Circus-specific extension of the 6th International Consensus Statement on Concussion in Sport

Abstract

While sport-related concussion (SRC) is a known risk in circus arts, no published guidelines exist to guide post-concussion return to circus, contributing to inadequate management in this population. The Concussion in Sport Group (CISG) published the 6th international consensus statement in 2023, providing updated guidance and assessment tools for the management of SRC. Sport and dance organisations have adapted these recommendations for their specific settings. The aim of this extension statement was to extend the CISG guideline to the circus arts training and performance context. Development included a review of literature, creation of the initial drafts by the working group, feedback from external reviewers and integration of the feedback into a final draft approved by the working group. This statement includes circus-specific recommendations for: (1) baseline testing; (2) immediate postinjury management including adapted Maddocks questions; (3) a criterion-based return-to-circus progression including guidance by circus discipline; (4) prognostic considerations; (5) risk reduction/prevention. While ongoing research specific to SRC in circus is needed, this guideline supports and advises circus organisations to develop concussion management protocols and policies. It also informs clinicians to assist their understanding of the unique aspects and demands of circus arts to provide tailored clinical care in the rehabilitation of circus artists as they return to training and performance following SRC.

Introduction

Circus arts training and performance often include acrobatic feats involving height, speed and physical contact that can result in impacts to the head or body causing injuries, including to the brain. One such injury is a sport-related concussion (SRC), defined by the Concussion in Sport Group (CISG) in part as ‘a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain in sports or exercise-related activities… Symptoms and signs may present immediately or evolve over minutes or hours…’.^{1 2} Symptom clusters include headache, dizziness and balance problems, as well as cognitive, emotional and sleep disorders.^{3 4} Typical time for clinical symptom resolution spans from 1 week to 4 weeks15,7; however, persistent postconcussion symptoms (PPCS), when symptoms continue beyond 4 weeks postinjury, occur in 8–35% of cases.^{8 9} Complete recovery, including full return to cognitive and sport activities following full symptom resolution, commonly takes 3–4 weeks.^{5 8} Return to sport (RTS) before full resolution of SRC symptoms may result in reduced performance and training capacity or secondary musculoskeletal injuries attributed to concussion-related deficits such as balance and reaction time impairments.10,13 Early RTS is also associated with more serious conditions including second impact syndrome and a protracted concussion recovery period, such as PPCS.14,16

While concussion prevalence in the circus arts has not been extensively studied, it appears to be low when compared with other injuries.17,20 Among longitudinal circus injury surveillance studies, one SRC was reported in 0.5–6.4%^{17 18 21} and two or three SRCs in 1.8% of the sample.²¹ Over a 5-year time period, SRC accounted for 2.4% of injuries resulting in 15 or more missed performances, equal to approximately 10 days, illustrating the impact on time loss from work.¹⁹ While these studies suggest a low incidence of SRC in circus, it is likely under-reported, as historically, it wasn’t as readily identified and diagnosed compared with more recent models of monitoring and classification.²² Pathologic changes in brain anatomy and function resulting from repetitive subconcussive impacts, similar to those from heading a ball in soccer,23,25 are likely also not recorded. In a circus context, repeated subconcussive impacts may occur during object manipulation such as juggling with a circus prop such as a staff. Healthcare provider presence at circus training facilities and performances is less common than in sporting environments, which also contributes to under-reporting. These factors further complicate the understanding, identification and diagnosis of concussion in circus arts.

The CISG convened for the 6th International Conference on Concussion in Sport in October 2022 to synthesise concussion research into a revised ‘consensus statement on concussion in sport’.¹ The CISG also updated and developed new concussion assessment tools that can be applied across a wide variety of sports and activities. These include the Concussion Recognition Tool-6 (CRT6),²⁶ Sport Concussion Assessment Tool-6 (SCAT6 and Child SCAT6)^{27 28} and the Sport Concussion Office Assessment Tool-6 (SCOAT6 and Child SCOAT6),^{29 30} with the child versions for ages 5–12 years. They also provided return to learn and RTS guidelines for athletes with SRC.¹ The physical and cognitive demands of circus arts have similar characteristics to gymnastics, cheerleading and dance, which have adapted the CISG guidelines for their specific contexts.31,34 However, the unique aspects of the circus arts, including skills and acts within this context, require a distinct and nuanced approach to concussion management. An example is the high vestibulo-ocular demands required by many circus artists to train and perform their acts safely, particularly at height. The intent of this statement is to extend the broad guidelines contained in the CISG 6th consensus statement¹ to the circus arts training and performance context.

Methods

The methods in this extension statement were informed by the Surveillance of Injuries in Research on Circus (SIRC) working group’s earlier work creating a circus-specific consensus statement as an extension of the International Olympic Committee 2020 consensus statement for methods of recording and reporting of epidemiological data on injury and illness in sport.^{35 36} The same methodological process was employed in developing this current statement. The aim of the SIRC working group is to develop international consensus and extension guidelines, and other collaborative efforts, to improve circus arts research, healthcare and training practices. The development of this circus-specific extension of the CISG consensus statement included three stages.

In the first stage, SIRC working group members including expert circus arts researchers in injury and illness epidemiology, performing arts medicine practitioners, circus artists and coaches from three countries (online supplemental appendix 1) convened in March 2024 to review the CISG 6th consensus statement¹ and propose circus arts specific recommendations for the management of SRC. All SIRC working group meetings were virtual due to the members’ geographic location. The working group reviewed and discussed the additional pertinent literature, including several sport guidelines31,33 and unpublished protocols used by the National Institute of Circus Arts in Australia³⁷ and Cirque du Soleil.³⁸ This review and author expertise informed the development of a Return to Circus guideline for SRC (online supplemental appendix 2), including a discipline-specific progression through low, moderate and high-risk activities (online supplemental appendix 3). In addition, the working group identified circus-specific considerations needed for each CISG consensus statement subsection and then assigned members to draft these sections based on their expertise and supporting research. The section drafts were reviewed by each working group member before every meeting, and then a discussion to reach consensus on needed revisions took place during the subsequent meeting. Dissenting viewpoints and minority opinions were recorded and discussed. Anonymous voting was not possible due to the nature of the meetings and group formation; however, agreement was defined as a priori of 75% majority.

In the second stage, the Return to Circus guideline first draft was sent via email to four clinicians with expertise in circus arts and concussion rehabilitation (Elizabeth Corwin (EC), Ashleigh Flanagan (AF), Dawn Muci (DMc), Emily Scherb (ES); online supplemental appendix 1) for review and comment. SIRC working group members individually reviewed the comments before meeting to discuss and come to consensus on addressing the feedback. The Return to Circus guideline was then compiled with the other sections to create a complete first draft of the circus-specific extension statement.

In the third stage, the first draft was sent out to six external reviewers including clinicians and researchers with expertise in concussion and circus arts (Jay Mellette (JMe), Jo Montgomery (JMo), DMc, Jeff Russell (JR), Clea Tucker (CT) and Kathy Yu (KY); online supplemental appendix 1) for critical review and feedback. A similar process was followed, with the working group members individually reviewing and noting their response to the feedback, followed by a meeting to come to a consensus for revisions. The second draft was created from these revisions, which was circulated to the working group for comment and revision. A dance-specific concussion guideline³⁴ was published in December 2024 and incorporated into the final draft. Dissenting viewpoints and minority opinions were again recorded and discussed at this stage. The working group approved and accepted the final version of the circus-specific extension statement, based on a priori of 75% majority, which provides circus-specific considerations for SRC management to be used alongside the CISG 6th consensus statement.¹

Medicolegal considerations

This statement is not intended as a clinical practice directive or legal standard of care and should not be interpreted as such. The information conveyed is provided in good faith and without warranties of any kind, either expressed or implied. It does not constitute medical, legal or other professional advice or services. This document is a general guide, consistent with the reasonable practice of a healthcare professional (HCP). Individual assessment, treatment, management and advice will depend on the facts and circumstances specific to each individual case. Given the many different cultures, resources, healthcare systems and other factors to be considered when managing circus artists at risk of or who have sustained a concussion, the summary of evidence and recommendations from this extension statement can be used and adapted to inform local and regional processes.

