Concussion in sport is a topic that has received a lot of media attention of late. This month Dr Stephen Freeman, team Doctor with Northern Suburbs Rugby and the Australian Junior Wallabies discusses some practical tips for players and parents to help identify and manage concussion injuries safely. If you are a rugby player or your children play rugby then this article is a must-read.
Concussion injury is a disturbance in brain function caused by a direct or transmitted force to the head. This means that it affects how our brain operates and processes information. It is fairly common in contact sport and is diagnosed clinically i.e. does not require special investigations. Concussion injuries usually settle with simple conservative management. When clinical assessment is equivocal and signs are present which create concern that there is a structural brain injury then imaging is required (usually CT or MRI scanning).
A direct injury is self-explanatory – the player sustains a blow to the head from another player, or impact with the ground. A transmitted injury is when the force to the brain is not from a direct blow such as a player who sustains a ‘whiplash-type’ injury or a twisting force which causes rotational effects on the head/brain, or a fall where the player may not strike their head directly but land on their knees or buttocks with enough force to jolt the brain inside the skull. While direct impacts are more common, transmitted injuries must not be missed. Younger players are more susceptible to concussion from both sorts of impact due to their increased relative head size and weight. A concussion injury should be suspected in the presence of any symptoms (eg. head ache, dizziness, irritability, drowsiness), physical signs (eg. reduced balance function), impaired brain function (eg. confusion, memory loss) or abnormal behaviour. Any athlete that has had a loss of consciousness or a suspected concussion must be removed from the field of play, be medically assessed and not return until cleared.
In the absence of clinical evidence of a structural injury, imaging is not required. Management consists of observation, rest from physical and cognitive activity, simple analgesia for headache if necessary (paracetamol, NOT aspirin or ibuprofen – in case of associated structural injury), and then a graduated return to play once COMPLETELY symptom-free. If symptoms are not settling as expected, or additional symptoms or complications develop, then further assessment is required – which will usually require imaging. Players who have had a concussion injury should rest and avoid strenuous exercise for 24hours, not drink alcohol or take sleeping tablets and not drive. If symptoms deteriorate or a change in behaviour is noticed then the player should go to the nearest hospital emergency department immediately.
At present, the Australian Rugby Union policy is that every player with suspected concussion should be assessed by a Doctor, preferably one familiar with identifying and managing concussion and also familiar with the current management guidelines. If the diagnosis is confirmed, a medical clearance is required to commence the graduated return to play protocol (GRTP), and a final clearance required prior to return to match play. In an ideal situation, the doctor would review prior to each phase of the GRTP. The minimum amount of time that a player can progress through the GRTP following a concussion injury is 6 days.
The current guidelines are in line with best practice internationally and are reviewed every 2-3 years by an international multisport and multidisciplinary committee. The sports administrators and medical specialists involved are all at the coalface of concussion research through data collection, laboratory research and clinical management. Australian sporting codes and doctors are well-represented.
To assist with player safety, it would be sensible for all involved players, coaches and parents to be familiar with the POCKET CONCUSSION RECOGNITION TOOL (which has superseded the Pocket SCAT2) – http://bjsm.bmj.com/content/47/5/267.full.pdf – which will help recognise some of the subtle signs of concussion. Further education is available from the ARU and International Rugby Board (see below). Every player with suspected concussion should be given a copy of the ARU Concussion Fact Sheet – http://www.rugby.com.au/LinkClick.aspx?fileticket=r2FM8EIt3E0%3d&tabid=1951 – which will help with diagnosis and management, and guide medical personnel, coaches, parents and players through the GRTP.
For further information, see the following:-
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