What is Concussion?
Head injuries themselves can be classified as mild, moderate or severe. True concussion is often defined as representing the immediate and transient symptoms of a mild traumatic brain injury (McCrory, Feddermann-Demont, et al., 2017) and sits in the mild category. The more significant, moderate and severe category is reserved for more structural brain damage.
Sports Related Concussion (SRC) is induced by biomechanical forces; either a direct blow to the head, face or neck or elsewhere on the body with impulsive forces transmitted to the head (McCrory, Meeuwisse, et al., 2017).
Incidence – Is it even an issue?
The incidence in contact sports such as Rugby and AFL as you would expect are significantly higher than those sports that do not involve contact. A systematic review of incidence of concussion in youth Rugby Union and Rugby League revealed ranges from 0.2 to 6.9 concussions per 1000 player-hours, equivalent to a probability for a player over a season of sustaining a concussion of between 0.3% and 11.4%. For rugby league there were two studies which reported 4.6 and 14.7 concussions per 1000, equivalent to a probability of 7.7-22.7% over a season! Surveys also revealed a staggering 48.1% of Irish players have already had at least one concussion previously. In a much higher population of South African players, the figure was 14.1%, however, other influences such as the style of game play due to conditions and reporting and recording could influence these regional variations. Concussion as a percentage of all injuries is reported to be from 2.2 to 24.6%. It is the most prevalent injury in professional rugby in England and figures suggest that 1-2 youth players in every youth rugby team will get a concussion each season (Kirkwood, Parekh, Ofori-Asenso, & Pollock, 2015).
HOW DO WE MANAGE THESE INJURIES – the 7 R’s
Recognition is the first step. Obviously, any impact injury to the head region would give you an immediate concern that a head injury has occurred. Loss of consciousness (LOC) is an immediate trigger and in these more severe instances, an experienced on-field medic should also consider injury to the neck. You may see any athlete with a reduced conscious state put in a rigid collar and placed on a spinal board until the conscious state improves and/or a cervical spine injury can be definitively excluded.
For less severe instances, there are many signs and symptoms that may be present that do not involve a LOC. For general untrained community recognition, the Pocket Concussion Recognition Tool (PCRT) is an excellent resource to assist with determining whether a concussion may or may not exist.
Generally, if there is any suspicion of concussion, albeit a very small one, the player should be removed from play. The player must at all times:
- Be in the care of a responsible adult
- Must not consume alcohol
- Must not drive a motor vehicle
Currently there is no evidence regarding the use of medications (Halstead, Walter, Council on Sports, & Fitness, 2010). The use of regular Panadol therefore can be used if required.
A player removed from the field with suspicion of concussion should be referred for medical consultation. The aim being to clinically confirm that a concussion did in fact occur. This is done most commonly by delivery of the Sports Concussion Assessment Tool (SCAT).
More obvious concussive episodes should be referred immediately to hospital ED.
Signs and symptoms that would trigger immediate primary care assessment include:
- All children with head injuries
- Severe neck pain
- More than 1 vomiting episode
- Inadequate post injury supervision. Monitor for deterioration min. 2 hrs.
- Skull fracture
- Deteriorating conscious state
- Obvious neurological signs; e.g. tonic posturing, balance disturbances
- Double vision
- Confusion or impaired consciousness > 30 mins
- Any convulsive movements
- Weakness or tingling or burning in arms or legs
Physical and cognitive rest is the most prescribed intervention. It may “ease discomfort during the acute recovery period (24-48hrs) by mitigating post-concussion symptoms and/or that rest may promote recovery by minimising brain energy demands following concussion” (McCrory, Meeuwisse, et al., 2017). This could include the potential that school work be reduced.
Early studies proposed adults could, on average, return to baseline in 7-10 days (Manzanero et al., 2017). More recently, the 2017 Berlin Consensus Statement defines expected time frames for normal clinical recovery to be different in adults (10–14 days) and children aged 18 or under (4 weeks)(McCrory, Meeuwisse, et al., 2017). As a result of the emerging evidence, each individual sport has established their own concussion return to play protocols (RTTP) and are worth reviewing on their particular websites. All protocols employ a period of rest according to age (19 or older = adult, 18 or younger = child), followed by a systematic and symptom-based approach to graded exercises resumption.
Rehabilitation involves a closely monitored, graded reinvolvement in aerobic exercise and ultimately physical contact. It may also involve specific physical and mental rehabilitation that addresses symptoms that may have resulted from the original insult e.g. cervical spine and vestibular concerns as well as any cognitive behavioural issues should they be present.
Below is a resource readily available from World Rugby that outlines this process.
Most sports organisations will require a medical clearance for return to play. Part of this involves having completed the GRTP protocol without symptoms. The minimum timeframe for a child (<19 years of age) is 19 days.
As a parent, after your child has been removed and referred for assessment, it really is almost up to you to manage your child’s ongoing concerns. Having a clear understanding of the process is crucial to preserve their ongoing physical and mental health and ensure they can return to full participation safely.
Injury Prevention Considerations
Concussion research is prolific and new findings are routinely coming to light which consequently informs best medical practise as well as sports specific rule making. Rugby has brought in more stringent head contact rules around tackling as well as introduced the blue card for referees to eject players on suspicion of head injury.
Contrary to popular belief, head gear used in rugby (and more recently other sports) has not been demonstrated to reduce the risk of concussion. A study by Menger et al reported 31.8% of collegiate players believed that it was protective of concussion and many players actually played more aggressively with protective head gear (Menger, Menger, & Nanda, 2016).
Whilst concussion in sport is very topical, the understanding of its management is still not necessarily well understood by all stakeholders. Arguably, the guidelines have changed so dramatically in the last 5 years that it can be challenging for organisations to disseminate new insights. Education to parents, coaches, players, teachers, referees, trainers along with medical professionals is key to appropriate management and the prevention of negative secondary sequelae and recurrence.
B.Phty, M. Phty (sport)
APA Sport & Exercise Physiotherapist
Halstead, M. E., Walter, K. D., Council on Sports, M., & Fitness. (2010). American Academy of Pediatrics. Clinical report–sport-related concussion in children and adolescents. Pediatrics, 126(3), 597-615. doi:10.1542/peds.2010-2005
Kirkwood, G., Parekh, N., Ofori-Asenso, R., & Pollock, A. M. (2015). Concussion in youth rugby union and rugby league: a systematic review. Br J Sports Med, 49(8), 506-510. doi:10.1136/bjsports-2014-093774
Manzanero, S., Elkington, L. J., Praet, S. F., Lovell, G., Waddington, G., & Hughes, D. C. (2017). Post-concussion recovery in children and adolescents: A narrative review. Journal of Concussion, 1. doi:10.1177/2059700217726874
McCrory, P., Feddermann-Demont, N., Dvořák, J., Cassidy, J. D., McIntosh, A., Vos, P. E., . . . Tarnutzer, A. A. (2017). What is the definition of sports-related concussion: a systematic review. Br J Sports Med, 51(11), 877-887. doi:10.1136/bjsports-2016-097393
McCrory, P., Meeuwisse, W., Dvořák, J., Aubry, M., Bailes, J., Broglio, S., . . . Vos, P. E. (2017). Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med, 51(11), 838-847. doi:10.1136/bjsports-2017-097699
Menger, R., Menger, A., & Nanda, A. (2016). Rugby headgear and concussion prevention: misconceptions could increase aggressive play. Neurosurg Focus, 40(4), E12. doi:10.3171/2016.1.FOCUS15615