Extension recommendations

Baseline testing

Preparticipation, or non-concussed state, baseline testing may be useful for the HCP to interpret postconcussion assessments by allowing for a comparison between the baseline and postinjury test performance. There is no consensus across sport for a particular testing regimen; however, baseline testing is increasingly common and widely accepted as best practice in professional sports such as the NFL, NHL and Australian Football League. In addition to the SCAT6/Child SCAT6^{27 28} for baseline testing, several computerised platforms are available (eg, Sway Medical (www.swaymedical.com), ImPACT (www.impactconcussion.com) and Cogsport (www.cogstate.com)). Incorporating the Vestibular Ocular Motor Screening (VOMS)³⁹ for circus artists should be strongly considered, given the extreme vestibular demands required to safely execute highly complex and multiplane circus skills. Special consideration should be given to artists with attention-deficit/hyperactivity disorder or a diagnosed learning disability as their baseline performance with the VOMS may be lower compared with community age-related norms.^{40 41}

Additionally, reaction time and balance assessment at baseline may enhance the validity of postinjury concussion diagnosis when used as a reference compared with using community norms.^{1 42 43} This has important functional implications for circus artists who often develop high levels of balance and reaction times to perform their skills. As such, reliance on community norms for the comparative standard may not be useful when dealing with such a unique and specialised circus athlete population.⁴⁴ Neurocognitive baseline test batteries which assess cognitive functions like memory, attention and decision making may also add value to assessing SRC and its sequelae, especially given the high load of cognitive symptoms often reported following concussion. However, there are limitations to this testing in the paediatric population due to ongoing cognitive development.¹ Regardless of the exact baseline test undertaken, the HCP should always interpret the results in the context of broader clinical findings, not in isolation, to inform management or diagnostic decisions.

Acute and postacute management

Overall, the management of SRC should be largely symptom-led, supported with objective clinical testing when possible and progressed with an abundance of caution. Impacts to the head, neck, face or body, which could potentially cause an SRC, are not uncommon in circus (table 1). When a concussion is suspected, basic first aid principles apply, including a systematic approach to the assessment of airway, breathing, circulation, disability and exposure.⁴⁵ Organisational concussion protocols should include stopping a class, show or competition, mid-performance when required, to safely assess the injured artist and determine the safest way to remove them from the area for further assessment. Before moving an artist, they should be screened for red flags using the CRT6²⁶ for non-HCPs and the SCAT6²⁷ or Child SCAT6²⁸ if an HCP is present including the acute assessment of awareness or Maddocks questions adapted for circus (Box 1). Cervical spine injuries should be suspected if there is any loss of consciousness, neck pain or an injury mechanism that could have led to spinal injury as per the Canadian C-Spine rules.^{46 47} If an HCP is present, they should follow the assessment procedures and clinical guidelines as directed in the SCAT6 and SCOAT6 protocols.^{27 29} For non-HCPs, a flow diagram (online supplemental appendix 4) is presented that can be used in conjunction with the CRT6²⁶ to guide acute management and a form (online supplemental appendix 5) that can be used for incident recording at the time of injury and initial assessment.

Table 1. Potential concussion injury mechanisms in circus arts.

