It seems timely to revisit this topic, with recent media interest being reignited around concussion in sport. It's important to distinguish between the decisions made in the elite sports environment and those made with everyday sports people. The testing, information available and ongoing assessment mean in many elite sporting cases, assessments and decisions can be made a lot faster while still having the players best interests at heart.
Firstly let us look at what can be done to limit the impact of a head injury if this is suspected. At an elite professional level there are many tools available to side-line support staff, and this may not just be the doctor or physiotherapist. There are 11 indications for permanent removal from the field (see Table below) that reflect a possible concussion, and these can be visible to side-line support staff, but also team analysts and coaching staff who view the game both in real-time and using video reviews. The use of video footage is now available to both team doctors and the Match Day Medical Team (MDMT, who have overall jurisdiction for all on-field medical matters) on the sideline and is frequently used to review suspicious incidents. For those players where it is not immediately clinically obvious, they are able to be removed from the field and assessed under the Head Injury Assessment (HIA) process. During this 10 minute period players are assessed using an electronic iPad based symptom score, neuro-cognitive testing and balance tests (use pre-season baselines for comparison).
This testing is aimed to confirm the clinical suspicion of concussion so any symptoms or reduction in scores from baseline are deemed to be a positive test and the player does not return to the field. If negative, it merely means that the testing at this point in time has failed to confirm a concussion but the player still can be prevented from returning to play should the team doctor, MDMT or player still have concerns. Should the player return to play then repeat on-field monitoring for any symptoms must continue as often players will develop symptoms.
But, at the recreational, amateur, non-professional level this process should not occur. ACC SportSmart guidelines are a valuable tool for this group of players with the simple - Recognise Remove Refer - ensuring that possible further damage is limited. These simple guidelines ensure that the amateur player is managed with the primary purpose of the brain in mind – that being for education or work, with recreational sport a secondary priority. Numerous phone apps are now available for use on side-lines and these may be helpful for assisting in the possible diagnosis of a concussion but should never be used to return players to the field. Again we must reiterate that if you think it = Recognise, and these players should be managed as if a concussion may have occurred.
Post-match the assessment and monitoring process needs to be continued. Further neuro-cognitive testing is useful using the validated SCAT 5 form (adult or child 5-12yrs old version) as abnormalities are most likely to be recorded within the first 3-4 days*. Supervision should be provided to that player by the team medical staff or a responsible adult, with written instructions to ensure any ‘red flags’ do not develop as this identifies those players that require further assessment, monitoring and possible imaging in a hospital-based Emergency Department. In the professional environment, players will have access to medical support to manage them through this period, but amateur and recreational athletes do not and we strongly encourage those with a suspected concussion to make an appointment at our Sports Concussion Clinic for an accurate diagnosis and treatment plan.
Given the correct management initially, being early removal from the field, 24-48hrs of rest then relative mental rest and light aerobic activity, 70% of those people who have sustained a concussion will be asymptomatic by Day 14 post-injury (unpublished Axis Sports Concussion Clinic data). This group should receive a graduated return to sport programme in accordance with their National Sporting Organisation guidelines (for rugby we have written about these guidelines here), ensuring medical clearance prior to any return to sport or contact based training. Those players that remain symptomatic by this time require further assessment in either a dedicated concussion clinic service or with a medical practitioner.
If you're interested in hearing more about what we look for in cases of suspected concussion and then how we manage a players recovery check out a recent interview done for Radio Sport
*McCrory et al. Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016. BJSM 2017.