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Sport injury epidemiology has received increased recognition as a field of sport medicine research that can improve the health and safety of athletes. Injuries among Paralympic powerlifters have not previously been systematically studied. The purpose of this prospective cohort study was to characterize injuries among Paralympic powerlifters. Athletes competing in the sport of powerlifting were followed over the 7-day competition period of the 2012 London Paralympic Games. The main outcome measurements were injury incidence rate ( IR; number of injuries per 1000 athlete-days) and injury incidence proportion ( IP; injuries per 100 athletes). A total of 38 injuries among 163 powerlifters were documented. The overall IR was 33.3 injuries/1000 athlete-days (95% CI 24.0-42.6) and the overall IP was 23.3 injuries per 100 athletes (95% CI 16.8-29.8). The majority of injuries were chronic overuse injuries (61%). The most commonly injured anatomical region was the shoulder/clavicle (32% of all injuries), followed by the chest (13%) and elbow (13%). The information obtained in this study opens the door for future study into the mechanisms and details of injuries into powerlifters with physical impairments. [ABSTRACT FROM AUTHOR]

Background: Limited guidance exists for conducting research on health disparities within the field of sport and exercise medicine (SEM). This review aimed to identify and summarise existing best practices for conducting equitable, diverse and inclusive research within SEM., Methods: A narrative review with evidence synthesis was conducted using electronic databases, reference lists, manual searches and relevant publications from other organisations. Search terms associated with steps of the research process were used in tandem with 'equity', 'inclusion' and 'health disparities'., Results: We developed a research roadmap for SEM researchers with methodological recommendations to develop and conduct equity-informed and equity-focused research. This roadmap serves as a tool for SEM researchers and clinicians to design, execute and disseminate research with a health disparities lens. We recommend SEM researchers should build an equitable, diverse and inclusive research team and include community members; apply a multilevel, intersectional framework; minimise and acknowledge potential biases in the study design and incorporate qualitative or mixed-methods approaches if appropriate; apply multiple inclusive strategies for recruiting and retaining diverse populations; collect accurate and representative data using inclusive data collection methods and tools with validity and reliability in the populations of interest; apply measures with evidence of validity and reliability in the populations of interest; implement a data analysis plan that reflects the conceptual and theoretical frameworks; and promote broad dissemination and interventions that ultimately address and reduce health inequities., Conclusion: SEM researchers should consider these methodological recommendations to conduct equity-informed and equity-focused research to address health disparities in SEM., Competing Interests: Competing interests: JAD is Editor-in-Chief and SK and CB are on the Editorial Board of BJSM., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objectives: To examine healthcare professionals (HCPs) attitudes, beliefs and preparedness towards the management of Para athlete mental health during the Tokyo 2020 and Beijing 2022 Paralympic Games., Methods: A cross-sectional observational study was conducted. National Paralympic Committee's HCPs (n=857) working at the Tokyo 2020 and Beijing 2022 Paralympic Games were invited to respond to an anonymous online survey regarding the management of Para athlete mental health in their team. Data were analysed using descriptive frequency statistics., Results: The survey was completed by 256 HCPs (30% of respondents). Most HCPs agreed that mental health was a concern in Para athletes (n=210; 82%). However, half (n=122; 48%) agreed that they did not screen Para athletes for mental health symptoms, and half (n=130; 51%) agreed that there was increased stigma around disclosure of mental health symptoms among Para athletes, compared with athletes without disability. Most HCPs (n=221; 86%) agreed they wanted to improve their knowledge and skills surrounding athlete mental healthcare. Culturally sensitivite, non-discriminatory and contextual factors were highlighted as desired areas of education for HCPs and active information dissemination for Para athletes., Conclusion: HCPs working at the Paralympic Games considered Para athlete mental healthcare important and reported perceived stigma, yet indicated low rates of mental health screening. Most respondents expressed the need for mental health education. Culturally sensitive training and active education strategies should be implemented to optimally manage Para athlete mental health., Competing Interests: Competing interests: All authors have declared no competing interests. WD is an associate editor of BJSM IPHP editions., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the epidemiology of injuries and illnesses sustained during the Beijing 2022 Paralympic Winter Games, organised in a closed-loop environment to adhere with COVID-19 restrictions., Methods: Injuries and illnesses from all teams were recorded on a daily basis by team medical staff on a web-based form and by local organising committee medical (polyclinic) facilities and venue medical support. Duplicates recorded on both systems were removed. Incidence of injuries and illnesses are reported per 1000 athlete days (95% CI)., Results: 564 athletes (426 male and 138 female) representing 46 countries were monitored for the 13-day period of the Beijing 2022 Paralympic Winter Games (7332 athlete days). The overall incidences were 13.0 injuries (10.6-15.8) and 6.1 illnesses (4.5-8.4) per 1000 athlete days. The incidence of injury in alpine skiing (19.9; 15.2-26.1) was significantly higher compared with Nordic skiing, ice hockey and wheelchair curling (p<0.05), while the incidence of respiratory illness was significantly higher in Nordic skiing (1.6; 0.9-2.9) compared with alpine skiing, ice hockey and snowboarding (p<0.05)., Conclusion: The incidence of both injury and illness at the Beijing 2022 Games were the lowest yet reported in the Paralympic Winter Games. The incidence of injury was highest in alpine skiing. These findings underscore the importance of ongoing vigilance and continued injury risk mitigation strategies to safeguard the well-being of athletes in these high-risk competitions. Respiratory illnesses were most commonly reported in Nordic skiing, which included the three cases of COVID-19 recorded at the games., Competing Interests: Competing interests: WD and MS are associate editors of BJSM IPHP editions., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: This study examines the challenges and accommodations for medical residents with disabilities within physical medicine and rehabilitation training programs. Medical residency presents unique stressors and responsibilities, with the potential for added complexities for residents with disabilities. Few data exist regarding the prevalence and experiences of people with disabilities as medical trainees and the limited studies available highlight an underrepresentation of individuals with disability in medical training and practice. Through cross-sectional surveys administered to physical medicine and rehabilitation residents, this research assesses disability prevalence, characterizations, barriers to training, and accommodations provided. Of 140 respondents, 9.3% identified as having disabilities, with varying prevalence among genders and disability types. Results revealed distinct challenges for residents with mobility and nonmobility disabilities, spanning learning environments, standardized testing, procedural skills, and accessibility. Self-provided accommodations exceeded program-provided ones, indicating room for improvement in program support. These findings underscore the need for proactive dialog between residents and leadership to address barriers, enhance accommodations, and create an inclusive training environment. The study's insights emphasize the importance of advocating for equal opportunities and cultivating supportive conditions to enable individuals with disabilities to thrive in medical residency programs, ultimately contributing to more diverse and inclusive medical communities., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Mass participation events include endurance events (e.g., marathon, triathlon) and/or competitive tournaments (e.g., baseball, tennis, football (soccer) tournaments). Event management requires medical administrative and participant care planning. Medical management provides safety advice and care at the event that accounts for large numbers of participants, anticipated injury and illness, variable environment, repeated games or matches, and mixed age groups of varying athletic ability. This document does not pertain to the care of the spectator., (Copyright © 2024 by the American College of Sports Medicine.)

Objective: Health disparities are widely prevalent; however, little has been done to examine and address their causes and effects in sports and exercise medicine (SEM). We aimed to summarise the focus areas and methodology used for existing North American health disparity research in SEM and to identify gaps in the evidence base., Design: Scoping review., Data Sources: Systematic literature search of PubMed, Scopus, SPORTDiscus, CINAHL Plus with Full Text, Web of Science Core Collection and Cochrane Central Register of Controlled Trials., Eligibility Criteria: Full-text, peer-reviewed manuscripts of primary research, conducted in North America; published in the year 2000 or after, in English; and focusing on organised sports were included., Results: 103 articles met inclusion criteria. Articles were classified into five focus areas: access to and participation in sports (n=45), access to SEM care (n=28), health-related outcomes in SEM (n=24), provider representation in SEM (n=5) and methodology (n=1). Race/ethnicity (n=39), socioeconomic status (n=28) and sex (n=27) were the most studied potential causes of health disparities, whereas sexual orientation (n=5), location (rural/urban/suburban, n=5), education level (n=5), body composition (n=5), gender identity (n=4) and language (n=2) were the least studied. Most articles (n=74) were cross-sectional, conducted on youth (n=55) and originated in the USA (n=90)., Conclusion: Health disparity research relevant to SEM in North America is limited. The overall volume and breadth of research required to identify patterns in a heterogeneous sports landscape, which can then be used to inform positive change, need expansion. Intentional research focused on assessing the intersectionality, causes and consequences of health disparities in SEM is necessary., Competing Interests: Competing interests: SAK, YAT-W and AR are associate editors for BJSM., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: TPEW received small honoraria for presentations about disability awareness, and receives royalties from his autobiography. We declare no other competing interests. The authors acknowledge Jennifer Griggs for her contributions to the conceptualisation of this Comment.