Type of contact	Examples
No single identifiable event	Repetitive subconcussive impacts of an object, such as a staff, contacting the base of skull during manipulation.
Non-contact (single event)	An artist quickly rotates/flicks their head, causing a sudden torsional force to be transmitted to the brain.
Indirect contact through object	A sudden upward pull of the rigging lines as an aerialist is descending quickly, resulting in a rapid deceleration.
Indirect contact with ground	A ground acrobat flyer falls out of a hand-to-hand balance landing on the floor on their back, resulting in a whiplash movement of the neck.
Indirect contact through another artist	A dancer is struck in the back by a ground acrobat completing a tumbling pass, resulting in a whiplash mechanism.
Direct contact with an object	A musician standing on stage is hit in the head by a rolling cyr wheel.
Direct contact with the ground	An aerial acrobat incorrectly wraps the silks so they are not secure when performing a drop skill, resulting in a fall, hitting their head on the ground.
Direct contact with another artist	Two ground acrobats passing through hoops in opposite directions make contact resulting in a kick to the head.

Box 1. Acute assessment of awareness or Maddocks questions adapted for circus (for use with CRT6 and SCAT6).

• Each question should be modified for setting and age of circus artist being assessed.

• Concussion should be suspected with failure to answer any of these questions correctly.

  • Where are you training/rehearsing/performing today?

  • What discipline were you just training/rehearsing/performing?

  • Who is your coach/director today?

  • Where did you train/rehearse/perform last week?

  • When was your last class/performance before this one?

A key concept of appropriate acute management for non-HCPs is, ‘when in doubt, sit them out’. Following the initial screening and when it is safe to do so, any circus artist suspected of sustaining a concussion should be moved to a quiet area for a ‘sideline’ assessment. The artist should not be permitted to return to any physical activity until they have been evaluated by an appropriately qualified HCP. The CRT6²⁶ is recommended to be used by a non-HCP, such as a coach or trainer, to identify a suspected concussion. The SCAT6²⁷ and Child SCAT6²⁸ are to be used in the case of an on-site HCP and require a minimum of 10–15 min to be properly administered. The SCAT6/Child SCAT6 should not be used in isolation and should be followed later by a comprehensive examination including other objective testing such as a cranial nerve exam, VOMS,³⁹ orthostatic testing and other relevant neurological testing to diagnose a concussion. Prompt diagnosis based on a comprehensive evaluation by an HCP with appropriate training and experience in concussion assessment and management is critical to enable correct management and prevention of further injury.¹

Staged rehabilitation

A team of concussion-trained HCPs should supervise postconcussion rehabilitation in collaboration with coaches, artistic directors, and in the case of children and adolescents, their parents/guardians and teachers. Ideally, this HCP team might include a physician, physical therapist or athletic trainer, mental health practitioner and sports dietician.48,50 General principles of acute and postacute management of concussion should follow the CISG 6th consensus return-to-learn and RTS strategies.¹ The CISG RTS progression begins with a graduated return to aerobic and resistive exercise, followed by sport-specific activities that involve gradually increasing risk of head impact (eg, non-contact vs full-contact training). It is important to reintroduce exercise within 24–48 hours after injury, as graded aerobic exercise with only mild symptom exacerbation between days 2–10, postconcussion, can reduce the risk of PPCS.^{7 51 52} The Buffalo Concussion Treadmill or Bike Tests are highly recommended to determine individual exercise tolerance and heart-rate threshold for exacerbation of concussion symptoms, allowing for more precise individualised aerobic exercise guidelines.^{53 54}

The CISG return to learn strategies¹ are focused on return to school-based cognitive tasks, but the principles can also be applied to occupational cognitive tasks. Special consideration should also be given to the significant cognitive demands involved in circus arts training and performance. Circus artists are often required to learn and reproduce complex and elaborate choreography as part of their acts. These cognitive demands are regularly overlaid and integrated into physically demanding performance sequences. Circus artists are in many cases, therefore, subjected to multitasking cognitive demands, while concurrently undertaking considerable physically demanding tasks. Graded cognitive loading should form an important part of the staged rehabilitation, especially from a functional and performance perspective.

