Introduction Concussions in contact sports are frequent occurrences, although many head relatedinjuries are under reported within the sporting arena. Of the head injuries reported, the majority are assessed by a physiotherapist/sports therapist on the pitch side as they are the first port of call.
The purpose of this review is to highlight the signs and symptoms related to concussionand the relative assessment procedures that can assist the therapist in performing theirexamination. In addition the procedure for management and return to play is alsodetermined to further assist the therapist when an athlete should commence physicalactivity. A large proportion of the research is based on the outcomes from the 3rdInternational Conference on Concussion in Sport in 2008.
A group of delegates from the 1 st International Conference on Concussion in Sport(3) compiled a five point classification system to define concussion:
Concussion may result from either a blow to the head, face or neck or blow elsewhere on the body resulting in an impulse force transmitted to the head.
●● Concussion typically results in the rapid onset of short lived impairment of neurological function that resolves spontaneously.
●● Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.
●● Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.
●● Concussion is typically associated with grossly normal structural neuroimaging studies.
The age old grading systems (Torg, Cantu, Colorado Medical Society (CMS) and the American Academy of Neurology (AAN)) for concussion were discarded at the 2 nd International Conference of Concussion in Sport. Simple versus complex concussion categories were proposed at the 2004 International Conference on Concussion in Sport but were subsequently discarded at the 2008 conference.
The panel in 2008 stated that the terminology of simple versus complex concussions did not fully describe the entities. The panel at the 2008 Conference on Concussion in Sport however maintained the view that 80-90% of concussions resolve in a short period over 7-10 days. This may be longer in children and adolescents than it is for adults.
A large proportion of head related injuries (90%) do not result in loss of consciousness and therefore remain unreported during competition. According to Delaney et al of all the players who played during the 1997 Canadian Football League season 48% of players experienced concussion, however only 18.8% of concussed players recognised that they had symptoms of concussion. Therefore the physiotherapist or doctor supervising a game must remain vigilant for the signs and symptoms outlined in Figures 1 and 2. It would be productive to educate players of the symptoms experienced during a concussive episode so they can inform a member of the medical staff.
Concussion occurs relatively frequently in football accounting for 2-4% of all injuries that occur during competition (Delaney et al , 2008). Numerous authors have found that there is little evidence to suggest that repetitive heading may result in concussion. The use of protective head gear has been widely speculated in competition; however, there is no substantial evidence to support the use of head garments to prevent concussion, although research has indicated a decreased force at impact to the brain with the use of helmets. The authors further added that the reduction in impact forces does not correlate with a reduction in the incidence of concussion.
Signs and Symptoms
The effects of concussion are not always profound on examination and therefore can be problematic in determining the neuro-cognitive deficits. When a patient is found unconscious, amnesi c or disoriented it becomes more clear-cut, however this is not the case in 90% of sporting scenarios. It should be noted that the symptoms cited below are not always related to concussion for instance dehydration, insomnia, eating disorders and overtraining can also elicit some of the symptoms indicated. Each of the signs and symptoms indicated in Figures 1 and 2 may present with a concussive episode, however, McCrory et al , stated that if any one or more of those highlighted in bold is present then concussion should be suspected and an appropriate management programme be implemented. Although some symptoms appear more regularly than others, for example headaches occur 83% compared to dizziness and confusion which appear less frequently at 65% and 57% respectively.
By Trevor Langford
Symptoms of concussion
l Behavioural changes (e.g. irritability)
l Appearing dazed or feeling like in a fog
l Nausea or vomiting
l Difficulty maintaining balance
l Vision disturbance
l Feeling ‘out of it'
l Poor concentration
l Tinnitus (ringing in ears)
l Photophobia (sensitive to light)
l Phonophobia (Fear of loud sounds)
Fig 1: Symptoms of concussion
Signs of concussion
l Loss of consciousness
l Inappropriate emotions
l Forgetting game rules
l Inability to recall score
l Poor physical coordination
l Slow verbal responses
l Personality changes
Upon initial evaluation of an injured athlete with concussion, the primary assessment of Airway, reathing, and Circulation (signs of life) is carried out. It should be assumed that an unconscious athlete has sustained trauma to the cervical spine and this should always be assessed in detail in the initial stages of any head injury.
The mechanism of injury may also indicate if trauma to the cervical spine is suspected. In addition teammates, opposing players and officials may assist with useful information relating to the mechanism of injury.