Objective: To explore the prevalence of symptoms of mental health conditions and burnout of healthcare professionals (HCPs) working during the Tokyo 2020 Paralympic Games and the Beijing 2022 Paralympic Winter Games., Methods: In this cross-sectional, observational study, HCPs working during the Tokyo 2020 and Beijing 2022 Paralympic Games were asked to complete an online, anonymous survey, which included demographic questions and questions regarding mental health symptoms including depression (Patient Health Questionnaire 9-item depression scale) and anxiety (Generalized Anxiety Disorder 7-item scale) as well as burnout (Maslach Burnout Inventory-Human Services Survey: depersonalisation, emotional exhaustion, personal accomplishment). Correlation coefficients (r) were calculated between demographic characteristics and mental health symptoms., Results: In total, 256 HCPs (of 857 HCPs; 30%) completed the surveys. Twelve and eight per cent of HCP scores fell within the moderate to severe depression and moderate to severe anxiety categories, respectively. More than 30% reported moderate to high burnout (depersonalisation: 36%; emotional exhaustion: 36%; personal accomplishment: 58%). In addition, thoughts of self-harm and/or suicidality were reported by some HCPs (8%). Weak correlations were observed between age and depression (r=-0.13, p=0.046), anxiety (r=-0.16, p=0.010) and burnout (emotional exhaustion: r=-0.14, p=0.032; personal accomplishment: r=0.27, p<0.001)., Conclusion: Although most HCPs reported good mental health, this study suggests that a subset of HCPs experienced symptoms of depression, anxiety, burnout or thoughts of self-harm during the Tokyo 2020 and Beijing 2022 Paralympic Games. While the generalisability of these findings outside of COVID-19 restrictions should be tested, appropriate guidance and mental health support of HCPs leading up to the Paralympic Games should be prioritised., Competing Interests: Competing interests: All authors have declared no competing interests. WD is an associate editor of BJSM IPHP editions.Competing interests, (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research., Competing Interests: Competing interests: OHA is a Senior Physiotherapist at University Hospitals Dorset NHS Foundation Trust (England) and is Para Football Physiotherapy Lead/Para Football Classification Lead at the Football Association (England). He also works on a consultancy basis with the Football Association as the squad physiotherapist to the England Cerebral Palsy Football squad and teaches a course on the Football Association’s Advanced Trauma and Medical Management in Football course on a consultancy basis. He has a Visiting Senior Lecturer position at the University of Portsmouth, England (unpaid). He sits on several disability sport committees, including Para Football Foundation as Medical Unit Co-Lead (unpaid), the International Federation of Cerebral Palsy Football as Medical and Sports Science Director (unpaid) and the International Blind Sports Association as Medical Committee member (unpaid). He has Associate Editor positions at the British Journal of Sports Medicine (unpaid) and BMJ Open Sports & Exercise Medicine (unpaid). He is also an Institutional Ethics Committee external member for World Rugby (unpaid) and co-chair of the Concussion in Para Sport Group (unpaid). CAB is an Associate Professor of PM&R Journal at Spaulding Rehabilitation Hospital/Harvard Medical School and Chief Medical Officer at Spaulding Rehabilitation Hospital. She receives grant funding from the US Center for Disease Control and Prevention and the US National Institute on Disability, Independent Living, and Rehabilitation Research. She serves on the Board of Directors of the US Olympic & Paralympic Committee (unpaid) as well as on the International Paralympic Committee Medical Committee (unpaid) and the IOC Medical & Scientific Commission (unpaid). She serves as an Associate Editor of the British Journal of Sports Medicine (unpaid) and the PM&R Journal (unpaid). SPB Current or past research funding from the National Institutes of Health; US Centers for Disease Control and Prevention; Department of Defence (DoD)—USA Medical Research Acquisition Activity, National Collegiate Athletic Association (NCAA); National Athletic Trainers’ Association Foundation; NFL/Under Armour/GE; Simbex and ElmindA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medicolegal litigation and received speaker honorarium and travel reimbursements (including Concussion in Sport Group (CISG)) for talks given. He is the coauthor of Biomechanics of Injury (3rd Edition) and has a patent pending on Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source (US Application No 17/164,490). He is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present) and British Journal of Sports Medicine (2008–2019). RCC Senior Advisor NFL Head Neck & Spine Committee NOCSAE and Chair Scientific Advisory Committee Co-Founder, Medical Director Concussion Legacy Foundation Royalties Houghton Mifflin Harcourt Legal Expert Opinion. GAD is a member of the Scientific Committee of the Sixth International Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee; Section Editor, Sport and Rehabilitation, Neurosurgery and has attended meetings organised by sport organisations including NFL, NRL, IIHF, IOC and FIFA; however has not received any payment, research funding or other monies from these groups other than for travel costs. JD is the co-founder and board member of CISG and Senior Advisor to BJSM. RJE is a paid consultant for the NHL and cochair of the NHL/NHLPA Concussion Subcommittee. He is also a paid consultant and chair of the Major League Soccer concussion committee and a consultant to the US Soccer Federation. He previously served as a neuropsychology consultant to Princeton University Athletic Medicine and EyeGuide. He is currently a co-principal investigator (PI) for a grant funded by the NFL (NFL-Long) through Boston Children’s Hospital. He occasionally provides expert testimony in matters related to mild traumatic brain injury (mTBI) and sports concussion and occasionally receives honoraria and travel support/reimbursement for professional meetings. CAE holds external peer-reviewed research funding from Canadian Institutes of Health Research, Canada Foundation for Innovation, IOC Medical and Scientific Committee, NFL Play Smart Play Safe Program and World Rugby. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is an external advisory board member for HitIQ. NF-D International independent FIFA Concussion Advisory Group. GOTS Concussion Committee Innovation and Technology Panel, UK Department for Digital, Culture, Media and Sport. International Consensus Group on Concussion in Sports (CISG), NINDSCDE Sports Concussion CDE Subacute Subgroup (National Institutes of Health). IFAB Concussion Expert Group. Member of Swiss Neurology Society, Swiss Society for Clinical Neurophysiology, European Neuro-Ophthalmology Society and CISG. Editorial Board Member of Journal of Concussion, Journal of Science and Medicine in Football. GF has received travel expenses to attend academic meetings from World Rugby. He has also collaborated on research projects with World Rugby as chief or co-investigator. He is a previous associate editor of the British Journal of Sports Medicine. He has not received any other payments or support from any sporting or commercial bodies. CCG discloses the following: Grants/research support: HitIQ (2022–2023); NIH NINDS (R01 NS110757 2019–2024); NINDS (U54 NS121688 2021-2026); UCLA Brain Injury Research Center, UCLA Steve Tisch BrainSPORT programme, Easton Clinic for Brain Health. Clinical Consultant (provide clinical care to athletes): NBA, NFL-Neurological Care Program, NHL/NHLPA, Los Angeles Lakers Advisory Board (non-compensated): Major League Soccer, NBA and US Soccer Federation. Advisory Board (compensated): Highmark Interactive Medicolegal: One or two cases annually Speaker’s bureau: None. Stock shareholder: Highmark Interactive stock options (2018). Other financial or material support: book royalties—Blackwell/Wiley Publishing: prioritized. Neurological differential diagnosis. KMG has received grant funding from NFL for the NFL LONG study. He also serves on the NCAA Scientific Advisory Board in an unpaid capacity. BH works full time as a paid employee of the NCAA as Senior Vice President, Sport Science Institute, and as Chief Medical Officer. I serve as a volunteer advisory member for: US Football Medical Advisory Panel; CrashCourse by TeachAids; NBJA Youth Health & Wellness Working Group; External Advisory Board, DIAGNOSE CTE (Boston University). I am on the Board of Directors for the US Tennis Association, the Grand Slam Board; the International Tennis Integrity Agency and the Datalys Center. I am chair of the International Tennis Federation Sports Science & Medicine Commission. SAH is co-founder and senior advisor of the Sports Institute at UW Medicine (unpaid). Centers for Disease Control and Prevention and National Center for Injury Prevention and Control Board Pediatric Mild Traumatic Brain Injury Guideline Workgroup (unpaid). CISG (travel support). NCAA Concussion Safety Advisory Group (unpaid). Team Physician, Seattle Mariners. Former Team Physician, Seattle Seahawks. Occasional payment for expert testimony. Travel support for professional meetings. GLI serves as a scientific advisor for NanoDX, Sway Operations and Highmark. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mTBIs (including former athletes) and on the topic of suicide. He has received past research support or funding from several test publishing companies, including ImPACT Applications, CNS Vital Signs and Psychological Assessment Resources (PAR). He receives royalties from the sales of one neuropsychological test (WCST-64). He has received travel support and honorariums for presentations at conferences and meetings. He has received research funding as a PI from the NFL and subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of NFL Players Association Members. He has received research funding from the Wounded Warrior Project. He acknowledges unrestricted philanthropic support from ImPACT Applications, the Mooney-Reed Charitable Foundation, the National Rugby League, Boston Bolts and the Schoen Adams Research Institute at Spaulding Rehabilitation. JK declares the following affiliations: NBA. US Ski and Snowboard. US Olympic & Paralympic Committee. NHL Players’ Association. Major League Soccer Players’ Association. NFL Players’ Association. NeuroSync. Cognivue. JJL receives grant/research support from NIH, DoD and AMSSM. He is a member of the Scientific Advisory Board for Neuronasal, Highmark Innovations and Quadrant Biosciences. Minority stock options in Highmark Innovations and 360 Concussion Care. Expert consultant to NCAA. Consults with NFL and NHL teams on athlete care but does not receive any compensation from these organizations. He is on the Editorial Board of Journal of Head Trauma and Rehabilitation. DM Neuropsychologist and lawyer—legal practice in Medical Law. Legal representation provided to parties in personal injury legal proceedings. Former member of AFL Concussion Working Group—no remuneration. Past legal advisor to Cricket Australia and the AFL. Legal advisor to various professional sporting clubs. Past ARF concussion research funding received through the Florey Institute of Neuroscience & Mental Health. Member of the AFL Grievance Tribunal—no remuneration received. Legal advisor to private schools. Lectures (neuropsychology/law) to education providers—no remuneration. Cricket Victoria—former Director/Chair—no remuneration. Melbourne Grammar School—Audit & Risk Committee Member—no remuneration. CISG Board Member—no remuneration. Travel support to attend the 2022 CISG meeting. Abstained from discussions in the 2022 CISG consensus process in relation to ‘chronic traumatic encephalopathy, neuropathological change and trauatic encephalopathy syndrome'and 'potential long-term sequelae'. MM Sport and exercise medicine physician working in private consulting practice. Shareholder of Olympic Park Sports Medicine Centre in Melbourne. Ex-senior physician at the Hawthorn Football Club (AFL). Ex-Chief Executive Officer of the AFL Doctors Association. Research grants received from the Australian Football League, outside the submitted work. Travel support received from the Australian Football League, FIFA and the IOC to attend and present at international conferences. Member of the Scientific Committee for the Sixth International Conference on Concussion in Sport. Honorary member of the International CISG. Honorary member of the Australian Rugby Union Concussion Advisory Group. Independent Concussion Consultant for World Rugby. GTM discloses grants from the US DoD—TBI Endpoints Development Initiative (Grant no W81XWH-14-2-0176), TRACK-TBI Precision Medicine (Grant no W81XWH-18-2-0042) and TRACK-TBI NETWORK (Grant no W81XWH-15-9-0001); NIHNINDS—TRACK-TBI (Grant no U01NS086090) and the NFL Scientific Advisory Board—TRACK-TBI LONGITUDINAL. US Department of Energy supports GTM for a precision medicine collaboration. One Mind has provided funding for TRACK-TBI patients’ stipends and support to clinical sites. He has received an unrestricted gift from the NFL to the UCSF Foundation to support the research efforts of the TRACK-TBI NETWORK. GTM has also received funding from NeuroTruama Sciences to support TRACK-TBI data curation efforts. Additionally, Abbott Laboratories has provided funding for add-in TRACK-TBI clinical studies. MAM has received research funding to the Medical College of Wisconsin from the National Institutes of Health (NIH), Department of Veterans Affairs, US Centers for Disease Control and Prevention, DoD, NCAA, NFL and Abbott Laboratories. He receives book royalties from Oxford University Press. He serves as a clinical consultant to Milwaukee Bucks, Milwaukee Brewers and Green Bay Packers, and is Co-Director of the NFL Neuropsychology Consultants without compensation. He serves as a consultant for NeuroTrauma Sciences. He receives travel support and speaker honorariums for professional activities. MJM Chair, Ethics Expert Group, WADA (2021–2023) (paid). Member, International Boxing Association, Ethics and Integrity Committee, (2021–2022; resigned October 2022) (paid). Chair, Therapeutic Use Exemption Fairness Committee (2020 to present) (paid). Member, Steering Group, Sex Segregation in Sport, IAAF/World Athletics, (2019–2020) (unpaid). Member, International Ice Hockey Federation, Ethics and Integrity Committee (2019–2021) (paid). Member, IOC Consensus Statement Expert Group on Injuries in Children and Adolescents (2017) (unpaid). Member, Ethics Expert Group, WADA (2016–2021) (unpaid). Member, IOC Consensus Statement Expert Group on Pain Management (2016) (unpaid). WM is employed as the Chief Medical Officer of the NHL. JSP is an Editor of BJSM for which he receives a honorarium. He is an unpaid consultant to the World Rugby Concussion Advisory Group for which he also serves as an Independent Concussion Advisor (fee per consultation). Other unpaid positions include being medical advisor to South African Rugby, Co-chair of the Scientific Committee, 6th International Conference on Concussion in Sport (travel and accommodation subsidised), Board member of the CISG and a Scientific Advisory Board Member of EyeGuide. LKP CASEM Board Member, President-Elect 2022–2023 NIH R34 Grant for EPICC Study (Eye Problems In Concussed Children), Site PI. Speaker at various conferences. CISG member. Expert panellist for the Sixth International Conference on Concussion in Sport (travel and accommodation subsidised). MP declares the following: Consultant, Chief Medical Officer, Major League Soccer. Senior Advisor, NFL Head, Neck & Spine Committee. FA Research Task Force Committee member. UK Concussion Foundation Protocol Forum. US Soccer Medical Advisory Committee. CDC Concussion Consultant. CISG expert panel. NOCSAE Scientific Advisory Committee. IOC Mental Health Working Group. USOPC Mental Health Advisory Committee. Team Physician, US Soccer. Received funding for research; NCAA-CARE-DoD 2.0, ended 2020. He received honoraria and reimbursement for travel for speaking and conferences amended. He has written chapters for UpToDate and received royalties for the Netter’s Sports Medicine textbook. He has provided work as an expert for cases involving concussion, team physician and other sports medicine topics. KJS has received grant funding from the Canadian Institutes of Health Research, NFL Scientific Advisory Board, IOC Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary with funds paid to her institution and not to her personally. She is an Associate Editor of BJSM (unpaid), independent consultant to World Rugby and has received travel and accommodation support for meetings where she has presented. She led and coordinated the writing of the systematic reviews that informed the Sixth International Conference on Concussion in Sport and Amsterdam Consensus Statement, for which she received an educational grant to assist with the administrative costs associated with the writing of the reviews (with funds paid to her institution and not to her personally). She is a member of the AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid position). She works as a physiotherapy consultant and treats athletes of all levels of sport from grassroots to professional. MT is employed full-time as the CEO and Medical Director of ICHIRF—a paid post he has held since April 2015. Hon Medical Adviser to the Professional Riders Insurance Scheme (PRIS)—discretionary Honorarium. Member of the Premier League Head Injury Advisory Group—no remuneration. Director of ICHIRF Ireland—no remuneration. Honorary Medical Adviser to the Concussion Foundation—no remuneration. Member of the expert panel for the Department of Digital, Culture, Media and Sport review into concussion in amateur sport—no remuneration. Attendance at conferences or meetings as a guest speaker—reimbursement of travel expenses, complimentary registration and payment of hotel accommodation and meals by the organising committee. No stocks or options in any concussion-related company. No consultancies, board or editorial positions related to concussion. KOY is Editor-in-Chief of the journal Neuropsychology and receives an editorial stipend from the American Psychological Association. He is an unpaid consulting editor for the journals Archives of Clinical Neuropsychology and Journal of Head Trauma Rehabilitation. He is an unpaid member of the Scientific Advisory Committee for Brain Injury Canada. He is the chair of the Canadian Concussion Network, which is funded by a grant from the Canadian Institutes of Health Research (CIHR) to his institution; he is the principal applicant for the grant but receives no income from it. He is a PI on another grant from CIHR from which he derives no income. He is a co-investigator on research grants from CIHR, the US NIH, Brain Canada Foundation and NFL Scientific Advisory Board; he derives income only from the grant from the NIH. He serves as a member of a CIHR grant review panel for which he receives a small honorarium. He receives book royalties from Guilford Press and Cambridge University Press. He has received travel support and honorarium for presentations to multiple organisations. He serves or has served on the following committees/boards for which he receives honorarium: (1) Independent Data Monitoring Committee, Care for Post-Concussive Symptoms EffecCveness (CARE4PCS-2) Trial, National Institute for Child Health and Human Development; (2) Observational Study Monitoring Board, Approaches and Decisions in Acute Pediatric TBI (ADAPT) Trial, National Institute of Neurological Disorders and Stroke National Research Advisory Council; (3) National Pediatric Rehabilitation Resource Center, Center for Pediatric Rehabilitation: Growing Research, Education, and Sharing Science, Virginia Tech University., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The purpose of this paper is to summarise the consensus methodology that was used to inform the International Consensus Statement on Concussion in Sport (Amsterdam 2022). Building on a Delphi process to inform the questions and outcomes from the 5th International Conference on Concussion in Sport, the Scientific Committee identified key questions, the answers to which would help encapsulate the current science in sport-related concussion and help guide clinical practice. Over 3½ years, delayed by 2 years due to the pandemic, author groups conducted systematic reviews on each selected topic. The 6th International Conference on Concussion in Sport was held in Amsterdam (27-30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews., Competing Interests: a Competing interests: OHA is a Senior Physiotherapist at University Hospitals Dorset NHS Foundation Trust (England) and is Para Football Physiotherapy Lead/Para Football Classification Lead at the Football Association (England). He also works on a consultancy basis with the Football Association as the squad physiotherapist to the England Cerebral Palsy Football squad, and teaches on the Football Association’s Advanced Trauma and Medical Management in Football course on a consultancy basis. He has a Visiting Senior Lecturer position at the University of Portsmouth, England (unpaid). He sits on several disability sport committees including Para Football Foundation as Medical Unit Co-Lead (unpaid), the International Federation of Cerebral Palsy Football as Medical and Sports Science Director (unpaid), and the International Blind Sports Association as Medical Committee member (unpaid). He has Associate Editor positions at the British Journal of Sports Medicine (unpaid) and British Medical Journal (BMJ) Open Sports & Exercise Medicine (unpaid). He is also an Institutional Ethics Committee external member for World Rugby (unpaid), and co-chair of the Concussion in Para Sport Group (unpaid). AB has received peer-reviewed research funding from the Social Sciences and Humanities Research Council. She is also a Sport Information Resource Centre board member and Canadian Athletic Therapists Association committee member. She has received an honorarium for the administrative aspects of the reviews. CB is an Associate Professor of Physical Medicine & Rehabilitation (PM&R) at Spaulding Rehabilitation Hospital/Harvard Medical School and Chief Medical Officer at Spaulding Rehabilitation Hospital. She receives grant funding from the United States (US) Center for Disease Control (CDC) and Prevention and the U.S. National Institute on Disability, Independent Living, and Rehabilitation Research. She serves on the Board of Directors of the United States Olympic & Paralympic Committee (unpaid) as well as the International Paralympic Committee Medical Committee (unpaid) and the International Olympic Committee Medical & Scientific Commission (unpaid). She serves as an Associate Editor of the British Journal of Sports Medicine (unpaid) as well as the PM&R Journal (unpaid). SB current or past research funding from the National Institutes of Health; Centers for Disease Control and Prevention (CDC); Department of Defense - USA Medical Research Acquisition Activity, National Collegiate Athletic Association (NCAA); National Athletic Trainers’ Association Foundation; National Football League (NFL)/Under Armour/General Electric (GE); Simbex; and ElmindA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medicolegal litigation, and received speaker honorarium and travel reimbursements (including Concussion in Sport Group -CISG) for talks given. He is coauthor of “Biomechanics of Injury (3rd edition)” and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (US Application No. 17/164,490). He is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present), British Journal of Sport Medicine (2008 to 2019). JSB is supported by the University of Calgary, the Natural Sciences and Engineering Research Council [CGSD3-559333- 2021], and an honorarium for the methods author work associated with Reviews two and four. RCC is a Senior Advisor NFL Head Neck & Spine Committee VP NOCSAE and Chair Scientific Advisory CommitteeCo-Founder Medical Director Concussion Legacy FoundationRoyalties Houghton Mifflin Harcourt Legal Expert Opinion. JDC National Collegiate Athletic Association payments for expert testimony. National Hockey League (NHL) payments for expert testimony. GAD is a member of the Scientific Committee of the 6th International Conference on Concussion in Sport; anhonorary member of the Australian Football League (AFL) Concussion Scientific Committee; Section Editor, Sport and Rehabilitation, NEUROSURGERY; and has attended meetings organised by sporting organisations including the NFL, National Rugby League (NRL), International Ice Hockey Federation (IIHF), International Olympic Committee (IOC) and Federation International de Football Association (FIFA); however, has not received any payment, research funding or other monies from these groups other than for travel costs. JD has nothing to disclose. RJE is a paid consultant for the NHL and co-chair of the NHL/NHL Players Association (NHLPA) Concussion Subcommittee. He is also a paid consultant and chair of the Major League Soccer concussion committee, and a consultant to the US Soccer Federation. He previously served as a neuropsychology consultant to Princeton University Athletic Medicine and EyeGuide. He is currently a co-Primary Investigator (PI) for a grant funded by the NFL (NFL-Long) through Boston Children’s Hospital. He occasionally provides expert testimony in matters related to mTBI and sports concussion, and occasionally receives honoraria and travel support/reimbursement for professional meetings. PE is a data consultant to the National Hockey League; received an honorarium for the administrative aspects of the reviews. CAE has received external peer-reviewed research funding from Canadian Institutes of Health Research (CIHR), Canada Foundation for Innovation, International Olympic Committee Medical and Scientific Committee, NFL Play Smart Play Safe Program, and World Rugby. She is an Associate Editor of British Journal of Sport Medicine (BJSM) (unpaid) and has received travel and accommodation support for meetings where she has presented. She is an external advisory board member (unpaid) for HitIQ. KAH has nothing to disclose. GI, PhD serves as a scientific advisor for NanoDX®, Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mTBIs (including former athletes). He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received research funding as a principal investigator from the NFL, and subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of NFL Players Association Members. He has received research funding from the Wounded Warrior Project™. He acknowledges unrestricted philanthropic support from ImPACT Applications, Inc., the Mooney-Reed Charitable Foundation, Boston Bolts, the National Rugby League, and the Schoen Adams Research Institute at Spaulding Rehabilitation. JJL receives grant/research support from National Institutes of Health (NIH), Department of Defence (DoD) and American Medical Society for Sports Medicine (AMSSM); is a member of the Scientific Advisory Board for Neuronasal, Highmark Innovations, and Quadrant Biosciences; minority stock options in Highmark Innovations and 360 Concussion Care; expert consultant to NCAA. Consults with NFL and NHL teams on athlete care but does not receive any compensation from these organisations; Editorial Board of Journal of Head Trauma Rehabilitation. MM is sport and exercise medicine physician working in private consulting practice. He is the Chief Medical Officer for the Australian Football League (AFL) and an independent consultant to World Rugby. He is a Shareholder of Olympic Park Sports Medicine Centre in Melbourne. He has previously held positions as the senior physician at the Hawthorn Hawks Football Club (AFL) and Chief Executive Officer of the AFL Doctors Association. He has received research grants from the Australian Football League, outside the submitted work. He has received travel support received from the Australian Football League, FIFA and the International Olympic Committee to attend and present at international conferences. Member of the Scientific Committee for the 6th International Conference on Concussion in Sport. Honorary member of the International CISG and an honorary member of the Australian Rugby Union Concussion Advisory Group. MMcC reports research grants from the US NIH, US Department of Defense, US CDC, US Department of Veterans Affairs, Abbott Laboratories, NFL, and NCAA, and consultancy with the Green Bay Packers and Neurotrauma Sciences, Inc. MMcN 1. Chair, Ethics Expert Group, World Antidoping Agency (WADA) (2021–23) (paid) 2. Member, International Boxing Association, Ethics and Integrity Committee, (2021–22; resigned Oct 2022) (paid) 3. Chair, Therapeutic Use Exemption Fairness Committee (2020–) (paid) 4. Member, Steering Group, Sex Segregation in Sport, International Association of Athletics Federations (IAAF)/World Athletics, (2019–20) (unpaid) 5. Member, International Ice Hockey Federation, Ethics and Integrity Committee (2019–21) (paid) 6. Member, International Olympic Committee Consensus Statement Expert Group on Injuries in Children and Adolescents (2017) (unpaid) 7. Member, Ethics Expert Group, WADA (2016–21) (unpaid) 8. Member, International Olympic Committee Consensus Statement Expert Group on Pain Management (2016)) (unpaid). WM is employed as the Chief Medical Officer of the National Hockey League. JP: Editor BJSM (honorarium); Member of World Rugby Concussion Advisory Group (unpaid); Independent Concussion Consultant for World Rugby (fee per consultation); Medical consultant to South African Rugby (unpaid); Co-chair of the Scientific Committee, 6th International Conference on Concussion in Sport (unpaid); Board member of the CISG (unpaid); Scientific Board member, EyeGuideTM (unpaid). ZP has no conflicts of interests to declare. MP declares the following: Consultant, Chief Medical Officer (CMO), Major League Soccer; Senior Advisor, NFL Head, Neck NCAA-CARE-DoD 2.0, ended 2020; Have received honoraria and reimbursement for travel for speaking and conferences attended; Have written chapters for UpToDate, and received royalties for the Netter’s Sports Medicine textbook; Have provided work as an expert for cases involving concussion, team physician and other sports medicine topics. AMR: Stipend for the clerical and administrative aspects of the systematic review. Tonal Strength Institute: Research grant (not specifically related to the present work). Alberta Bone and Joint Strategic Clinical Network: Research grant (not specifically related to the present work). PER has no conflicts of interest to declare. GMS is an owner of a multidisciplinary practice (managing patients with MSK pain disorders). He is a board member of Hockey Calgary (Calgary, AB, Canada) and Chair of the Alberta Association of Physiotherapy. He received funding for the administrative aspects of the writing of two of the systematic reviews that informed the consensus process. KJS has received grant funding from the CIHR, NFL Scientific Advisory Board, International Olympic Committee Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary, with funds paid to her institution and not to her personally. She is an Associate Editor of BJSM (unpaid), Independent consultant to World Rugby and has received travel and accommodation support for meetings where she has presented. She coordinated the writing of the systematic reviews that informed Amsterdam International Consensus on Concussion in Sport, for which she has received an educational grant to assist with the administrative costs associated with the writing of the reviews (with funds paid to her institution). She is a member of the AFL Concussion Scientific Committee (unpaid position), Brain Canada (unpaid positions) and Board member of the Concussion in Sport Group (CISG)(unpaid). She works as a physiotherapy consultant and treats athletes of all levels of sport from grass roots to professional. JT: Doctoral funding through the CIHR; Jason also received an honorarium for the administrative parts of the review. KOY holds the Ronald and Irene Ward Chair in Pediatric Brain Injury funded by the Alberta Children’s Hospital Foundation. He is a principal investigator on grants from the CIHR, and co-investigator on research grants from CIHR, Brain Canada Foundation, Social Science and Humanities Research Council (Canada), and NFL Scientific Advisory Board. He is the Editor of Neuropsychology, for which he receives an editorial stipend from the American Psychological Association. He chairs the Canadian Concussion Network, which is funded by CIHR. He is a member of the Scientific Advisory Committee for Brain Injury Canada and the National Research Advisory Council for the National Pediatric Rehabilitation Resource Center., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: GAD is a member of the Scientific Committee of the 6th International Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee; Section Editor, Sport and Rehabilitation, NEUROSURGERY; and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF, IOC and FIFA; however has not received any payment, research funding or other monies from these groups other than for travel costs. JSP: Editor BJSM (honorarium), Member of World Rugby Concussion Advisory Group (unpaid), Independent Concussion Consultant for World Rugby (fee per consultation), Medical consultant to South African Rugby (unpaid), Co-chair of the Scientifc Committee, 6th International Conference on Concussion in Sport (unpaid), Board member of the Concussion in Sport Group (unpaid), Scientific Board member, EyeGuideTM (unpaid). LKP: CASEM Board Member, President-Elect 2022-2023NIH R34 Grant for EPICC Study (Eye Problems In Concussed Children), Site PI, Speaker at various conferences. VA: Financial: Australian National Health and Medical Research Council and Medical Research Future fund: research grants. Royalties: Pearson Publishing (Test of Everyday Attention) Collaboration: Australian Football League (Partnership agreement to fund research – funds go to my institute) Boards: Editorship: Journal of Neuropsychology, Neuropsychology, Journal of Clinical & Experimental Neuropsychology. GAG reports grant funding from CDC TEAM and OnTRACK grants, NIMH APNA grant, royalties from PAR, consulting fees from NFL Baltimore Ravens, Zogenix International and Global Pharma Consultancy and travel support for professional meetings. He is a member of USA Football Medical Advisory Panel. CCG: Grants/Research Support: Hit-IQ (2022-2023); NIH NINDS (R01 NS110757 2019-2024); NINDS (U54 NS121688 2021-2026); UCLA Brain Injury Research Center, UCLA Steve Tisch Brain SPORTprogram, Easton Clinic for Brain Health Clinical Consultant (provide clinical care to athletes): NBA, NFL-Neurological Care Program, NHL/NHLPA, Los Angeles Lakers Advisory Board (Non compensated): Major League Soccer, National Basketball Association, US Soccer Federation. Advisory Board (Compensated): Highmark Interactive Medicolegal: One or two cases annually Speaker’s Bureau: None. Stock Shareholder: Highmark Interactive stock options (2018). Other Financial or Material Support: Book royalties – Blackwell/Wiley Publishing: Prioritized Neurological Differential Diagnosis Other: None. KOY: is Editor-in-Chief of the journal Neuropsychology and receives an editorial stipend from the American Psychological Association. He is an unpaid consulting editor for the journals Archives of Clinical Neuropsychology and Journal of Head Trauma Rehabilitation. He is an unpaid member of the Scientific Advisory Committee for Brain Injury Canada. He is the chair of the Canadian Concussion Network, which is funded by a grant from Canadian Institutes of Health Research (CIHR) to his institution; he is principal applicant on the grant but receives no income from it. He is a principal investigator on another grant from CIHR from which he derives no income. He is a coinvestigator on research grants from CIHR, the US National Institutes of Health (NIH), Brain Canada Foundation and National Football League Scientific Advisory Board; he derives income only from the grant from NIH. He serves as a member of a CIHR grant review panel for which he receives a small honorarium. He receives book royalties from Guilford Press and Cambridge University Press. He has received travel support and honorarium for presentations to multiple organisations. He served or serves on the following committees/boards for which he received honorarium: (1) Independent Data Monitoring Committee (IDMC), Care for Post Concussive Symptoms Effectiveness (CARE4PCS-2) Trial, National Institute for Child Health and Human Development. (2) Observational Study Monitoring Board (OSMB), Approaches and Decisions in Acute Pediatric TBI (ADAPT) Trial, National Institute of Neurological Disorders and Stroke National Research Advisory Council, National Pediatric Rehabilitation Resource Center, Center for Pediatric Rehabilitation: Growing Research, Education and Sharing Science (CPROGRESS), Virginia Tech University. OHA is a Senior Physiotherapist at University Hospitals Dorset NHS FoundationTrust (England) and is Para Football Physiotherapy Lead/Para Football Classification Lead at the Football Association (England). He also works on a consultancy basis with the Football Association as the squad physiotherapist to the England Cerebral Palsy Football squad, and teaches on the Football Association's Advanced Trauma and Medical Management in Football course on a consultancy basis. He has a Visiting Senior Lecturer position at the University of Portsmouth, England (unpaid). He sits on several disability sport committees including Para Football Foundation as Medical Unit Co-Lead (unpaid), the International Federation of Cerebral Palsy Football as Medical and Sports Science Director (unpaid) and the International Blind Sports Association as Medical Committee