Consensus Statement Concussion – Mastering Concussion Management
At the end of 2022, the International Conference on Concussion in Sport took place for the 6th time in Amsterdam. The goal of this conference is to increase our understanding of concussion in sport and to help further develop our assessment and treatment protocols for the injury.
The conference consisted of 31 panelists from multiple disciplines, who last met in 2016 and helped develop the SCAT-5 concussion screening, which has become a vital tool in the recognition and continuous assessment of concussion in athletes of all varieties. Concussion is one of the biggest causes of participation loss by athletes, and repeated concussion is one of the leading causes of athlete retirement at elite levels. More obvious symptoms can include loss of consciousness, amnesia, and headaches; however, other symptoms such as slowed reaction-time, irritability, drowsiness, and emotional lability can also be indicative of concussion (Daneshvar et al, 2011).
The most recent consensus statement refers to the “12 Rs” of Sports Related Concussion to provide a logical flow of concussion management:
Recognition of the problem is the first step of managing the problem. Concussion can be caused by a direct blow to the head or neck, but can also be caused by a blow to the body. Symptoms may develop immediately, or may develop over the course of minutes hours, and last for days or weeks. Considering the Mechanism of Injury is an important tool for recognition of concussion, alongside observation of clinical signs such as loss of consciousness, alteration in mental status, amnesia, and other acute neurological signs. The consensus statement recommends using the Mild Brain Injury Task Force diagnostic criteria guidelines for on-field recognition (Silverberg et al, 2023).
Preventing concussion is one of the main ways sport’s governing bodies can go about lowering the incidence of injury. This than come about by modifying rules (like World Rugby are in the process of doing by lowering the legal tackle height), using protective equipment (gumshields), or modifying training strategies (limiting contact practice in training) can all be helpful for lowering the risk of concussion. Neuromuscular Training warm-ups have also been shown to reduce the incidence of concussion in contact heavy sports such as Rugby Union.
Players should be removed from the field of play if there is a possible or suspected concussion. This can be based on the signs and symptoms observed by medical staff, other players, or game officials. Immediate removal from the field should take place if there has been a loss of consciousness, or other symptoms such as tonic posturing, seizure, ataxia, poor balance, confusion, or amnesia. Player experiencing these signs should return to the field of play unless evaluated by an experienced professional with a multimodal assessment. The SCAT-6 is a multimodal assessment protocol that has been developed by the conference panel to assess SRCs.
The conference panel have developed the SCOAT-6, to be used as a sub-acute assessment protocol for players who have sustained an SRC. This can be performed up to 72 hours post injury to help paint a picture of the players current conditions and where they may be having issues. In the case that the SCAT-6 was performed at the time of injury, it can be extremely valuable to compare the scores from the two tests and see how the players complaints have developed.
Relative rest consisting of standard daily activities and a reduced screen-time is recommended for the first 48 hours post injury. Patients should be able to return to light walking roughly 24-48 hours post-injury, provided it does not exacerbate symptoms. Patients can be prescribed aerobic exercise in the 2-10 days following injury based on Heart Rate exertion values, and symptom exacerbation. Complete rest until symptoms have subsided has been shown to be ineffective following concussion.
Referral to clinicians with specialised knowledge and skill should be considered for patients suffering with persisting symptoms of concussion. Symptoms are considered persisting conditions if they have been present for over 4 weeks following injury. Serial use of the SCAT-6/SCOAT-6 can be used to identify patients with persistent symptoms, gauge the severity of symptoms, and serve as a guideline for referrals.
Patients who are still experiencing neck pain or headaches 10 days post-injury, cervicovestibular rehab is recommended. For teenagers or adults with dizziness or balance problems, vestibular rehabilitation may prove beneficial after injury. As previously mentioned, subsymptom aerobic exercise should be considered alongside cervicovestibular rehab. If there is a recurrence of symptoms throughout the rehabilitative process, re-evaluation and possibly referral may be of benefit to the patient.
In order to measure and assess patient recovery, the consensus panel recommends using 3 main outcomes measures. Assessment of symptoms, which should be performed while patient is at rest, performing cognitive activities, and after physical exertion. Vestibulo-ocular reflex and oculomotor function should also be assessed and whether or not the testing can be performed without symptom reproduction. The final outcome measure is the assessment of return-to-learn or return-to-sport markers, which will be outlined in the next section.
Return-to-learn can be recommended provided that any changes to symptoms are both brief and mild (less than 2 on a scale of 0-10 for less than 1 hour). Educators can also offer academic supports to students Returning-to-learn if deemed necessary, such as environmental adjustments (modified attendance or frequent breaks), physical adjustments (allowing the student to avoid contact activities), curriculum adjustment (extra time for homework/assignments), and testing adjustments (delaying tests or allowing additional time to complete them). It is important to note that not all students will require modifications or a plan to return-to-learn, many patients will be able to seamlessly reintegrate. The Return-to-learn strategy can be implemented as early as 24-48 hours following injury with an incremental increase in cognitive load guided by symptoms.
Athletes should immediately be allowed to engage in activities of daily living, including walking following injury. The consensus panel outlines 6 steps to Return-to-sport, which are outlined in the following table.
This study also investigated and reconsidered the potential long-term effects of concussion. They found that amateur athletes in American Football and Soccer were not at increased risk of developing mental health issues in later life. They also found that amateur athletes were at no increased risk of developing neurological disorders (Dementia) or disease (ALS, MND). Professional athletes in American football, however, were shown to have an increased risk of developing such conditions. The study does mention that there are still insufficient samples of the required populations to make an accurate statement regarding the effects of contact sport on the development of Chronic Traumatic Encephalopathy (CTE).
Decisions regarding retirement from contact sport should are often complex. In most sports, there are no clear guidelines that unequivocally lead to the advice of retirement. The discussion should take place between an athlete and a clinician with expertise in Traumatic Brain Injuries and collision sports. The decision should also be assisted by the advice of a team of multidisciplinary healthcare practitioners and take in all aspects of the patient-specific, sport-specific, and injury-specific factors before the advice to retire is given.
Daneshvar, D. H., Nowinski, C. J., McKee, A. C., & Cantu, R. C. (2011). The epidemiology of sport-related concussion. Clinics in sports medicine, 30(1), 1-17.
Silverberg, N. D., Iverson, G. L., Group, A. B. I. S. I., Cogan, A., Dams-O-Connor, K., Delmonico, R., … & Zemek, R. (2023). The American Congress of rehabilitation medicine diagnostic criteria for mild traumatic brain injury. Archives of physical medicine and rehabilitation.
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