Continual loss of, or fluctuating in and out of, consciousness should result in the patient being transferred to hospital by medical personnel with the cervical spine protected. It is also important to recognise that concussion doesn't have to involve loss of consciousness or amnesia. Although it is useful to note that an athlete may have regained consciousness when the therapist arrives on the pitch.
Athletes, who are conscious and the cervical spine has been cleared of injury, must undergo a thorough neuropsychological assessment. Although there may be pressure for a player to return to the field of play quickly, it is essential that a player undergoes a thorough examination.
A secondary assessment of a concussed athlete should be undertaken. Firstly dialogue with the injured player can determine a degree of consciousness. It is then important to determine if the athlete is suffering with retrograde or anterograde amnesia. Retrograde amnesia refers to memories working backwards prior to the incident i.e. do you remember being hit? Do you remember arriving at the ground today? Anterograde amnesia refers to the events after being hit, i.e. do you remember walking off the pitch? Who was the first person you saw after the incident? Attention should be paid to the individual's normal speech pattern i.e. inability to say correct words when responding to questions. Attention should also be paid to the athlete's pupil size, response to light, and whether the player complains of double vision (diplopia). An evaluation of pulse and blood pressure should be noted as increased intracranial pressure from a brain haemorrhage may result in a life threatening condition. Elevated blood pressure is expected following activity but if it remains high at 10 minutes following game play and combined with a lower than expected pulse rate following activity, concerns should be raised. At the same time the facial bones and those of the cranium should be assessed for a depression fracture.
McCrory et al stated that the standard orientation questions i.e. time, place, person questions are unreliable within the sporting context. McCrory et al suggested that the Standardized Assessment of Concussion (SAC) and the Maddocks protocols are reliable and valid instruments for cognitive assessment on the field of play. McCrea et al ascertained that the SAC is a reliable tool to use in both male and female, in children, adolescents, amateur and elite athletes and acceptable across different educational levels.
The SAC requires a maximum of 5 minutes to complete and is suitable for those with no prior experience of psychometric testing. In contrast the Maddocks questions can be completed much quicker than the SAC although both remain effective.
In a clinical setting the Sport Concussion Assessment Tool (SCAT2) questionnaire incorporating the SAC, Maddocks, symptom evaluation, physical evaluation, Glasgow Coma Scale, balance and coordination must be used to determine neuropsychological function regardless of whether a simple or complex concussion presents. It would be productive to obtain a baseline score, during pre-season, of the SCAT2 format in the event of a concussive episode. Although the committee at the 3rd International Conference of Concussion in Sport agreed that research to determine the validation of the SCAT2 is required. It is important to recognise that Concussive symptoms may present several hours after an incident and therefore great care should be taken in allowing an athlete to continual participation. McCrory et al indicate that brain scans, or where available Brain MRI, should be employed not to contribute to concussion evaluation but when an intracerebral structural lesion exists.
Management and Return to play
The fundamental principal of concussion management is to rest from all physical and cognitive activities until the symptoms have resided. In the first 24 hours after a concussive episode an individual should not be left alone as symptoms may worsen, particularly with exertion. A blow to the head may cause an individual to appear drowsy particularly if a child is involved. If the individual wishes to sleep, allow them to do so, but check to make sure they are breathing and sleeping normally.
The athlete/patient should then undergo the graded return to play protocol ( Table 1 ) having obtained clearance from their medical practitioner. In a large quantity of scenarios the symptoms will resolve with rest after several days allowing the patient to progress through the return to play protocol. It should be reinforced that during this entire process the athlete should refrain from unnecessary physical or cognitive activities. Activities such as video gaming, texting and reading may exacerbate an individual's symptoms and therefore should be avoided until symptoms have resolved. It should be noted that different sporting governing bodies take a different position stance to concussion management, i.e. the Rugby Football Union insists on a minimum 3 week absence from training/games participation. This should be checked with the appropriate governing body/organisation before participation in training and games programme is re-commenced.
1. No activity
2. Light aerobic exercise
3. Sport specific exercise
4. Non contact training drills
5. Full Contact Practice
6. Return to normal training/games program
Complete physical and cognitive rest Walking, swimming or stationary cycling <70MHR (no resistance training) No head impact activities. Running drills or specific drills to sport Progression to more complex drills i.e. passing drills for football or throwing drills in rugby Following medical clearance, participate in normal training activities Recovery Increase heart rate
Add movement Exercise, coordination Restore confidence Assessment of skills (McCrory et al, 2005, 2009)
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