference is to review the latest research into concussions, brain injuries, and the short- and long-term effects of head impacts in sport, then produce a consensus statement about the best ways to diagnose and treat them.

It doesn’t matter whether you play in the Premier League or a Sunday league, the consensus document shapes the treatment you’ll receive if you’re hit in the head while playing. CISG is one small group among the large international community of doctors, scientists and researchers who work in this field. The last consensus was signed by 36 people, but the group is supported by the IOC, Fifa and World Rugby, among other sports bodies, which means it has an outsize authority and influence.

Their last conference was held in 2016 and the last consensus was published the following year. They are supposed to happen every four years, but this one was postponed, twice, because of the pandemic, which means the current guidance is six years old. It’s not clear why the organisers felt it was preferable to wait two years to hold an in-person world conference rather than stage an online or hybrid one, but given everything else that has happened in the meantime, it is, at this point, the least of the questions facing CISG.

The chair, Dr Paul McCrory, resigned in March after it emerged he had plagiarised an article he had written for the British Journal of Sports Medicine. McCrory said it was an editing error, but after more investigation the British Medical Journal retracted nine more of his articles, and added expressions of concern to another 74. “The scientific record relies on trust,” the BMJ said, “and BMJ’s trust in McCrory’s work – specifically the articles that he has published as a single author – is broken.”

McCrory was a founder member of the CISG, an influential presence on its committees, and lead author on several iterations of the consensus statement.

Paul McCrory resigned as chair of the CISG.
Paul McCrory resigned as chair of the CISG. Photograph: Florey Institute

The BMJ reviewed the last consensus statement and while they concluded there was no plagiarism involved, they did point out that “the question of the extent of McCrory’s contribution to, and influence on, the five versions of the consensus statement is a matter within the purview of the scientific committee appointed by CISG”. Which was an eloquent way of saying “over to you”.

The problem is not just that McCrory’s own research has been discredited. As an influential member of the CISG scientific committee, he was passing judgment on the credibility and quality of everyone else’s research. The consensus statements have, for instance, consistently questioned the link between head impacts and the neurodegenerative disease CTE. The current one states “a cause-and-effect relationship has not yet been demonstrated between CTE and sports-related concussions or exposure to contact sports”, a line that has been repeatedly cited by the sports’ governing bodies as they defend themselves against calls for reform.

The decision about whether the new consensus should acknowledge the clear and considerable body of evidence of a causal link between CTE and repeated head impacts will be one of the key decisions made at the conference.

Trust in the consensus process was already low, especially among players suffering with the kinds of injuries it is trying to address. There were concerns around the lack of transparency about potential conflicts of interest, the selection methods used to decide who sits on the committees and the criteria used to evaluate research. In the wake of McCrory’s resignation, Fifa, the IOC and World Rugby committed to reviewing the consensus process.

Eight months later, Fifa says “positive steps have been made in relation to the international concussion conference. This includes a revised governance model, the confirmation that CISG remains independent, and changes to the leadership group of the scientific committee.”

Those “changes to the leadership group” refer to the inclusion of Prof Robert Cantu, medical director of the Cantu Concussion Centre, and the independent medical ethicist Prof Mike McNamee. Beyond that, there is not a lot of detail about what’s new. One spokesperson said an effort was being made to include “more critical voices in the room”, although the critical voice they mentioned, Dr Ann McKee, the director of Boston University’s CTE Center, told the Guardian she had decided not to attend. Others will, having paid the €500 fee to be there.

They include Dr Judith Gates and Dr Sally Tucker of the Repercussion Group. “I think of the McCrory case as a stone in the pond,” says Gates. “It has sent ripples through an entire research network, it spreads everywhere his work has been referenced, or quoted, or used to direct new research projects. The ramifications are immense. That’s why this week’s conference is so important. As a community we need to stand up and say: ‘This work is potentially polluted and we don’t yet know the extent of the pollution. So how do we get it back to where we need to be?’”

The Repercussion Group have submitted a white paper to the conference that suggests ways to do it. It asks for a clear, upfront, disclosure of all potential conflicts of interest from CISG members and the inclusion of players, patients and care providers in the process.

“We believe the consensus process should be more precautionary and more player-centred,” says Gates. “We’re not thoughtlessly calling for change, we’re not in the blame game, but we’re saying to CISG: ‘You should have those voices at your table.’”

At heart, the question in Amsterdam is whose consensus this is and whether it reflects the views of CISG or the broader sports community who are subject to its influence.