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Concussion

A concussion, historically, referred to an injury induced by a low velocity force which resulted in the ‘shaking’ of the brain. Most commonly seen in contact sport (rugby and soccer in particular), a concussion is recognised as a brain injury that can be rather debilitating and cause a player to be in recovery from several days to a few weeks. In recent times, a great deal of attention has been brought to the condition in order to clearly define guidelines for its diagnosis and management.  Pivotal Motion Physiotherapy is a supporter of Sports Medicine Australia to whom have published a position statement on concussion which can be viewed here.

A concussion is scientifically defined as a “complex pathophysiological process affecting the brain, induced by biomechanical forces”. It may be caused by a direct blow to the head, neck or another part of the body which could therefore result in force transmitted towards the brain. The symptoms of a concussion are usually short lived and represent a disruption in functioning of the brain rather than damage to the brain structure.

Some symptoms of a concussion

  • Headache.
  • Cognitive symptoms such a delayed reaction time. Some also report ‘feeling in a fog’.
  • Emotional symptoms such as labiality.
  • Behavioural changes such as irritability.
  • Amnesia, short or long term.
  • Sleep disturbance.
  • Loss of consciousness.

A player that is displaying any of these symptoms requires immediate medical attention and must stop playing until assessed by a health professional. An important part of this screen is an assessment of cognitive function. Research has found that quick on field screens for example orientation questions (name, place and time) are not reliable measures of cognitive function and therefore a thorough assessment of this system using a standardized assessment tool is necessary. The SCAT3 (for ages 13-17 and over) and the ChildSCAT3 are such tools that offer a reliable measure of the severity of a concussion.

A comprehensive history maybe required from eyewitnesses that were present when the injury occurred or from relatives or coaches that may have noticed behavioural changes. In addition to this, neuroimaging may be necessary to eliminate the possibility of structural damage to the brain.

Management of a Concussion

The management of a concussion usually involves cognitive and physical rest for a period of 24- 48 hours, followed by a short period of gradual exertion prior to obtaining medical clearance for sport. It seems that the majority of injuries will resolve over a few days, however it is important to monitor the player for any persisting symptoms of a concussion. No player should return to play on the day of the injury. Though there is little good quality evidence to evaluate the effectiveness or rest followed by treatment, the rehabilitation following a concussion is usually based on a step-by-step increment in activity. In this form of rehabilitation, by the player cannot progress into the next stage if he or she is not symptom free. The steps of return to play include rest, light aerobic exercise, sport-specific drills, non-contact drills, full contact practice and finally return to play. The use of multimodal physiotherapy treatment may also be useful in the event that there is vestibular or cervical dysfunction. Cases where symptoms persist for greater than 10 days ( 10-15% of cases) require further rehabilitation with a multidisciplinary team.

Little can be done to prevent a sporting concussion other that stress the importance of fair and safe play and implement rule changes to the sport where applicable. Prevention of head and facial injuries in sport can be achieved through the wearing of protective helmet and mouthguards. However, there is little conclusive evidence to relate the use of protective gear with a reduction in concussions.

It is often forgotten that concussions can occur both on and off the sporting field and can at times be managed by sports trainers. Concussions have also been identified in whiplash patients following motor vehicle accidents. It is important to recognise the vitality of diagnosing the injury and appropriately treating the concussion so as to avoid a delay in returning to routine activities.

References:

McCrory,P., Meeuwisse,W., Aubry,M., Cantu,B.,Dvorak, J., Echemendia, R, Engebretsen, Johnston, K., Kutcher, J., Raftery, M., Sills, M., Benson, B., Davis, G., Ellenbogen, R., Guskiewicz, K., Herring, S., Iverson, G., Jordan, B., Kissick, J., McCrea, M., McIntosh, A., Maddocks, D., Makdissi, M., Purcell,L., Putukian, M., Schneider, K., Tator, C., Turner, M. (2012) Journal of Science and Medicine in Sport. Consensus statement on Concussion in Sport—The 4th International Conference on Concussion in Sport held in Zurich, November 2012.16:178-189

Teel, E., Register-Mihalik, J., Blackburn, T., Guskiewicz, K. (2013) Journal of Science and Medicine in Sport. Balance and Cognitive performance during a dual task: Preliminary implications for use in concussion assessment. 16:190-194.