member (unpaid). He has Associate Editor position sat the British Journal of Sports Medicine (unpaid) and BMJ Open Sports & Exercise Medicine (unpaid). He is also an Institutional Ethics Committee external member for World Rugby (unpaid) and co-chair of the Concussion in Para Sport Group (unpaid). CB is an Associate Professor of PM&R at Spaulding Rehabilitation Hospital/Harvard Medical School and Chief Medical Officer at Spaulding Rehabilitation Hospital. She receives grant funding from the US Center for Disease Control and Prevention and the US National Institute on Disability, Independent Living and Rehabilitation Research. She serves on the Board of Directors of the United States Olympic & Paralympic Committee (unpaid) as well as the International Paralympic Committee Medical Committee (unpaid) and the International Olympic Committee Medical & Scientific Commission (unpaid). She serves as an Associate Editor of the British Journal of Sports Medicine (unpaid) as well as the PM&R Journal (unpaid). DJC - has no financial relationships to disclose; his time is supported by National Institute of Neurological Disorders and Stroke of the National Institutes of Health under award number K23NS128275-01. CLM reports no financial COI. Volunteer positions: Concussion team physician, Shipley School Board of Trustees, American College of Sports Medicine Board of Directors, American Medical Society for Sports Medicine Board of Directors, Pediatric Research in Sports Medicine Executive Committee, Council on Sports Medicine and Fitness, American Academy of Pediatrics Advisory Board, Untold Foundation, Pink Concussions, Headway Foundation Editorial Board, Journal of Adolescent Health, Frontiers in Neuroergonomics, Exercise, Sport and Movement. GMS is an owner of a multidisciplinary practice (managing patients with MSK pain disorders). He is a board member of Hockey Calgary (Calgary, AB, Canada) and Chair of the Alberta Association of Physiotherapy. He received funding for the administrative aspects of the writing of two of the systematic reviews that informed the consensus process. JvI is the founder of R2P Concussion Management. RJE is a paid consultant for the NHL and cochair of the NHL/ NHLPAConcussion Subcommittee. He is also a paid consultant and chair of the Major League Soccer concussion committee and a consultant to the US Soccer Federation. He previously served as aneuropsychology consultant to Princeton University Athletic Medicine and EyeGuide. He is currently a co-PI for a grant funded by the NFL (NFL-Long) through Boston Children’s Hospital. He occasionally provides expert testimony in matters related to MTBI and sports concussion,and occasionally receives honoraria and travel support/reimbursement for professional meetings. PF is a co-investigator on a research grant from the NFL’s “Play Smart. PlaySafe.” Initiative and an Executive committee member of the Canadian Concussion Network (financed by the Canadian Institute of Health Research). He received honorarium for an Expert group discussion on blood biomarkers for concussion in December 2020. GWF has received travel expenses to attend academic meetings from World Rugby. He has also collaborated on research projects with World Rugby as chief or co-investigator. He is previous associate editor of the British Journal of Sports Medicine. He has not received any other payments or support from any sporting or commercial bodies. He has no other conflictsof interest. SH: Co-founder and senior advisor, The Sports Institute at UW MedicineCenters for Disease Control and Prevention and National Center for Injury Prevention and Control Board Pediatric Mild Traumatic Brain Injury Guideline Workgroup NCAA Concussion Safety Advisory GroupTeam Physician, Seattle Mariners Former Team Physician, Seattle Seahawks. KGH: Research Development Director, Pac-12 Conference Member, Pac-12 Brain Trauma Task Force Member, NFL Head Neck and Spine Committee Deputy Editor, British Journal of Sports Medicine Head Football Physician, University of Washington. KH received an honorarium for administrative aspects of the reviews. ML is the CMO GB Boxing, CMO GB Snowsports. NE Director GB Taekwondo. NE Director SWA (share options). Director Active Movement. Director GB Obstacle course racing. Founder and medical board member of Safe MMA. Director of Marylebone Health Group. Private medical practice at ISEH 170 Tottenham Court Road. Private medical practice Marylebone Health Group. MM: Sport and exercise medicine physician working in private consulting practice. Shareholder of Olympic Park Sports Medicine Centre in Melbourne. Ex-senior physician at the Hawthorn Football Club (AFL) Ex-Chief Executive Officer of the AFL Doctors Association. Research grants received from the Australian Football League, outside the submitted work. Travel support received from the Australian Football League, FIFA and the International Olympic Committee to attend and present at international conferences. Member of the Scientific Committee for the 6th International Consensus Conference on Concussion in Sport. Honorary member of the International Concussion in Sport Group. Honorary member of the Australian Rugby Union Concussion Advisory Group. Independent Concussion Consultant for World Rugby. MMc has received research funding to the Medical College of Wisconsin from the National Institutes of Health, Department of Veterans Affairs, Centers for Disease Control and Prevention, Department of Defense, National Collegiate Athletic Association, National Football League and Abbott Laboratories. He receives book royalties from Oxford University Press. He serves as clinical consultant to Milwaukee Bucks, Milwaukee Brewers and Green Bay Packers and is Co-Director of the NFL Neuropsychology Consultants without compensation. He serves as consultant for Neurotrauma Sciences, Inc. He receives travel support and speaker honorariums for professional activities. WPM receives royalties from ABC-Clio publishing for the sale of the books, Kids, Sports and Concussion: A guide for coaches and parents and Concussions; from Springer International for the book Head and Neck Injuries in Young Athlete; and from Wolters Kluwer for working as an author for UpToDate. His research is funded, in part, by philanthropic support from the National Hockey League Alumni Association through the Corey C Griffin Pro-Am Tournament and a grant from a grant from the National Football League. PO’H is an employee of Marker Diagnostics UK Ltd. He has worked on a sessional basis for the English RFU and FA. He has previously received research funding from the English RFU, ECB and The Drake Foundation. ZP: No COI to declare. MP declares the following: Consultant, CMO, Major League Soccer, Senior Advisor, NFL Head, Neck & Spine Committee, FA Research Task Force Committee member, UK Concussion Foundation Protocol Forum, US Soccer Medical Advisory Committee, CDC Concussion Consultant, Concussion in Sport Group expert panel, NOCSAE Scientific Advisory Committee, IOC Mental Health Working Group, USOPC Mental Health Advisory Committee, Team Physician, US Soccer, Received funding for research; NCAA-CARE-DoD 2.0, ended 2020, have received honoraria and reimbursement for travel for speaking and conferences attended, have written chapters for UpToDate and received royalties for the Netter’s Sports Medicine textbook, have provided work as an expert for cases involving concussion, team physician and other sports medicine topics. IJS does not have any conflicts of interest to disclose. MT is employed full-time as the CEO and Medical Director of ICHIRF – a paidpost he has held since April 2015. Hon Medical Adviser to the Professional Riders Insurance Scheme (PRIS) – discretionary honorarium Member of the Premier League Head Injury Advisory Group (HIAG) – no remuneration Director of ICHIRF Ireland Ltd – no remuneration Honorary Medical Adviser to the Concussion Foundation Ltd – no remuneration Member of the expert panel for the Dept of Digital, Culture, Media and Sport review into concussion in amateur sport – no remuneration Attendance at conferences or meetings as a guest speaker – reimbursement of travel expenses, complimentary registration and payment of hotel accommodation and meals by the organising committee. No stocks or options in any concussion-related company. No consultancies, board or editorial positions related to concussion. KV has no conflicts of interest to disclose. NW: Chair, British Paralympic Association (voluntary) IPC Medical Committee Member (voluntary) Concussion in Para Sports (CIPS), founding member (voluntary) BJSM Editorial Board member (voluntary) Sports Horizon, Board of Directors – equity share – see https://www.sportshorizon.co.uk. KJS: has received grant funding from the Canadian Institutes of Health Research, National Football League Scientific Advisory Board, International Olympic Committee Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary) with funds paid to her institution and not to her personally. She is an Associate Editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is coordinating the writing of the systematic reviews that will inform the 6th International Consensus on Concussion in Sport, for which she has received an educational grant to assist with the administrative costs associated with the writing of the reviews. She is a member of the AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid positions). She works as a physiotherapy consultant and treats athletes of all levels of sport from grass roots to professional.

Competing Interests: Competing interests: None declared.

Objective: To describe the incidence and burden of illness at the Tokyo 2020 Paralympic Games, which was organised with strict COVID-19 countermeasures., Methods: Daily illnesses were recorded via the web-based injury and illness surveillance system (teams with their own medical staff; n=81), and local polyclinic services (teams without their own medical staff; n=81). Illness proportion, incidence and burden were reported for all illnesses and in subgroups by sex, age, competition period, sports and physiological system., Results: 4403 athletes (1853 female and 2550 male) from 162 countries were monitored for the 15-day period of the Tokyo Paralympic Games (66 045 athlete days). The overall incidence of illnesses per 1000 athlete days was 4.2 (95% CI 3.8 to 4.8; 280 illnesses). The highest incidences were in wheelchair tennis (7.1), shooting (6.1) and the new sport of badminton (5.9). A higher incidence was observed in female compared with male athletes (5.1 vs 3.6; p=0.005), as well as during the precompetition versus competition period (7.0 vs 3.5; p<0.0001). Dermatological and respiratory illnesses had the highest incidence (1.1 and 0.8, respectively). Illness burden was 4.9 days per 1000 athlete days and 23% of illnesses resulted in time loss from training/competition>1 day., Conclusion: The incidence of illness at the Tokyo 2020 Paralympic Games was the lowest yet to be recorded in either the summer or winter Paralympic Games. Dermatological and respiratory illnesses were the most common, with the burden of respiratory illness being the highest, largely due to time loss associated with COVID-19 cases. Infection countermeasures appeared successful in reducing respiratory and overall illness, suggesting implementation in future Paralympic Games may mitigate illness risk., Competing Interests: Competing interests: All authors have declared no competing interests. WD is an associate editor of BJSM IPHP editions., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: Physical medicine and rehabilitation requires teamwork and innovation to help patients reach their goals and to optimize their quality of life, and one way is through participation in sports ( Sports Med Arthrosc Rev . 2019;27:73-82; PM R . 2015;7(10):1081-8; PM R . 2012;4(11):851-6; Phys Med Rehabil Clin N Am . 2019;30(1):289-99). Unfortunately, people with disabilities participate in sports ~20% less than their peers, and reasons for this disparity include equipment cost and availability ( Sports Med Arthrosc Rev . 2019;27:73-82; PM R . 2015;7(10):1081-8; Pediatrics . 2008;121(5):1057-61; Res Dev Disabil . 2017;67:9-18). A unique way for physical medicine and rehabilitation clinicians to aid in overcoming these barriers is to collaborate with other fields to make adaptive equipment that meets patients' needs.A multidisciplinary team including a physical medicine and rehabilitation resident physician and biomedical engineer, physical therapist, and machinist collaborated through a local nonprofit organization to design and build adaptive equipment solutions. This team designed two types of adaptive putters that are useable by golfers of various ages and functional ranges and a removable golf club grip for a player with limited grip strength.Implementation of a design team for creating adaptive equipment solutions is possible and can be done in the community setting or as part of a hospital system. In the authors' experience, taking a multidisciplinary team approach allowed developing more innovative and diverse solutions, and the athletes benefited by being able to participate in their desired sports activities., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To adapt key components of exertional heat stroke (EHS) prehospital management proposed by the Intenational Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020 so that it is applicable for the Paralympic athletes., Methods: An expert working group representing members with research, clinical and lived sports experience from a Para sports perspective reviewed and revised the IOC consensus document of current best practice regarding the prehospital management of EHS., Results: Similar to Olympic competitions, Paralympic competitions are also scheduled under high environmental heat stress; thus, policies and procedures for EHS prehospital management should also be established and followed. For Olympic athletes, the basic principles of EHS prehospital care are: early recognition, early diagnosis, rapid, on-site cooling and advanced clinical care. Although these principles also apply for Paralympic athletes, slight differences related to athlete physiology (eg, autonomic dysfunction) and mechanisms for hands-on management (eg, transferring the collapsed athlete or techniques for whole-body cooling) may require adaptation for care of the Paralympic athlete., Conclusions: Prehospital management of EHS in the Paralympic setting employs the same procedures as for Olympic athletes with some important alterations., Competing Interests: Competing interests: WD reports grants from IOC Research Centers Grant, other from IPC Travel Support, grants from World Rugby, grants from AXA, grants from Ossur, outside the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Concussion is a frequent injury in many sports and is also common in para athletes. However, there is a paucity of concussion research related to para sport, and prior International Concussion in Sport (CIS) consensus papers have not substantively addressed this population. To remedy this and to improve concussion care provided to para athletes, the concussion in para sport (CIPS) multidisciplinary expert group was created. This group analysed and discussed in-depth para athlete-specific issues within the established key clinical domains of the current (2017) consensus statement on CIS. Due to the onset of the COVID-19 pandemic, the group held all meetings by video conferencing. The existing Sport Concussion Assessment Tool 5 (SCAT5) for the immediate on-field and office-based off-field assessment of concussion was evaluated as part of this process, to identify any para athlete-specific concerns. Regular preparticipation and periodic health examinations are essential to determine a baseline reference point for concussion symptoms but pose additional challenges for the interpreting clinician. Further considerations for concussion management for the para athlete are required within the remove, rest, reconsider and refer consensus statement framework. Considering return to sport (RTS), the 2017 CIS consensus statement has limitations when considering the RTS of the para athlete. Case-by-case decision making related to RTS following concussion is imperative for para athletes. Additional challenges exist for the evaluation and management of concussion in para athletes. There is a need for greater understanding of existing knowledge gaps and attitudes towards concussion among athlete medical staff, coaches and para athletes. Future research should investigate the use and performance of common assessment tools in the para athlete population to better guide their clinical application and inform potential modifications. Concussion prevention strategies and sport-specific rule changes, such as in Para Alpine Skiing and Cerebral Palsy Football, also should be carefully considered to reduce the occurrence of concussion in para athletes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In 2020, the IOC released a consensus statement that provides overall guidelines for the recording and reporting of epidemiological data on injury and illness in sport. Some aspects of this statement need to be further specified on a sport-by-sport basis. To extend the IOC consensus statement on methods for recording and reporting of epidemiological data on injury and illness in sports and to meet the sport-specific requirements of all cycling disciplines regulated by the Union Cycliste Internationale (UCI). A panel of 20 experts, all with experience in cycling or cycling medicine, participated in the drafting of this cycling-specific extension of the IOC consensus statement. In preparation, panel members were sent the IOC consensus statement, the first draft of this manuscript and a list of topics to be discussed. The expert panel met in July 2020 for a 1-day video conference to discuss the manuscript and specific topics. The final manuscript was developed in an iterative process involving all panel members. This paper extends the IOC consensus statement to provide cycling-specific recommendations on health problem definitions, mode of onset, injury mechanisms and circumstances, diagnosis classifications, exposure, study population characteristics and data collection methods. Recommendations apply to all UCI cycling disciplines, for both able-bodied cyclists and para-cyclists. The recommendations presented in this consensus statement will improve the consistency and accuracy of future epidemiological studies of injury and illness in cycling., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

