Concussions

August 31, 2023

Have you or someone you know suffered a concussion?

The 2022 6th International Consensus on Concussion in Sport builds on the principles outlined in previous concussion statements and aims to develop a better understanding of sport-related concussion.  The recommendations made in this article are based on these guidelines that were announced in June 2023. A link to the consensus article is here https://bjsm.bmj.com/content/57/11/695 . Rather than providing a comprehensive resource on Concussions here, we have chosen to provide links to two excellent Canadian Websites below who are funded to stay current on latest research developments and have full time staff to educate people on recognizing, diagnosing, and managing concussions.  It may take the on-line resources a few more months to catch up to the new recommendations as they are extensive, however we wanted to provide the notable changes made to the previous 2017 guidelines in red below.

Concussion Definition:

 A Sport Related Concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sport and exercise-related activities.  This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change, and inflammation affecting the brain.  Symptoms and Signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged.

 

Prevention:

Policy or Rule Changes:

A policy disallowing body-checking in child and adolescent ice hockey reduced the rate of concussion by 58%.  Policies and rules limiting the number and duration of contact in practices and strategies restricting collision time in practices in American Football across all age groups have led to an overall 64%reduction in practice related concussion and to reduce head impact rates.

 

Personal Protective Equipment:

Mouthguards were associated with a 28% reduced concussion rate in ice hockey across all age groups, indicating that mouthguards should be mandated in child and adolescent ice hockey and supported at all levels of play.

 

 

 

Training Strategies:

Participation in on-field neuromuscular training (NMT) warm-up programs completed at least three times per week has been associated with a lower rate of concussion in Rugby Union (rugby), across all age groups.

 

Concussion Management:

Optimal concussion management strategies including implementing laws and protocols (e.g. Mandatory removal from play following actual of suspected concussion; requirements to receive clearance to return to play from an HCP; and education of coaches, parents, and athletes regarding concussion signs and symptoms) are associated with a reduction in recurrent concussion rates.

 

Sideline Evaluation and Removal from Sport:

 

Removal of a player from the field of play should be done if there is a suspicion of possible concussion to avoid further potential injury.  Signs that warrant immediate removal from play include actual or suspected loss of consciousness, seizure, tonic posturing, ataxia (challenges with walking), balance issues, confusion, behavioral changes, or amnesia.  The guidelines now contain strong language:

 

Players exhibiting these signs should not return to a match or training that day, unless evaluated acutely by an experienced HCP with a multi-modal assessment (as noted below) who determines the sign was not related to a concussion (e.g. The player has sustained a musculoskeletal injury and thus is unable to balance)

Symptoms and signs of a concussion may evolve over minutes, hours, or days.   Whether acute or suspected concussion the player should be serially re-evaluated in the coming hours and days.

 

There are two tools that have been updated for sideline evaluation of sport related concussion.   The first is for non- health care professionals (coaches, parents, etc.).  It is called CRT6 and is available here https://bjsm.bmj.com/content/57/11/692.

 

The updated sideline assessment tool for Health Care Professionals is called the SCAT6 ( https://bjsm.bmj.com/content/57/11/622 ). It has been updated and also verified that this tool in only really valid for the first 72 hours up to 7 days post concussion.  There is a ChildSCAT6 for those athletes ages 8-12 years.

 

Typically, the process of conducting a multi-modal screen to evaluate a concussion takes at least 10-15 minutes.  Sport organizations are strongly advised to allow for at least that amount of time for an adequate evaluation and to accommodate such an assessment off-field, preferably in a quiet area away from the pressures and scrutiny of match play. For athletes with potential signs of a concussion, any screening assessment short of a multi-modal evaluation of symptoms, signs, balance, gait, neurological and cognitive changes associated with a potential concussion may be inadequate to allow continued sports participation.  Sports whose rules do not facilitate such evaluations should strongly consider enacting rule changes in the interest of player welfare.

 

Re-evaluation: The office assessment:  

 

The new 2022 consensus group developed an office tool for Health Care practitioners (physicians, physiotherapists, chiropractors, athletic therapists, etc.)   as a standardized, expansive, and age-appropriate clinical guide to a multi-modal evaluation in the sub-acute phase (72 hours to weeks post injury), with a view to guide individualized management.  It is called the SCOAT6 (  https://bjsm.bmj.com/content/57/11/651 )  This does not replace the practitioner’s individual clinical knowledge, or expertise, but provides a standardized framework to inform the clinical practice in an office setting.  There are many factors at play (e.g. Previous history of concussions) that affect the management of the athlete.

 

New additions to this clinical evaluation include:

  • Measurement of blood pressure changes from lying down to standing
  • Evaluation of Cervical spine Range of Motion
  • Neurological examination of cranial and spinal nerves
  • Timed tandem gait as well as dual task activities
  • A modified Vestibulo-Ocular Screen (more comprehensive vision testing)
  • Mental Health questionnaire
  • Computerized testing, while adding some clinical information, and should not be used in isolation to inform management or diagnostic decisions.

 

Rest and Exercise:

 

The Consensus document made some changes to the principles of immediate (first 72 hours) of management of concussion:

 

The best available evidence shows that recommending strict rest until the complete resolution of concussion-related symptoms is not beneficial following Sport Related Concussion.  Relative (not strict) rest, which includes activities of daily living and reduced screen time, is indicated immediately and for up to the first 2 days after injury.  Individuals can return to light-intensity physical activity (PA)such as walking that does not more than lightly exacerbate symptoms, during the initial 24-48 hours following a concussion.

 

  • Clinicians are encouraged to recommend light physical activity such as walking or stationary biking while avoiding the risk of contact, collision or fall.
  • The best data on cognitive exertion show that reduced screen use in the first 48 hours after injury is warranted, but may not be effective after that.
  • Health Care Professionals with access to exercise testing can safely prescribe sub-symptom threshold aerobic exercise treatment within 2-10 days after Sport Related Concussion. This prescribed exercise has been shown to be effective for reducing the incidence of persisting symptoms as well as facilitating recovery with individuals suffering from symptoms lasting longer than 1 month.
  • If symptoms increase more than slightly, the individual should be taken back to the previous level of progression.
  • Sleep disturbances in the 10 days after concussion is associated with an increased risk of persisting symptoms and may warrant evaluation and treatment.

 

Referral:

 

Where the clinical environment allows, referral to clinicians with specialized knowledge and skills in concussion management should be considered for the targeted treatment of persisting symptoms.  This may include the management of cervicogenic symptoms, migraine and headache, cognitive and psychological difficulties, balance disturbances, vestibular signs, and oculomotor manifestations. 

 

The term persisting symptoms is used for symptoms that persist >4 weeks across children, adolescents, and adults.  A multi-modal clinical assessment, ideally by a multidisciplinary team, is indicated at that time.   This SRC clinician network may include Sports Medicine Physicians, athletic therapists, sport physiotherapists, occupational therapists, sports chiropractors, vestibular therapists, neurologists, neurosurgeons, neuropsychologists, ophthalmologists, optometrists, physiatrists, psychologists, and psychiatrists.

 

Rehabilitation:

 

If dizziness, neck pain, and/or headaches persist for more than 10 days, cervicovestibular rehabilitation is recommended. If symptoms persist beyond 4 weeks in children or adolescents, active rehabilitation, and collaborative care may be of benefit.

 

Recovery:

 

The determination of clinical recovery was found to vary across research studies and healthcare practices and depended on the research question under evaluation.  Primary recovery outcomes include symptom ratings, specific clinical tests or groups of tests and functional domains such as Return to Learn and Return to Sport strategies.

 

Advanced neuroimaging, fluid-based biomarkers, genetic testing and other emerging technologies are useful for research focused on sport related concussion diagnosis, prognosis, and recovery.  However, further research is required to validate their use in clinical practice to assess recovery and aid in clinical management of Sport Related Concussion.

 

Return to Learn (RTL) and Return to Sport (RTS):

 

These strategies have been in place for some time and help with a step-wise progress for athletes to return to activity after suffering a concussion.

 

The systematic review of RTL and RTS found that continuing to play and delayed access to healthcare practitioners after Sport Related Concussion are associated with longer recovery.

 

The systematic review revealed that the vast majority of athletes (93%) of all ages have a full Return to Learn (RTL) with no additional support by 10 days.

 

Return to Learn progressions have not changed, with each stage having increased cognitive load.  There are 4 steps to the process:

 

  • Daily activities that do not result in more than a mild increase in symptoms
  • School Activities
  • Return to School part time
  • Return to School full time.

 

Each steps takes approximately 24 hours, and the athlete can be progressed in symptoms do not increase significantly.  If they do increase the athlete is held at the present level of progression until symptoms resolve.

 

RTL can happen in conjunction to RTS, but should be completed prior to RTS.

 

Return to Sport progressions have not changed, each step with increasing physical load.   There are 6 steps to this process, each taking a minimum of 24 hours.

 

  1. Symptom limited activity
  2. Aerobic exercise
  3. Individual Sport Specific exercise (non contact)

MEDICAL CLEARANCE TO PROCEED

  1. Non-Contact training drill
  2. Full Contact practice
  3. Return to Sport.

 

The athlete is only progressed to the next level is their symptoms do not increase from the level they are participating in.

 

Medical Determination of readiness to return to at-risk activities should occur prior to returning to any activities at risk of contact, collision or fall. (e.g. Prior to stage 4) This recommendation should be by a Health Care Professional with experience in Concussion Management, and in keeping with local law requirement. (some provinces require physician clearance).

 

Retirement from Sport:

 

There are some situations, following repeat concussion that the tough decision for the athlete not to compete in contact sports may be required.

 

There is no clear evidence of the factors that, if present, would unequivocally lead to the retirement or discontinued participation in contact or collision sport.   However, some sports have their own specific medical regulations regarding clearance for participation (e.g. Retinal detachment in boxing).

 

Decisions regarding retirement or discontinuation from contact or collision sports are complex and multifaceted and should involve clinicians with expertise in traumatic brain injury and sport and preferably a multidisciplinary team.  The discussion should provide the athlete, and their parents, with the scientific evidence and uncertainties of their condition balanced against the benefits of participation in sport.

 

 

The following two Canadian resources, while not currently updated to the new guideline (will be soon), provide more in-depth information about symptoms, return to learn and return to sport progressions etc.

 

Concussion Awareness Training Tool – CATT online           https://cattonline.com/ 

Developed by Dr. Shelina Babul, Associate Director/Sports Injury Specialist with the BC Injury Research and Prevention Unit, BC Children’s Hospital, Vancouver, British Columbia, Canada, CATT is based upon the established principles of the Consensus Statement on Concussion in Sport.

Research and evidence on concussions is evolving and the knowledge base is continually changing. As a result, this website is updated on a regular basis to provide current information, tools, and resources to support concussion recognition, diagnosis, treatment, and management.

CATT is part of the Concussion Harmonization Project, a federal initiative to increase the prevention, recognition, and treatment of concussions in Canada.

 

CATT online is currently being upgrading to the new recommendations.

 

Parachute    https://www.parachute.ca/en/injury-topic/concussion/

Parachute, founded in 2012 through the amalgamation of four charities in the injury prevention field, has become Canada’s leader in injury prevention focused on three key areas where people are unintentionally injured: in the home, at play, and on the move. We educate and advocate for preventing serious injury in our homes, in sports and recreation and on our roads.

Parachute’s approach to injury prevention is based on the following values and principles:

  • Evidence-based – Parachute uses an evidence-based approach to setting priorities, designing implementable and cost-effective solutions, and evaluating impact.
  • Implementation focused – Parachute builds capacity and provides best practice solutions that are scalable and meet the needs of our diverse stakeholder and injury prevention network across the country, focusing on programs and initiatives that are achieving the desired impact and outcomes.
  • Policy driven – Parachute provides thought leadership and focus to public policy dialogue and actions across Canada.
  • Collaborative and complementary – Parachute strengthens the cause of injury prevention and sets the national agenda by bringing together leading practices, from Canada and around the world. We work with federal, provincial, and territorial injury prevention initiatives, as well as corporations and foundations, to augment and accelerate their efforts, avoid duplication, and share leading practices.
  • Innovative – Parachute attracts innovators and influencers to injury prevention. We embrace new approaches, ideas, technologies, and processes that can help us achieve our goals.

 

Both of these sites are evidence based, continually updated, and excellent resources in the management of concussion.   Of course, this is for education purposes and does not replace seeing a certified Sports Medicine or Rehabilitation professional to be assessed and treated.  Contact the Sport PEI Athlete Health and Performance Program or sportpeiahp@gmail.com if you have any questions.