Concussion

Concussion

Concussion is a very serious condition that is often seen in sport and more and more incidents are being reported in sport. It can range from very mild to very severe depending on the circumstances and it is usually caused by a sudden impact to the head from a traumatic (contact) event.

Severe concussions can result in permanent brain injury or even death so all head injuries MUST be taken seriously. Concussion is an injury to the brain caused by a direct blow to the head. It can, but does not always, involve loss of consciousness and symptoms can include headaches, dizziness and sickness but the level of these symptoms vary significantly depending on severity of injury

Symptoms of Concussion

Mild cases of concussion may include slight mental confusion (with possibly some memory loss), mild tinitus (or “ringing in the ear”), mild dizziness and/or a headache. There is also likely to be pain in the area of initial contact to the head. The athlete will often demonstrate a normal ability to balance and will usually not have lost consciousness during the incident. The degree of memory loss and ability to recall information will vary from athlete to athlete.

Moderate cases include symptoms such as mental confusion (with often some associated memory loss), moderate tinitus (or “ringing in the ears”), moderate dizziness and often a headache. Overall balance may be altered and the player may experience feeling nauseous (sick) or even vomiting (being physically sick). Loss of consciousness may have happened, but this will usually have lasted no longer than a few seconds. The degree of memory loss and the ability to recall information will vary from athlete to athlete.

Severe cases will more than likely result in a degree of mental confusion that may last for several minutes or hours. Ringing in the ears (or tinnitus) may be a symptom and often the athlete fails to recall events just prior to the impact. Loss of consciousness for several minutes is possible along with an associated increase in blood pressure and a decrease in heart rate.

Assessment

If concussion is suspected, then the athlete MUST be removed immediately from the training session or match, and MUST NOT be left alone. You should always seek professional medical advice to determine the extent of the head injury and in no circumstances, should the athlete return to playing sport until they have been fully assessed by a doctor.

Doctors may use a test called a “SCAT5 Test” to assess the extent of the head injury and possible concussion. SCAT stands for Sport Concussion Assessment Tool and has been developed over a number of years to be sensitive enough to detect subtle symptoms and monitor the progress of an athlete as they recover from a possible episode of concussion. The test is very detailed and consists of several questions and short physical and mental tests to assess the athlete’s symptoms, including their ability to balance and their ability to memorise and recall information.
The doctor will perform a SCAT5 test as soon after the incident as possible and then repeat the test over a period of several days or weeks until the results are back to normal. It should be noted that this may take a number of weeks to normalise.
SCAT5 is a tool that should be used by doctors and trained healthcare professional only, but for information purposes only, it can be downloaded here but remember, this must always be carried out by a medical doctor
For non-healthcare professionals, you can use the concussion Recognition Tool5 (CRT5) and this can be downloaded here and is a simplified version of the SCAT5 to assist in detecting if an athlete has suffered concussion.

Treatment – “Rest is Best”

The main treatment advice following a possible concussion involves resting from all activities until the symptoms have completely subsided. Rest includes both physical AND MENTAL activities, such as computer games, reading, school work and this is to ensure that the brain is not overworked and allows full cognitive recovery from the impact.

Return to Playing Sport (RTP)

Once all symptoms have completely subsided (and sometimes after a mandatory minimum period of rest), and only at this stage, the doctor will allow the athlete to slowly and progressively start exercising but he/she will be constantly monitored by the doctor to see if any of the symptoms reoccur.  If this happens, then the physical activity will have to stop immediately and the athlete will need to wait until the symptoms fully disappear again before starting re-starting the RTP process.  This will continue until the athlete can perform a progressive level of physical activity without any adverse reaction.  This process could take a number of weeks depending on the athlete and/or the severity of the initial concussion and this can be very frustrating to both the athlete and his/her team mates and coaches, however it is VITAL that this graduated RTP protocol is not rushed and is always supervised by a doctor or qualified healthcare professional.

A typical example of a graduated return to play protocol can be found in the Football Association “Guidelines on Concussion” and this can be accessed here by clicking here

1. When the athlete does not have any symptoms at rest, then they may be able to start light exercise which may include stationary cycling or walking.
2. The next stage would be to increase the intensity of the exercise to increase heart rate.
3. The next stage would be to include change of direction and more challenging activities.
4. The next stage would involve some sport specific on-field practice drills without any contact with opponents.
5. The final stage is full contact sport.