The proposed Return to Circus guideline (online supplemental appendices 2 and 3) builds on the CISG framework by providing a criterion-based progression for returning to circus training and performance after concussion and is intended to be applied across recreational to professional circus settings. It includes a novel progression of low, moderate and high-risk circus skills organised according to the previously described discipline subgroups³⁵ in place of the non-contact to full-contact sport progression and integrates the return to learn concepts for school, occupational and circus-related cognitive activities. Risk of head impact, collision or fall was considered in determining the risk categories and additionally the risk of secondary musculoskeletal injury, which is elevated while recovering from concussion.10,13 The Return to Circus guideline adds two additional stages to account for the circus performance context, as safe return to full training does not account for the unique cognitive and environmental demands of performance, for example, learning new choreography, movement dynamics, performance cues, exposure to music, stage lights, performing in front of an audience and costumes. The supervising HCPs should additionally integrate objective concussion-specific assessments to individualise rehabilitation and to address other symptom generators such as cervical spine, vestibular, oculomotor, autonomic nervous system, as well as balance, cognitive and psychological impairments.

The Return to Circus guideline adopts the CISG criteria for progression through stage 3 (online supplemental appendix 2), which includes a minimum of 24 hours and no more than mild symptom exacerbation with prescribed activities.¹ Mild symptoms are defined as an increase of less than or equal to two points from pre-exercise baseline of symptom severity based on a 0–10 scale (0 representing no symptoms and 10 representing the worst imaginable symptoms) and the symptoms lasting less than 1 hour.¹ Criteria to proceed to stage 4 (online supplemental appendix 2) includes an absence of concussion symptoms with physical or cognitive activities, or any abnormalities on related objective concussion testing. Following the Return to Circus guideline, the earliest return to full training would be 8 days postinjury and 9 days for performance. However, symptoms and recovery from concussion are unique and variable, so artists and coaches should understand that appropriate progression through each stage often requires more than 1 day and, therefore, longer than 8–9 days to safely return to full training or performance. It is acknowledged that some professional sports settings with an on-site HCP team with concussion training and a structured concussion management plan choose to use an accelerated/enhanced RTS protocol, with earliest return of 6 days postinjury.⁵⁵ Circus companies and professional organisations with access to an enhanced HCP management protocol may also choose to make similar decisions about their individual RTS protocols based on their available resources, baseline testing, clinical skill sets and overall risk management assessment.

HCP reassessment and clearance is considered most critical before moving a circus artist from stage 5 moderate risk circus skills to stage 6 high risk circus skills (online supplemental appendix 2) to best align with current international sports and dance protocols. Though in cases with accessible healthcare, an HCP should be providing reassessment and guidance throughout the course of recovery for a circus artist. This is consistent with the dance guideline³⁴ that recommends HCP clearance before moving to high-risk activity and concomitant heightened physiological load. It is also consistent with sports guidelines, where similarly, the CISG recommends medical clearance before progression from moderate aerobic exercise to individual sports-specific exercise that may involve the risk of inadvertent head impact¹ and the Australian Sport Commission concussion guideline which places HCP checkpoint clearance before an athlete’s return to contact and high-risk activities.⁵⁶

There are additional considerations with applying the examples of low, moderate and high-risk activities (online supplemental appendix 3) during the progression of circus skill training. Risk level for different individuals performing the same skills/acts will vary based on the experience and skill level (eg, a back handspring may be high-risk for a novice ground acrobat but considered low risk for a professional). Therefore, when structuring the skill portion of the return to circus progression, the supervising HCP should collaborate with artists and coaches to understand the breadth and proficiency of skills that the individual was regularly training or performing prior to the concussion. In addition, introducing new skills or choreography is not recommended until stage 7 due to the higher cognitive demand.²¹ Supervision and spotting during skill progressions is also recommended, as well as the use of safety equipment such as crash mats and spotting lines as appropriate to minimise the risk of a head impact or other injury. Finally, full return to circus is considered stage 7 for individuals not currently involved in a show or performance, with an additional stage 8 that applies only to artists returning to performance.

Additional considerations for youth or artists without HCP access

Significantly less is known regarding the rates, progression and management of concussion in youth athletes below age 18 years compared with adults.^{1 9} Prevalence of concussion in youth athletes may range 10–18% or higher due to under-reporting.4157,59 However, there is also a growing body of evidence to suggest that symptom resolution and time to full recovery may be prolonged in the youth athlete compared with adults,^{57 60 61} so some guidelines require a greater time interval between steps for youth athletes.^{31 56 62} The Australian Sports Commission guideline requires athletes under age 19 and those without a dedicated HCP to guide recovery to have no resting symptoms for 14 days before return to contact training and a minimum of 21 days from concussion for return to competitive contact sport.⁵⁶ A similar differential exists between athletes under age 16 and adults in the English Football Guidelines.⁶²

Within the context of youth circus artist concussion management and those artists without a dedicated HCP with experience in circus arts and concussion management, an abundance of care should guide any decision making. Progressions between stages may need to be slower; careful consideration of the broader psychosocial presentation must be understood, and a clear appreciation as to the level of risk activities the artist is seeking to return to must be established (online supplemental appendix 3). It is likely that a longer recovery time may be expected for both cohorts in this example, and that time and skill progressions between stages may need to be moderated.

Prognostic factors

Individual symptom presentation and recovery time including full RTS varies widely with SRC; however, it is still helpful to have benchmarks for comparison. Across the literature, recovery timelines in older studies may be skewed by early RTS when athletes were still symptomatic, which is now strongly recommended against. A systematic review evaluating RTS after SRC found the median time was 21 days in 80% of included studies,⁵ and in a large study of collegiate athletes, 1 month postinjury was the threshold for 85% of athletes achieving full RTS.⁸ However, 20–30% of children, adolescents and college athletes have persistent symptoms beyond 1 month.^{6 9} One challenge is that clinical assessment to determine full recovery is not standardised. It may include symptom severity (eg, SCOAT6²⁹/Child SCOAT6³⁰ symptom evaluation), neurocognitive testing (eg, SCOAT6²⁹/Child SCOAT6³⁰ cognitive tests, Sway Medical testing, ImPACT testing), vestibulo-oculomotor assessment (eg, VOMS),³⁹ balance testing (eg, Modified Balance Error Scoring System, tandem gait) and dual tasking assessment.¹ This further highlights the utility of baseline testing to have a comparison to more accurately guide clinical decision making and progression. The CISG recommends three components to evaluate clinical recovery: symptom report assessment, symptom-specific measures for ongoing symptoms and return to learning/sport measures.¹ Additional assessment to account for behavioural, psychological and social factors in recovery, including fear, should also be considered.^{63 64}

Several extrinsic and intrinsic factors can increase the time to recover from concussion. Continued sport participation and delayed access to healthcare after concussion is associated with a prolonged recovery.⁷ A large study in college athletes and military academy cadets with SRC found that for every 30 min of continued participation after injury, time to symptom resolution increased by 8.1%.¹⁵ Delayed symptom reporting was also associated with greater symptom burden and longer recovery.¹⁵ Intrinsic factors associated with an increased risk for developing PPCS include the development of headaches or depressive symptoms in the subacute stage, history of previous concussion or mental health disorders, especially depression.⁶⁵ High school or teen athletes, female sex and post-concussive symptoms of depression are also factors associated with higher risk of PPCS.^{9 65 66} The Predicting and Preventing Post-concussive Problems in Pediatrics (5P) score is an assessment tool using nine variables: age, sex, prior concussion and migraine history, as well as early signs and symptoms including slow question response, headache, fatigue, sensitivity to noise and balance impairments. It can be used as an early predictor of PPCS in youth athletes and could reasonably be applied to youth circus.^{67 68} Very little is known about PPCS in the circus arts specifically, but it is reasonable to expect that circus artists suffering PPCS will be faced with similar physical, cognitive, behavioural and emotional symptoms as those seen in the general athletic and sports population. A case study of a professional circus artist with PPCS following multiple concussions detailed a constellation of ongoing physical and psychosocial symptoms including fatigue, lack of focus, loss of consciousness during performance, social isolation and denial of injury,¹⁶ similar to the presentation of PPCS in athlete populations.

