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Concussion in sport: a medical perspective

Key learning points:

- Recognise the signs and symptoms of a sports concussed patient

- Be aware of the implications a sporting concussion has on a patients health

- Understand how to treat a patients suffering from a concussion due to sporting activities

Concussion continues to be the predominant medical condition of concern in world sports. In the last month alone there have been three high profile cases, which have featured heavily in the media (George North-Wales Rugby, Mike Brown-England Rugby and Fernando Alonso-Formula 1).

The problem is becoming more evident through the injury surveillance systems that have been put in place: in 2013-2014 season in English professional rugby there were on average 10.5 concussions per 1,000 playing hours.

In comparison there were 17 concussions per 1,000 hours in professional boxing and 25 incidents per 1,000 hours in jump horse racing. These figures are in part due to a greater awareness by all in the sport including players, coaches and officials, through organised education, media coverage but also due to a lower threshold for diagnosis by healthcare professionals.

With the focus on the highest echelons of sports it is easy to forget that concussion is not isolated to elite sport, or to sport for that matter, and as primary healthcare professionals it is very likely that we may be required to recognise and manage this in our patient population.

What is a concussion and how do you recognise it?

A concussion is a traumatic brain injury that is caused by a direct blow to the head, face, neck or an indirect force such as a hit to the body. It typically results in the rapid onset of neurological dysfunction that resolves spontaneously but in some cases symptoms and signs can take several hours to evolve. Contrary to popular belief less than 10% of concussions involve a loss of consciousness and these can be so momentary that they can be missed altogether.

To date there is no objective clinical test, or imaging that can confirm the diagnosis of a concussion hence it is fundamentally down to the clinician's experience, which introduces the variable of human interpretation. In order to reduce the subjectivity an international consensus has come up with a list of signs and symptoms that if present will most likely confirm the diagnosis (see Table 1).

The features that are assessed can be divided into symptoms (such as headache and/or dizziness), physical signs (imbalance), cognitive impairment (difficulty remembering), mood and sleep disorder. These features make up the basis of the sideline concussion assessment tool (SCAT3) that is now commonly used across most sports to support the diagnosis.

Unfortunately as symptoms are non-specific and in some cases can take several days to manifest making an acute diagnosis can be difficult. As a result the recommendation is that if there is suspicion of a concussion the individual should be permanently removed from the activity.

Women and children first

Although concussion is synonymous with collision sports it is not isolated to it. In fact it seems children (including adolescents) and females are more susceptible to developing the condition. The reasons for this are not entirely clear but one suggestion is that because a child's head is proportionately significantly heavier than the rest of their body compared to the adult's it makes them more prone to head and neck injuries.

A child's skull is thinner making the brain more susceptible to a direct blow. Moreover, the child's brain is in a state of development continuing to make nerve connections with growth and new experiences. Disruption could potentially hinder this process.

Popular explanations for why females have double the risk their male counterparts do in a given sport again relates to the head/neck size and musculature; it is believed that girls have smaller, weaker necks making their heads more susceptible to trauma.

There is a possible hormonal influence; if injury occurs in the premenstrual phase when progesterone levels are high there is an abrupt fall in the hormone, which causes a hormonal withdrawal that, may cause or accentuate symptoms like headache, dizziness and trouble concentrating. This may be the reason why women's symptoms last longer compared to men who have low pre-injury levels of progesterone. This supposed elevated sensitivity to the symptoms may also mean that girls are more likely to report them.

Acute management and return to activity

Initial management is focused on a period of relative physical and cognitive rest, meaning that the patient should try to limit activities that stimulate the mind such as excessive use of personal electronic devices, watching television or even driving. Once the symptoms have completely resolved the individual undergoes a programme of gradually increasing stimulus before they are medically cleared to return to all activities.

The analogy I tend to use is following a muscle injury in the leg; a player will rest the area before gradually increasing their activity before resuming playing. For concussion this usually requires starting with a simple exercise, like stationary cycling for 20 minutes, progressing to increasingly complex activities till the individual is able to do everything without symptoms.

Usually there is a 24-48 hour period between each progression, depending on the patient's age, to see if symptoms recur and in such cases the individual is put back to the previous stage of the protocol. For children a sensible approach is a gradual return to school and social activities before returning to sport.

To ignore symptoms or to rush a player back to sports before they are recovered, which is the concern in professional sports, puts them at a higher risk of developing another concussion due to impaired decision-making, impaired reactions and reduced awareness, akin to driving intoxicated. At worst, to continue to play with a concussion puts the patient at risk of developing a second-impact syndrome causing rapid swelling of the brain, which can be fatal.

Are there different types of concussion?

Generally there as been a move away from describing concussions as mild or severe for fear of trivialising it.

A major concern about the sequelae of concussion is that it may result in chronic neuropathological conditions including early dementia. Although a number of high profile cases of retired National Football League (NFL) players in the US with the condition of chronic traumatic encephalopathy have been reported, presently it is unclear who will go on to develop this.

Another complication is a post-concussive syndrome in which the individual may suffer from prolonged symptoms, which can last for several months and significantly affect their quality of life. Again it is unclear who will be afflicted in such a manner although there are potential factors that if present can lead to a protracted recovery:

- Multiple previous concussions.

- Increasingly less force required to cause a concussion.

- History of migraine, epilepsy, meningitis/encephalitis.

- History of anxiety, depression or sleep disorder.

- Presence of a learning disability such as dyslexia, attention deficit hyperactivity disorder.

Between 80-90% of acute concussions have an uncomplicated recovery generally resolving in seven to 10 days. These are simple concussions the majority of which can be looked after by their general practitioners ideally with experience of looking after patients with the condition. Where this is not available a sports and exercise medicine consultant with experience in collision sports or a neurologist/neurosurgeon should be sought.

For the small proportion of patients whose recovery is not so straight forward such cases are best managed by a multidisciplinary team. These complex concussions may require the input of a neuropsychologist, vestibular-cochlear rehabilitation specialist, neurologist and/or exercise medicine consultant to help them feel themselves again and get back to their activities.

The Institute of Sports, Exercise and Health (ISEH) in collaboration with the National Hospital for Neurology and Neurosurgery, is establishing a concussion service to address this obvious public health need. The service will initially be in the private sector with the view to roll it out in the public sector. In addition through establishing a national initiative the experts at ISEH will be looking to carry on research into the diagnosis and management of concussion.

Concussion in sports is highly emotive and the ideal management is still unclear.

The media coverage it continues to get worldwide serves to increase awareness of the condition, which should hopefully drive progress in it's management, and as importantly cause a change in the attitude of people/players that have not historically taken it seriously.


For more information about concussion, a graduated return
to activity protocol the SCAT3 for adults and children follow
the links: