Sport-related injuries in young athletes are common. Concussion is a serious type of sport-related injury that is generally under reported or goes unrecognised. More and more young adults participate in contact sports in Australia and this trend increases the risk of sport-related concussion. Contact sports include rugby, boxing and mixed martial arts. Long-term cognitive and behavioural complications are of particular concern in these individuals. There are numerous preventative strategies, such as education and modification of sport rules; however, there is limited evidence to support effectiveness of these preventative measures. How do we diagnose, manage and prevent sport-related concussion?
Concussion is a temporary unconsciousness or confusion and other symptoms caused by a direct impact to the head or from indirect forces transmitted to the brain from an impact elsewhere on the body. In contact sports such as rugby football, mixed martial arts, boxing and hockey, sport-related injuries to the head are common and therefore there is an increased risk of concussions.
In the short term, concussions do not pose a serious problem; however, the real danger occurs after repeated concussions suffered by the same player, if the player returns to play immediately after contracting a concussion or too soon after suffering one. In this circumstance, there is an increased risk of another concussion (which is much more serious) as well as to the rest of the body due to a slower reaction time.
Players with repeated concussions can also suffer from a number of psychological issues like depression, as well as permanent brain damage and severe brain swelling. A player, regardless of age or level of competition, should not return to play or training following a concussion, without a medical clearance from a registered medical doctor.
Symptoms in concussion are vast and somewhat vague, but are vitally important to identify and differentially diagnose:
- Changes in mental status. Impaired recall of events, confusion, disorientation as to time, place and person; increased distractibility; drowsiness; feeling foggy; impaired level of consciousness; change in play behaviours; deterioration in concentration and attention; slow speech; difficulty in following directions; seeing ‘stars’ or ‘flashes’;
- Changes in behaviour or psychosomatic. Emotional lability; irritability; changes in personality; anxiety; nervousness; feeling sad; depression; decreased frustration tolerance;
- Physical. Poor balance; changes in vision; double vision; deterioration in sport performance; dizziness; undue fatigue; headache; light-headedness; nausea; vomiting; poor coordination; ringing in ears; vacant look; rarely seizures.
Australian concussion rates
There has been growing concern in Australia and internationally about the incidence of sport-related concussion and potential health ramifications for athletes. Concussion affects athletes at all levels of sport from the part-time recreational athlete to the full-time professional. If managed appropriately most symptoms and signs of concussion resolve spontaneously, however complications can occur including prolonged duration of symptoms and increased susceptibility to further injury.
Rugby is a popular contact sport in Australia. It can be classified into two different codes, rugby union and rugby league. Both are played at a very high level of intensity with full contact allowed, and as such has one of the highest concussion rates in the world, let alone Australia. Studies conducted into the incidence of concussion in professional and amateur levels of rugby have revealed that approximately 3.9 concussions per 1000 hours of play occur in professional rugby (1 concussion in every 6 games). Playing at the amateur level, concussion rates are much lower measured at 1 in every 21 matches (1.2 per 1000 hours). This amounts to roughly 5–7 concussions per team per season. Similar statistics are seen in sports like Australian Football League (AFL). A study showed that out of 1015 AFL players tested, 78 of them were concussed, 9 of which were concussed multiple times. The players mental functions were tested at controlled intervals with 38.6% of players still displaying symptoms at 48 hours after being concussed but after 96 hours, only 1.1% displayed any symptoms.
Trends in sport
While most of Australia’s professional sporting codes are now monitoring concussion, there were no statistics being collected in community sports. The evidence that’s coming out of United States of America is that it leads to long-term death and long-term high risk of suicide and mental health.
State Government Departments require all funded State Sporting Associations to have a Concussion in Sport policy. All sport and recreation organisations are encouraged to develop policies consistent with their peak body that encompass the following key areas:
- Education of coaches, guides, leaders, officials and support personnel;
- Activity/game day management; and
- Rehabilitation inclusive of returning to activity, training and game environments.
Management of athletes with concussion has evolved rapidly over the past decade resulting in the development of different guidelines that describe a similar approach for the management of concussions. For example, loss of consciousness is now not essential to define concussion. Laws have been enacted that require medical evaluation and clearance prior to return to play; however, evidence thus far does not show that laws have been effective in reducing the incidence of concussions in sport.
Individual athletes may have a variable course from injury to recovery. So, a step-by-step plan for athletes to return to play is preferred. Return to play decision is based more on clinical recovery rather than pre-determined number of days of rest. Studies have shown that most athletes fully recover from concussion from 2–3 week to 1–3 months. Generally, it is a common practice to remove the athlete from sport participation following a concussion for 7–10 days before beginning the return to play protocol.
Guidelines and tools
The Zurich concussion guidelines recommend the following stepwise process for athletes with concussion:
- No activity, complete physical and cognitive rest;
- Light aerobic exercise (walking, stationary cycling keeping intensity more than 70% maximum predicted heart rate, and no resistance exercise);
- Sport specific exercises (skating in hockey, running in soccer);
- Non-contact training drills (progression to more complex training drills, for example, passing drills in football; may also start resistance training);
- Full contact practice following medical evaluation and clearance;
- Return to unrestricted sport participation.
During the implementation of the step wise protocol, the athlete should be symptom free at current level of the protocol before proceeding to the next step. If symptoms recur, the athlete should rest for 24 hours and try the same step again. Before returning to full sport participation, the athlete should be completely free of any signs or symptoms, and must have a normal neurological examination.
The Sport Concussion Assessment Tool Third Edition (SCAT3) is a standardised tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older. Evidence for the reliability and validity of this tool in the literature is not well documented, but it has shown to be a reasonably good multimodal tool.