I recently reviewed an article I had written in early 2010 (“Concussion confuses more than footballers”), which addressed contemporary 2010 knowledge on concussion in sport and “best practice” medical management. Oh how times have changed!! You are welcome to read the 2010 article on my website below, but only for historical value, as it represents the contemporary knowledge and accepted medical practice at that time. It is most certainly out of date (and out of fashion) now.
In this new piece, I will attempt to bring you up to date with the current (2015) state of knowledge and perhaps look forward to future developments in the management of sport concussion.
The management of head injury and concussion in sport has attracted unprecedented media focus over the past 5 years. As a result of the progressive understanding of the effects of concussion and further research into its assessment, mechanisms and outcomes, it is fair to say the medical management of concussion has been turned on its proverbial sore head.
In 2010 I attended an International Olympic Committee seminar on the management of head injury and concussion in elite sport. This was held during the Winter Olympic Games in Vancouver Canada. At that conference there was considerable debate as to whether an injured player should be allowed to return to participation on the day of a concussive episode and the consensus then was that, as a result of growing concerns, most sports at the elite level had adopted an increasingly conservative attitude. The clear message was to exclude any concussed player for the remainder of the competition on the day of the incident. At the time this was at odds with the practice of concussion management in elite Australian sport including AFL, NRL and other codes.
However as a result of this increased focus, new concussion guidelines were introduced and adopted by the AFL which resulted in more conservative management of concussion episodes from the beginning of the 2011 football season. These guidelines were further tightened in 2013 with the use of the 20 minute substitute rule to allow doctors to perform a detailed concussive assessment where there was some clinical concern following any head injury to a player. The match day concussion assessment process was further strengthened by refinements to the Sport Concussion Assessment Tool (SCAT) test which currently is in version number three ( SCAT3) and used now internationally as an adjunct to the doctors clinical assessment skills. The decision to pass a player fit to return to participation on the same day as the incident should always remain a purely medical one.
In tandem with this more conservative management program there has been significant worldwide focus on the longterm effects of multiple concussions particularly in retired players who have developed certain behavioural problems. These concerns have ranged from depression, anxiety, memory loss, drug abuse and other mental health disorders through to suicidal behaviour and alcoholism. There has been considerable research going on over many years now looking at any direct causal relationship between multiple concussions and subsequent brain disturbance and this research is still incomplete and requiring further detailed study and analysis. Nevertheless the concept that a concussed player be allowed to return to competitive sport on the day of the incident is now widely condemned at all levels of elite, sub-elite and lower levels including junior sport. The brain must be protected at all costs and our understanding of what truly constitutes a concussion episode has evolved.
More sinister longterm potential concerns such as chronic traumatic encephalopathy (CTE) remain a hotly debated item. However there is no scientific consensus yet as to a direct relationship with this diagnosis (which can only be made post mortem following the death of an individual). Whilst CTE bears some similar clinical features to Alzheimers disease and Parkisonism, it is considered a separate entity at this stage. The total number of worldwide CTE cases documented is actually less than 160 as of 2015.
In addition the post concussion medical management protocol has evolved considerably and now takes a longer period of time before a player is passed fit to return to activities. There is no set time frame which can be put on the recovery process but players must undergo a series of clinical assessments, practical tests and detailed cognitive function assessments in addition to completing a graduated re-introduction of physical training. It is important that players pass all stages of the assessment process and do not return to competitive sport until they are symptom-free and given full medical clearance. Unfortunately this detailed practice has not been universally adopted at all levels of professional sport but the AFL to their credit has been a leader in this area in Australia.
It is important to recognise a concussion can occur from a relatively innocuous blow to the head and does not require a high velocity incident and certainly does not require loss of consciousness. Players will often develop one or several symptoms following a head trauma incident and this symptom development can evolve over a period of many minutes rather than being an instantaneous onset. It highlights the importance of regular checks on a player who may have had a simple “head knock” and seemed to have recovered quickly but it is important that the medical assessment at the stadium or arena is undertaken in a timely and progressive manner. There is an onus on the players themselves to provide honest and complete information so that medical assessment can be undertaken in the best interests of their welfare.
In the future players concussed in elite sporting codes will be monitored over the long term to assess any lingering effects of their concussive episode, whether single or multiple. In addition, research is under way to look back at players who sustained concussions many years ago to evaluate any post concussion effects especially where comparative testing is available from their initial head injury assessments.
Concussion is a complex process and the complete knowledge of this condition is still evolving.
- Any player that is concussed during a match or competitive situation should not return to the same activity on the day of the event.
- There is no set time frame of exclusion from sport after a concussion. All cases must be individually assessed and a return to activity program designed to suit the specifics of the case.
- The sports medical world, in cooperation with sporting codes and associations worldwide, continues to address this complex topic and refine the concussion management process in order to provide the highest level of care to protect the welfare of all participants.
- The match day management of concussion must follow a medical model, with no undue influence from team management or coaches.
- The longterm consequences of concussion (or multiple concussions) have not been well established but require ongoing research, much of which is currently underway.
- All sports, administrators and associations need to be well educated on the concussion process and appropriate first aid measures be put in place at all sporting venues.
- The brain is an irreplaceable organ and needs to be treated with the utmost care and a structured medical process followed to ensure complete recovery before any player resumes sport following a concussion episode. This applies to all levels of sport including junior sport.
Dr Peter A. Larkins
MBBS, BMedSc (Hons) FASMF, FACSP, FFSEM (UK)
Sports and Exercise Physician