By; Dr. Alan Hetherington/ Sports Injury Writer
Sports related concussions are a growing concern in the world of athletics and affect athletes of all ages. Remaining up to date on identification and management of sports related concussion ensures parents, athletes, and coaches follow an appropriate recovery plan for the long-term well being of the athlete. A 2022 update by The Concussion in Sport Group defined sport related concussion as a traumatic brain injury caused by a direct blow to the head, neck, or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. This initiates altered flow of chemical signals in the brain with possible injury to signaling pathways, blood flow change, and inflammation affecting the brain. These cellular injuries produce symptoms that can be immediate or delayed onset.
When a forceful blow is suspected of causing a head injury, the player should be removed from the field of play to avoid further injury. This was mandated in 2018 with Rowans Law requiring athlete’s parents, coaches to review concussion awareness resources, code of conduct, and have removal and return to sport protocols. Signs for immediate removal and assessment include lying motionless on the field, slow to get up after direct or indirect hit to the head, disorientation, confusion, blank look, poor balance, stumbling, or facial injury. The athlete should be promptly evaluated, if they experience loss of consciousness, double vision, seizures, or other red flag symptoms, emergency services are required.
Assessment tools have been developed for healthcare providers to evaluate athletes at sideline. The Sport Concussion Assessment Tool (SCAT) is shown to be the most effective tool to discriminate between concussed and unconcussed athletes within 72 hours of injury. It evaluates red flags, symptoms, cognition, memory, balance, cervical spine, and neurological systems. The SCAT will not exclusively diagnose or rule out a concussion. It is used to assess the immediate impact of the injury and requires a quiet area away from the pressures of the playing field. The athlete should be held out from play and re-evaluated unless an experienced healthcare provider determines their symptoms are unrelated to a concussion (a musculoskeletal injury as reason for lost balance or remaining down on the field). The SCAT is designed for use by medical professionals, if your team does not have a medical professional on staff there is a Concussion Recognition Tool (CRT5) that can help parents and coaches identify suspected concussions for further management. The CRT5 provides red flags for emergent care, observable signs and symptoms, memory assessment, and points on proper handling of athletes suspected of having a concussion. The CRT5 is a public document, readily available to teams to include with their medical kit. Following a sideline assessment, suspected concussions should seek immediate follow up with a physician or nurse practitioner for re-evaluation. This is a vital step because continuing to play and delay access to healthcare provider after a concussion is associated with longer recovery.
A concussion diagnosis enters the athlete into the return to sport strategy; a stepwise pathway developed to ensure full recovery for returning to the playing field (table 1). Best evidence shows that strict rest until complete symptom resolution is not beneficial follow sports related concussion. Instead, the first 24-48 hours following injury should involve relative rest while maintaining activities of daily living and decreased time watching screens. Neck pain, dizziness or headaches symptoms caused by concurrent musculoskeletal and vestibular injuries should be addressed with appropriate treatment and rehabilitation. Sleep disturbance 10 days after sport related concussion is associated with increased persistent symptoms and warrants evaluation and treatment.
Following relative rest, athletes advance to light-intensity physical activity including walking or cycling that does not more than mildly (2/10 intensity increase) and briefly (under 1 hour) exacerbate concussion symptoms. This is performed in a safe, supervised environment and requires a minimum 24 hours before further advancement. If symptoms are aggravated more than a mild degree, activities are stopped until the next day. Recovering athletes proceed to perform sports specific exercises away from the team with no risk of head impact. Drills include athletic movements such as running and changes of direction that prepare the athlete for integration in unpredictable sports environments. There is no advancement until full resolution of symptoms and cognitive function before and after physical exertion. The further stages should be managed by a healthcare provider, if any symptoms return, the athlete is sent back to sports specific drills until full symptom resolution with physical exertion. Without setbacks, higher intensity, non-contact drills are performed in a team setting. Before being approved for a full return to sport, athletes must be able to participate for full contact training without provoking symptoms.
Table 1. Return to sport strategy steps from Consensus Statement on Concussion in Sport1
Unexpected injuries can occur at a moment’s notice. Managing head injuries properly from the initial onset ensures the athlete is setup for their quickest recovery. This requires recognizing collisions that put an athlete at risk followed by removal and thorough evaluation using best practice tools. Seeking early management by a healthcare provider and following the return to sport strategy steps can aid in limiting the impact a concussion has on the quality of life of the athlete.
References
- Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, Davis GA, Echemendia RJ, Makdissi M, McNamee M, Broglio S, Emery CA, Feddermann-Demont N, Fuller GW, Giza CC, Guskiewicz KM, Hainline B, Iverson GL, Kutcher JS, Leddy JJ, Maddocks D, Manley G, McCrea M, Purcell LK, Putukian M, Sato H, Tuominen MP, Turner M, Yeates KO, Herring SA, Meeuwisse W. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med. 2023 Jun; 57(11):695-711. doi: 10.1136/bjsports-2023-106898. PMID: 37316210.
- Leddy JJ, Burma JS, Toomey CM, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Br J Sports Med 2023: bjsports-2022-106676.
- Sport Concussion Assessment Tool 6 (SCAT6) British Journal of Sports Medicine 2023; 57:622-631.
- Concussion recognition tool 5©British Journal of Sports Medicine 2017; 51:872.
- Davis GA, et al. Br J Sports Med 2017; 0:1. doi:10.1136/bjsports-2017-097508CRT5
- Elbin RJ, Sufrinko A, Schatz P, et al. Removal From Play After Concussion and Recovery Time. PEDIATRICS 2016; 138(3).