Remember that all of these stages must be closely monitored by the medical professional and symptoms need to be constantly assessed throughout. Although this may seem to be a very slow process to the athlete, the step by step progression is absolutely vital to the athlete’s health and must not be compromised or ignored, otherwise, the following conditions could develop….

Post Concussion Syndrome

This is a complication that may occur as a result of a head injury, and will involve other symptoms developing after the main symptoms of the original injury have gone. If the athlete experiences strange symptoms such as loss of taste or smell, anxiety or depression among a number of potential symptoms then they must seek medical advice immediately.

Read more on Post Concussion Syndrome.

“Second Impact” Syndrome (SIS)

This is a condition where a second impact takes place before the symptoms for the first hit have completely cleared up. This can cause a sudden swelling of the brain and can ultimately result in severe brain injury or even death. It can happen days or weeks after the first impact and there have been a number of high profile cases in the media in where athletes have reportedly suffered SIS. For this reason, and knowing that even the mildest of concussions can lead to SIS, is why all head injuries MUST be taken seriously.  There are a number of sports men and women who have died as a result of SIS and there are a number of associated legal cases that have taken place with this.

On field management

What to do if a head injury is sustained or suspected during a match or competition.
Remember, every time a player sustains a head injury during a game, they could be at risk of a more serious brain injury if not correctly diagnosed and treated. It is not always possible to carry out a full assessment at the time of the injury as the patient may be confused and difficult to examine, however any player that has suffered a suspected blow to the head must be treated as if they have concussion until proven otherwise.   This means stopping the physical activity immediately and, if safe to do so, removing them immediately from the field of play.
A more serious structural brain injury may be suspected if:

  • There has been a high-speed impact or trauma to the head or if the head makes contact with a hard surface or body part such as the knee.
  • Symptoms worsen over a short period of time, e.g. nausea or headaches.
  • The patient lost consciousness immediately after the impact (however short the time was), or they have fallen unconscious since.
  • The patient has a seizure or fit.
  • Bleeding or fluid leaking from the nose or ear which could be evidence of a skull fracture and needs immediate assessment by a qualified healthcare professional.
  • Focal neurological deficit is detected by the doctor when examining the patient. This means that the brain is not functioning normally and this may affect sensation or muscular movements anywhere in the body. It can also refer to memory loss and emotional changes.

If a player is suspected of having concussion then they should be fully assessed by a doctor as soon as possible and if they lost consciousness at any stage, then they must be taken to hospital so the athlete can be assessed fully. The doctor may decide (but not in all cases) to organise a brain scan to see if there has been any bleeding within the skull or brain and therefore if there has been any injury to the brain.

Immediate first aid

The priorities when approaching an injury are based on the principles of DR ABC but this assessment should only be carried out by a person who has completed an Emergency Aid training course.  
DR ABC stands for:

  • D for danger. Ensure the player and any staff assisting are not in further danger for example from any game play still occurring.
  • R for response. Is the player responding? Can they talk? Are they conscious?
  • A is for Airway. Remove any objects such as mouth guards from the mouth and ensure the airway is clear and in the optimized position.
  • B is for breathing. Ensure the patient is able to breath sufficiently.
  • C is for Circulation.  This can be assessed by feeling for a pulse, however If the patient is not breathing normally or not at all, then CPR must start immediately.

Once the above stages have been assessed, then the next priority is to remove the player from the field, but first checking for any neck or spinal cord injury. This may appear as tenderness in the neck, deformity, change in sensation in the arms or legs or if the patient complains of neck pain. If this is suspected then they should not be moved until they have been immobilized in a brace. If the patient loses consciousness at any stage during or after the impact, then a neck injury should always be suspected until it can be discounted.

If you are interested in attending a basic first aid training course, many organisations such as St John’s Ambulance, the RFU or the FA organise a number of courses every month in your local area (see websites for details).

Examination

If there is a doctor present pitch side and there is no neck injury suspected, then a full neurological examination will be carried out, usually back in the changing rooms where it is quiet. It is possible the patient may be disorientated, uncooperative or convulsing (fits). If a suitably qualified person is not present, then the patient should always be taken to hospital or an ambulance called.  It is vital to establish an accurate diagnosis, as the consequences of missing concussion or associated brain injury could be fatal (see SIS).

Doctors will use the SCAT3 assessment tool or concussion and once concussion has been fully assessed, then the patient will be continually monitored right up until full recovery (see treatment and return to play).

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