What is a concussion?

Concussion is defined as a “complex pathophysiological process affecting the brain, induced by traumatic biomechanics features :

1. Caused by either a direct blow to the head, face, neck or elsewhere in the body with an “impulsive force transmitted to the head.”
2. Results in a rapid onset of short lived impairment in neurological function that resolves spontaneously.
3. Functional disturbance, rather than a structural injury
4. Results in a graded set of clinical symptoms that may, or may not, involve loss of consciousness.
5. No abnormality on standard neuroimaging is seen in a concussion (1)

Concussion Rates in school sports

It was recently estimated that 3.8 million recreation and sport related concussions occur annually in the United States (2).

A lack of a proper Injury tracker in youth sports (2), makes this number in accurate for concussions in the paediatrics population, however, highlights the need for school injury surveillance to be able to quantify concussions in this population group. 

Represents approximately 8.9% of all high school injuries in the USA. (3) 

The 6 R’s of concussion (4)

Recognize

1. The suspected diagnosis of a concussion can include one or more of the following domains
   1. Symptoms – Somatic(headache), cognitive (feeling in a fog) and/or emotional symptoms (labile mood)
   2. Physical signs (loss of consciousness, amnesia)
   3. Behavioral changes (Irritability)
   4. Cognitive impairment (slowed reaction times)
   5. Sleep disturbance (Insomnia)

1. On field care
   1. Clear indicators of a concussion – immediate removal from field of play (What you see) (4)
      1. Seizure (fits)
      2. Loss of consciousness – confirmed or suspected
      3. Unsteady on feet or balance problems or falling over or poor coordination
      4. Confused
      5. Disorientated – not aware of where they are or who they are or the time of day : Dazed, blank or vacant look
      6. Behavioural changes e.g. more emotional or more irritable
   2. Suggestive of a concussion (What you see) (4)
      1. Lying motionless on ground
      2. Slow to get up off the ground
      3. Grabbing or clutching of head
      4. Injury event that could possibly cause concussion
   3. Symptoms of a concussion (What you are told) (4)
      Headache
      Dizziness
      Mental clouding, confusion, or feeling slowed down
      Visual problems
      Nausea or vomiting
      Fatigue
      Drowsiness / Feeling like “in a fog“ / difficulty concentrating : “Pressure in head”
      Sensitivity to light or noise
      Difficulty concentrating
      
      

Remove from field of play immediately if concussion is confirmed of suspected

Re-evaluate/Refer

1. Patients who have had a concussion or suspected concussion should not be placed back on the field until being evaluated by a trained health care practitioner.
   1. Clinical evaluation should be done including the latest SCAT 5
   2. Determination of the clinical status of the patient – has the patient improved or worsened
   3. Determine the need for further concussion investigations
      1. Neuropsychiatric testing – done to evaluate the patients cognitive recovery. According tho the Berlin consensus, it forms a “cornerstone” of concussion management, however, it should never be used as the sole diagnostic marker for a concussion. 
      2. In cases of a structural brain injury being suspected, CT scans are the most predictive in assessing fractures and intra-cerebral bleeds. Generally patients with underlying structural damage deteriorate over the course of the injury. (2) 

Rest

1. Cognitive rest
   1. Due to the functional nature of the brain injury, athletes often have trouble with focusing at school, taking tests and trying to keep up with assignments.
      1. Rest may include temporary leave from school, shortening of the athletes school day ,reduction in work loads.
      2. Taking standardized tests while recovering should be discouraged because lower than expected scores can occur.
      3. Other activities which can exacerbate symptoms such as video games, playing on a laptop etc should be avoided to ensure symptoms do not worsen. (2)

Return to school strategy (5)

1. Physical Rest
   1. Physical rest is required to restore the energy imbalance following the concussion. 
   2. The exact amount of rest still needs to be adequately defined (5), however, a good guideline is 14 days for athletes under the age of 18. Following this minimum “stand down period” (3), athletes can enter their graded return to play.
   3. It can take some athletes under 18 almost 4 weeks to recover from a  concussion. Age appropriate symptom scores should be used (Child SCAT 5)
   4. Patients should have total rest for 24-48 hours after which they can gradually increase activity as long as it does not exacerbate symptoms.

Return to Play/Rehabilitation

1. “When in doubt, sit them out”
2. Although a vast majority of patients with a concussion will become asymptomatic within a week of their concussion numerous studies demonstrate a longer recovery of full cognitive function is required as compared to adults – 7-10days longer. (5)
3. Graded Return to play protocol should be employed once the patient is symptom free. It will take an athlete a minimum of 5 days to progress through the protocol to resume full game participation, provided symptoms don’t return. If symptoms re-occur, the patient is required to go back to a previous stage before progressing.

References

1. McCrory et al. Br J Sports Med. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Berlin, October 2016
2. Halstead et al. Sport related concussion in children and adolescents. American Academy of Paediatrics, Volume 126, (3) September 2010
3. Gessel et al. Concussion among United States collegiate athletes. J Athl Train.2007:42 (4):495-503 
4. World Rugby Concussion guidance, implemented 01 August 2015
5. McRoy et al. Br J Sports Med. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016.