A second head impact before recovery from SRC symptoms may have the most serious potential consequence for prognosis for recovery. Second impact syndrome is a rare condition with mixed definitions in the literature.^{14 69 70} It may occur when a second head trauma is sustained before full resolution of an existing concussion and can result in catastrophic cerebral oedema, leading to death in more than half of the reported cases.⁷⁰ The typical characteristics for susceptibility include male sex, age 13–24 and involvement in contact sports like American football, rugby, boxing or ice hockey.^{14 70} Although there are no published cases of this in a circus context, strong consideration should still always be given to avoid secondary head trauma until SRC symptoms resolve.

Prevention/risk reduction

The CISG guideline recommends prioritising primary concussion prevention in sports to decrease injury burden, citing the impact of policy changes, protective equipment and training strategies that have reduced concussion rates in ice hockey, rugby and American football.^{1 71} While the lack of circus-specific SRC risk reduction research constrains the recommendation of specific strategies for circus artists, it is worthwhile to consider what has been effective in sports. For example, neck strengthening can reduce the risk of concussion in certain athletes,^{72 73} and neuromuscular warm-up programmes have been effective in reducing concussion rates in rugby.⁷⁴ Many circus arts disciplines and apparatus have a fall risk or require artists to train and perform at height. Falls are often associated with concussion; therefore, safety measures should aim to reduce the risk of falls. For example, appropriate equipment maintenance including rigging checks, appropriate skill progression, proper instruction for skills performed at height and use of mats and/or spotting could be relevant safety measures to reduce the risk of falls.

Limitations/barriers

As previously noted, a limitation to this guideline is the lack of concussion research in the circus context. Research to guide appropriate management of concussion in para-athletes is also lacking overall,^{1 75} and this circus-specific extension may also need to be further adapted for optimal concussion management in para-artists. Assessment tools such as the SCAT6²⁷/SCOAT6²⁹ are available in English and have been translated into some other languages; however, circus is a global art form and the recommended assessment tools may not be available in the artist’s native language, limiting their utility in some circus settings. In a performance environment, pressure for ‘the show to go on’ may be a barrier to take the time to properly administer the SCAT6,²⁷ Child SCAT6²⁸ and other assessment tools. This has been demonstrated in professional sports environments where inadequate assessment has been performed, and players are returned to play in a game with concussion.⁷⁶ The SIRC working group and our expert reviewers were clinicians and researchers from different disciplines, but only 4 countries (USA, Canada, Australia, UK) were represented, potentially limiting the generalisability of this statement globally. This extension statement may provide a source of standardisation that circus professionals in other regions can use to further progress this important area of healthcare. A barrier to the implementation of the Return to Circus guideline is the availability of concussion-trained providers to perform objective testing to individualise the rehabilitation process and safely guide the progression. In this instance, some artists or coaches without these resources may be left to implement this progression with only symptoms as a guide.

Conclusion

This is the first specific guideline for the management of concussion in circus arts. The circus-specific extension is intended to be used in conjunction with, and as an adaptation to, the recommendations of the CISG 6th consensus statement on concussion in sports.¹ It includes considerations around physical and cognitive demands of acrobatic movements and the context of a circus training and performing environment related to baseline and postinjury assessments, as well as rehabilitation postinjury. This guideline should be updated as research emerges on the epidemiology and management of concussion in circus artists. The recommendations in this extension guideline should be used by circus organisations to assist in the development of policies and standards for concussion management and for clinicians to assess and rehabilitate circus artists after a suspected or diagnosed concussion.