In 2020, the IOC proposed a universal methodology for the recording and reporting of data for injury and illness in sport. Para sport is played by individuals with impairment, and they have a unique set of considerations not captured by these recommendations. Therefore, the aim of this addendum to IOC consensus statement was to guide the Para sport researcher through the complexities and nuances that should be taken into consideration when collecting, registering, reporting and interpreting data regarding Para athlete health. To develop this translation, experts in the field of Para sports medicine and epidemiology conducted a formal consensus development process, which began in March 2020 with the formation of a consensus group that worked over eight phases, incorporating three virtual consensus meetings to finalise the translation. This translation is consistent with the IOC consensus statement, yet provides more detailed Para athlete specific definitions and recommendations on study population, specifically, diagnostic and eligible impairment categorisation and recording of adaptive equipment, and defining and classifying health problems in the context of Para sport. Additionally, recommendations and Para athlete specific examples are described with regards to injury mechanism, mode of onset, injury and illness classification, duration, capturing and reporting exposure and risk. Finally, methods and considerations are provided to cater to the varied needs of athletes with impairment with respect to data collection tools. This harmonisation will allow the science to develop and facilitate a more accurate understanding of injury and illness patterns for tailoring evidence-informed prevention programmes and enabling better planning of medical services for Para sport events., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The objective of this scoping review was to map the evidence on measurement properties of body composition tools to assess whole-body and regional fat and fat-free mass in adults with SCI, and to identify research gaps in order to set future research priorities. Electronic databases of PubMed, EMBASE and the Cochrane library were searched up to April 2020. Included studies employed assessments related to whole-body or regional fat and/or fat-free mass and provided data to quantify measurement properties that involved adults with SCI. All searches and data extractions were conducted by two independent reviewers. The scoping review was designed and conducted together with an expert panel (n = 8) that represented research, clinical, nutritional and lived SCI experience. The panel collaboratively determined the scope and design of the review and interpreted its findings. Additionally, the expert panel reached out to their professional networks to gain further stakeholder feedback via interactive practitioner surveys and workshops with people with SCI. The research gaps identified by the review, together with discussions among the expert panel including consideration of the survey and workshop feedback, informed the formulation of future research priorities. A total of 42 eligible articles were identified (1,011 males and 143 females). The only tool supported by studies showing both acceptable test-retest reliability and convergent validity was whole-body dual-energy x-ray absorptiometry (DXA). The survey/workshop participants considered the measurement burden of DXA acceptable as long as it was reliable, valid and would do no harm (e.g. radiation, skin damage). Practitioners considered cost and accessibility of DXA major barriers in applied settings. The survey/workshop participants expressed a preference towards simple tools if they could be confident in their reliability and validity. This review suggests that future research should prioritize reliability and validity studies on: (1) DXA as a surrogate 'gold standard' tool to assess whole-body composition, regional fat and fat-free mass; and (2) skinfold thickness and waist circumference as practical low-cost tools to assess regional fat mass in persons with SCI, and (3) females to explore potential sex differences of body composition assessment tools. Registration review protocol: CRD42018090187 (PROSPERO)., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To develop an assessment and recognition tool to identify elite athletes at risk for mental health symptoms and disorders., Methods: We conducted narrative and systematic reviews about mental health symptoms and disorders in active and former elite athletes. The views of active and former elite athletes (N=360) on mental health symptoms in elite sports were retrieved through an electronic questionnaire. Our group identified the objective(s), target group(s) and approach of the mental health tools. For the assessment tool, we undertook a modified Delphi consensus process and used existing validated screening instruments. Both tools were compiled during two 2-day meeting. We also explored the appropriateness and preliminary reliability and validity of the assessment tool. SPORT MENTAL HEALTH ASSESSMENT TOOL 1 AND SPORT MENTAL HEALTH RECOGNITION TOOL 1: The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) was developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for or already experiencing mental health symptoms and disorders. The SMHAT-1 consists of: (i) triage with an athlete-specific screening tool, (ii) six subsequent disorder-specific screening tools and (iii) a clinical assessment (and related management) by a sports medicine physician or licensed/registered mental health professional (eg, psychiatrist and psychologist). The International Olympic Committee Sport Mental Health Recognition Tool 1 (SMHRT-1) was developed for athletes and their entourage (eg, friends, fellow athletes, family and coaches)., Conclusion: The SMHAT-1 and SMHRT-1 enable that mental health symptoms and disorders in elite athletes are recognised earlier than they otherwise would. These tools should facilitate the timely referral of those athletes in need for appropriate support and treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Studies have revealed a higher incidence of injury and illness among elite adaptive athletes when compared to able-bodied athletes in competition. However, individuals with disabilities report poorer access to health care., Objective: The purpose of this study is to identify differences in healthcare access, satisfaction, and unmet needs between recreational adaptive and able-bodied athletes in all sports and within a single sport (hockey)., Design: Cross-sectional, survey-based study., Setting: Recreation sports programs in Boston, MA and Chicago, IL., Participants: Adult, recreational, competitive adaptive, and able-bodied athletes., Interventions: Not applicable., Main Outcome Measure(s): The Short-Form Patient Satisfaction Questionnaire (PSQ-18) for healthcare access and satisfaction; percentage of athletes reporting unmet sports-related healthcare needs in the prior year., Results: Sixty adaptive athletes (78% male, age 35.7 ± 12.4 years) and 65 able-bodied athletes (40% male, age 34.9 ± 11.9 years) participated. Mean access and satisfaction scores were not significantly different between groups in all sports (P = .53 and P = .19, respectively) or hockey (P = .28 and P = .55, respectively). Unmet needs were more commonly reported among adaptive athletes (18.3% all sports, 20.0% hockey) as compared to able-bodied athletes (9.2% all sports, 4.0% hockey). This reached statistical significance in the hockey group (P = .03), but not all sports (P = .12)., Conclusions: No differences were seen between groups in healthcare access or satisfaction scores. Adaptive athletes of the same sport reported a higher rate of unmet sports-related healthcare needs but with few doctor's visits in the preceding year, suggesting discrepancies in expectations and healthcare-seeking behavior., Level of Evidence: III., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Objective: To describe the epidemiology of sports injury at the Pyeongchang 2018 Paralympic Winter Games., Methods: 567 athletes from 49 countries were monitored daily for 12 days over the Pyeongchang 2018 Paralympic Winter Games (6804 athlete days). Injury data were obtained daily from teams with their own medical support (41 teams and 557 athletes) and teams without their own medical support (8 teams and 10 athletes) through two electronic data capturing systems., Results: 112 of 567 athletes (19.8%) reported a total of 142 injuries, with an injury incidence rate (IR) of 20.9 per 1000 athlete days (95% CI 17.4 to 25.0). The highest IR was reported for para snowboard (IR of 40.5 per 1000 athlete days [95% CI 28.5 to 57.5]; p<0.02), particularly in the lower limb and head/face/neck anatomical areas. Across all sports at the Games, acute traumatic injuries (IR of 16.2 per 1000 athlete days [95% CI 13.2 to 19.8]) and injuries to the shoulder/arm/elbow complex (IR of 5.7 per 1000 athlete days [95% CI 4.2 to 7.8]) were most common. However, most injuries (78.9%) did not require time loss., Conclusion: The new Paralympic Winter Games sport of Para snowboard requires attention to implement actions that will reduce injury risk. The shoulder was the most injured single joint-a consistent finding in elite para sport., Competing Interests: Competing interests: All authors have declared competing interests., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the incidence rate (IR) and illness burden (IB) at the Pyeongchang 2018 Paralympic Winter Games., Methods: A total of 567 athletes from 49 countries were monitored for 12 days over the Pyeongchang 2018 Games (6804 athlete days). Illness data were obtained daily from teams with (41 teams, 557 athletes) and teams without (8 teams, 10 athletes) their own medical support, through electronic data capturing systems., Results: There were 87 illnesses reported, with an illness IR of 12.8 illnesses per 1000 athlete days (95% CI 10.2 to 16.0) and IB of 6.8 days lost per 1000 athlete days (95% CI 3.4 to 13.5). The highest IR was reported for Para snowboard (IR of 19.7 [95% CI 12.0 to 32.2]). Illnesses in the respiratory system (IR of 4.1 [95% CI 2.9 to 5.9]; IB of 1.4 [95% CI 0.6 to 3.0]), skin and subcutaneous system (IR of 2.5 [95% CI 1.5 to 4.1]; IB of 0.6 [95% CI 0.1 to 2.9]), and eye and ocular adnexa (IR of 1.6 [95% CI 0.9 to 3.1]; IB of 0.5 [95% CI 0.1 to 3.3]) were the most common., Conclusion: This is the first study to report both the IR and IB in this setting. There was a high IR of illness in the new sport of Para snowboard. The respiratory system had both the highest IR and IB., Competing Interests: Competing interests: All authors have declared competing interests., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.