Concussion

Concussion in sport has gained much attention over the recent years. A lot of research has gone into identifying and prevention concussion which is now much better understood.

On this page:

  • What is concussion?
  • Recognising concussion
  • Have I got concussion?
  • Treatment for concussion
  • When can I return to play?

What is concussion?

  • A sports-related concussion has been defined by the Concussion In Sport Group (CISG) as a ‘traumatic brain injury induced by biomechanical forces’. In laymans terms this means trauma to the brain from impact or shaking.
  • It may be caused either by a direct blow to the head, face, neck or any other part of the body, which results in sudden force transmitted to the head.

Always treat a concussion seriously. Even mild symtoms can cause much longer term problems or mental health issues.

  • A concussion can result in rapid onset of short-lived impairment of brain function. Often it occurs spontaneously, but in some cases, features of a concussion can evolve over several minutes or even hours hours.
  • Symptoms are mainly due to a disturbance or disruption in how your brain functions and not due to a structural injury. Therefore, routine neuroimaging (MRI scans) will not show any abnormality.
  • Concussion results in a range of clinical signs and symptoms which could, but not always involve loss of consciousness.
  • It is mainly seen in contact sports like rugby, American football, and ice hockey, but is not limited to them.

Recognising Concussion

Several domains are used in recognising a concussion. This include symptoms such as headache, neck pain, nausea or vomiting, dizziness, blurred vision, sensitivity to light, sensitivity to noise, feeling slowed down, fatigue or low energy. Often athletes would say they are feeling like “in a fog”, “don’t feel right” or have “pressure in the head”. Some of them could be drowsy or confused. Some present with being more nervous or anxious as usual, more emotional, sad or irritable. Sleep disturbance is also common with trouble falling asleep. On testing, they may show impairment in balance as well as cognitive impairment with difficulty concentrating or remembering.

These features are not specific to a concussion and therefore are not diagnostic. It has been reported that the severity of the symptoms can be a predictor of slower recovery from a concussion. While having a previous concussion is a risk factor for developing a future concussion, having multiple previous concussions can be associated with having more physical, cognitive and emotional symptoms.

Assessment of concussion

There is no perfect diagnostic test to immediately diagnose a concussion. Therefore, if a concussion is suspected, 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 under no circumstances, should the athlete return to playing the sport until they have been fully assessed by a doctor.

How do I know if I have concussion?

Doctors may use a test called “SCAT5” to assess a possible concussion. SCAT stands for Sports Concussion Assessment Tool developed by the CISG and is currently in its 5th edition 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 a 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. Certain sporting bodies have their own tools to assess head injuries (e.g.: Head Injury Assessment Tool 1,2 & 3 introduced by World Rugby to be used in elite professional rugby teams)

The doctor will perform the immediate or on-field assessment part of SCAT5 soon after the incident and then repeat the test in a distraction free environment. It may be repeated over a period of several days or weeks until the results are back to normal. It should be noted that this may take several weeks to normalise.

SCAT5 is a tool that should be used by doctors or 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 a concussion.

Treatment for concussion

There is no specific treatment for a concussion. The current recommendation is to rest during the initial 24-48 hours following the injury and gradually and progressively becoming more active but staying below a threshold level of physical and cognitive activity which might bring on or worsen any symptoms.

As concussion can result in diverse symptoms and problems and can result in concurrent injury to the cervical spine and peripheral vestibular system, a variety of treatment modalities may be required to address these.

An adult athlete who continues to have symptoms after 2 weeks of the injury (>4 weeks in children) is said to have ‘persistent symptoms’ and may require a referral to a specialist based on the on-going symptoms.

Return to Play (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 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 several 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 teammates 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 is outlined below:

Stage 1 – When the athlete does not have any symptoms at rest, they may be able to start daily activities (getting back to work/school) that do not provoke symptoms.

Stage 2 – Light aerobic exercises like walking or stationary cycling at a slow to medium pace to increase the heart rate.

Stage 3 – Adding movement with sport specific exercises like running or skating drills.

Stage 4 – Increasing exercise, coordination and thinking by carrying out non-contact training drills and introducing progressive resistance training.

Stage 5 – Restoring confidence in full contact practice by taking part in normal training activities

Stage 6 – Returning to normal game play

There should be at least 24 hours before progression to the next step. Most importantly, if symptoms worsen during any of these steps, the athlete should drop back to the previous asymptomatic stage.

It is also important that the athlete is symptom free when they are not on in medication which may mask or modify any of the symptoms.

Remember that all 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 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 several high-profile cases in the media where athletes have reportedly suffered from 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 sportsmen 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 of Concussion

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 a 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.
  • The 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 a 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 the 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 for Concussion

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 gameplay still occurring.
  • R for a 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 breathe 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 the 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 SCAT5 assessment tool or concussion and once a concussion has been fully assessed, then the patient will be continually monitored right up until full recovery (see treatment and return to play).

References

  • McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 Br J Sports Med 2017;51:838-847.
This article has been written with reference to the bibliography.