Concussion in sport – more than just a headache

What is Concussion?

A concussion is a type of traumatic brain injury caused by a coup (acceleration) and counter coup (deceleration) motion whereby the brain makes a forceful impact with the front of the skull, and then again at the back of the skull. A concussion does not necessarily mean there is a blow or impact to the head. Examples of concussion could be in the form of a hard tackle in Rugby, or in the event of a car crash.

Concussion results in a metabolic energy crisis. During the acute phase of concussion, the brain is highly susceptible to further injury, therefore it is critical to recognize and manage early on. MRI or CT scan will not diagnose a concussion as it is a chemical injury to the brain. However advanced imaging will show any internal bleeding or fractures that may be present.

The visual system is a major player in concussion. 70% of sensory processing in the brain is dedicated to visual information. 9 out of the 12 cranial nerves are involved in vision. Up to 90% of concussions manifest at least one oculomotor dysfunction (vision problem) (Ciuffreda et a. 2007). Common visual impairments post concussion include:

• Disorders of visual tracking and fine eye movements
• Difficulty focusing
• Convergence insufficiency: When your eyes are unable to work together
• Visual motion sensitivity
• Peripheral/spatial awareness issues

Clinical conceptual plan for on site concussion management:

1. RECOGNISE a concussion:
   1. Concussion symptoms: & symptoms impaired (see table below).
   2. Remove from play entirely. “When in doubt, sit them out.” Remember; if the brain has suffered a concussion, it is highly susceptible to further injury
2. ADDRESS early:
   1. Educate
   2. Objective assessment
   3. Follow concussion criteria to plan return to sport (see criteria below)
3. ASSESS
   1. First aid/CPR
   2. Rule out red flags
   3. Identify symptoms affected, treat symptoms impaired
   4. Monitor symptoms

Concussion symptoms: & symptoms impaired

See next our in depth management of concussion using our concept plan above:

1. Immediate sideline evaluation:

Red flags: 

•  ​Neck pain or tenderness
• Double vision
• Weakness or tingling / burning in arms/legs
• Severe or increasing headache
• Seizure or convulsion
• Loss of consciousness
• Deteriorating conscious state
• Vomiting
• Increasingly restless, agitated or combative

Observable signs 

• Lying motionless on playing surface
• Balance/gait difficulties / motor incoordination: stumbling, slow/laboured movements
• Disorientation or confusion, or an inability to respond to appropriate questions
• Blank or vacant look
• Facial injury after head trauma i.e. Blood, fractures, teeth, punctures, eye injury, lacerations etc

Memory assessment – Maddocks question 

• Tell me what happened
• What venue are we at today
• Which half is it now
• Who scored last in this match
• What team did you play last week / game
• Did your team win the last game

Cervical spine assessment 

• Does the person/athlete report that their neck is pain free at rest
  • If no – does the person/athlete have full range of ACTIVE pain-free movement?
• Is the limb strength & sensation normal?

2. Symptom evaluation 

3. Cognitive screening 

Orientation 

• What month is it
• What is the date today
• What is the day of the week
• What year is it
• What time is it right now (within 1 hour)

Immediate memory 

• List of specific 5 or 10 word per trial list (e.g. finger, penny, blanket, lemon, insect) → ask person/athlete to repeat as many words in any order

Concentration

• Count digits backwards – e.g. say 3-8-1-4 & person/athlete repeats numbers in opposite order
• Months in reverse order

4. Neurological screen

• Full range of pain-free active and passive cervical spine movement
• Without moving their head or neck, can the patient look side-to-side or up & down without double vision
• Finger nose coordination test
• Tandem gait

Balance assessment 

• Double leg stance
• Single leg stance (non-dominant foot)
• Tandem stance (non-dominant foot at back)

Concussion injury advice summary:

• If you notice any change in behaviour, vomiting, worsening headache, double vision or excessive drowsiness, please telephone your doctor or the nearest hospital emergency department immediately.
• Initial rest: Limit physical activity to routine daily activities (avoid exercise, training, sports) and limit activities such as school, work, and screen time to a level that does not worsen symptoms
  • Avoid alcohol
  • Avoid prescription or non-prescription drugs without medical supervision. Specifically:
    • Avoid sleeping tablets
    • No aspirin, anti-inflammatory meds or stronger pain meds such as narcotics
  • Don’t drive until cleared by healthcare professional
  • Return to play/sport requires clearance by healthcare professional

Book Here to have us assess and manage your concussion.

Concussion resources:

• (a) Consensus Statement on Concussion in Sport: The 5th International Conference on Concussion in Sport held in Berlin, October 2016 (McCrory et al) http://bjsm.bmj.com/content/51/11/838
• (b) Pocket Concussion Recognition Tool, found here: http://bjsm.bmj.com/content/bjsports/47/5/267.full.pdf
• (c) SCAT 5 – Sport Concussion Assessment Tool – 5th Edition, found here: http://bjsm.bmj.com/content/bjsports/51/11/851.full.pdf
• (d) Child – SCAT5- Sport Concussion Assessment Tool (for children ages 5-12 years), found here: http://bjsm.bmj.com/content/bjsports/early/2017/04/28/bjsports-2017-097492childscat5.full.pdf
• (e) Concussion in Sport Australia Position Statement (November 2018) (Elkington, Manzanero and Hughes), found here: https://www.concussioninsport.gov.au/home#position_statement
• (f) Graduated Return to Play Protocol (Annexure 1 to this Concussion Policy)
• (g) Graduated Return to Play Protocol – Children and Adolescents (Annexure 2 to this Concussion Policy