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Author: Charlotte Elliott, Rebecca Saunders, James Davies, Michael Whitlock / Editor: Charlotte Davies, Liz Herrieven / Codes: SLO4, TP1 / Published: 08/09/2020


Intro by Charlotte Davies

Concussion. It’s hard to believe we didn’t used to care much about it, and if your CT was normal, we were happy. Increasingly though, every sport is beginning to think about the role of their sport in concussion, and a lot of excellent guidelines and research are being created. RCEMlearning have also been thinking about this for a while, with not just one, not two but three previous podcast segments! We’ve tried something different for this blog and have a brief introduction followed by application of what we know in common sporting activities. Did we miss out your sport’s concussion guidelines? Get in touch! 

Before we start talking about the science of concussion, I’d just like to remind you that our patient’s interpretation of concussion and its impact is very different to ours. Dabney Ewin wrote in the last pages of his book about concussion, and as it’s at the end I can always find and reproduce easily!

When a doctor tells a patient he had a concussion, without pointing out that his neurological exam is perfectly normal and his prognosis is excellent (whether he thinks he was unconscious or not), a bag of worms is opened. He goes home and tells his wife that the doctor said he had a concussion, she tells her friends, there are questions about any headaches or behaviour changes (see nocebo), and so on, and when the doctor sees the patient next week, he’s full of subjective symptoms that are not explainable on a physical basis, and disability may have set in already. There are exceptions to this, but in head injuries we must be particularly careful what we say. “
“Imaginary” concussion reliably showed expectations in controls of a coherent cluster of symptoms virtually identical to the post-concussion syndrome reported by patients with head trauma.

This blog was written before the guidelines for concussion in non-elite sport were written, and the content below has not been re-reviewed. If in doubt, sit them out. No screens for 48 hours. Graduated return to play – not before 21 days. 

Concussion – by Charlotte Elliott

Concussion is a disturbance of the brain’s function caused by a direct or indirect force to the head. It does not show up on CT scans but does affect how the brain works. It most often does not involve a loss of consciousness and can result in a variety of signs and/or symptoms. 80-90% of concussions resolve in a 7-10 day period with a gradual improvement of symptoms. Common symptoms of concussion include headache, nausea, dizziness, slowed reactions, memory problems, poor attention, irritability or low energy. It is advised that anyone suspected having a concussion has plenty of rest, avoids stressful situations and uses painkillers such as paracetamol.

The Sport Concussion Assessment Tool (SCAT) is in its 5th edition and is therefore referred to as SCAT5. It is a standardized tool for evaluating concussions designed for use by physicians in athletes aged 13 and older. It recognises that a head impact either from a direct or indirect blow can be associated with a serious and potentially fatal brain injury. There is a Child SCAT5 for children aged 12 and younger.

A person may still have a concussion even if their SCAT5 is normal.

The SCAT5 begins with an on-field assessment with recognition of any red flags after sustaining a head injury which include
– neck pain or tenderness,
– severe or increasing headache,
– weakness or tingling in arms or legs,
– vomiting,
– loss of consciousness,
– seizure or
– deteriorating consciousness state.

It goes on to assess observable signs
– is the player lying motionless?
– do they have an unbalanced gait?
– are they confused or disorientated?
– do they have a blank or vacant look?
– have they sustained a facial injury post trauma?

 

The sportsperson should be immediately and safely removed from participation if there are any red flags or any observational signs are noted. Questions relating to the game are then asked, for example “Which venue are we at today?” and “Who is your opponent?”. A GCS and c-spine assessment completes part 1 of the SCAT5.

The second part is designed for use off-field and includes the athlete’s background including any medical issues. A symptom evaluation is then completed by the sportsperson where the they rate any symptoms out of 6 (where 6 is severe and 0 is none). Symptoms include headache, dizziness, sensitivity to noise, balance problems, confusion, sadness and nausea. A cognitive screen forms part 3 which includes orientation to time, a recall test (immediate memory) and concentration (repeating digits back to the examiner and saying months in reverse order). Step 4 is a neurological screen which tests coordination, gait, reading, following instructions and balance. Step 5 tests delayed recall. Step 6 brings together the results of the previous sections and allows the doctor to make a decision about the sportsperson.

Studies have modified this tool for use in the Emergency Department but it is yet to be validated. Other studies suggest the SCAT measures mild traumatic brain injury well and could be useful in the ED setting. Personally (editor), I think the SCAT is the only tool we have even in the ED for assessing concussion and, as long as the user understands its sensitivity and specificity, there’s no harm in using it.

Treatment of Concussion

Treating concussion is difficult. No imaging is required as standard. The BMJ offers some advice on recovery. Headway is generally considered the place to go to for information for professionals and patients. 

Concussion in Boxing – Lottie Elliott

SCAT5 is a mandatory examination for all boxers who have received a knock-out, a transient knock-out due to head blows, or received multiple head blows where there is a possibility of the boxer having suffered a concussion. Any athlete suspected of having a concussion should be removed from play.

There is a protocol to follow for deciding when the boxer can get back to the ring and a graded return to boxing follows a review by a doctor.

Suspension periods exist to protect the boxer’s health. These are recorded in the table below.

  Rest period
No loss of consciousness but suffers a knockout as a result of a blow/blows to the head 30 days
Loss of consciousness <1 minute 3 months
Loss of consciousness >1 minute 6 months
If during a 3-month period a boxer twice loses a bout due to KO or TKO due to a head blow with no loss of consciousness. 3 months
If during a period of 12 months a boxer suffers 3 KOs (with loss of consciousness <1 minute) or if 3 bouts are stopped by the referee due to heavy blows to the head. 1 year

A review of injuries sustained during training and competition by the Great Britain amateur boxing squad between 2005 and 2009 showed there were more injuries affecting the hand than any other body location. Most of the injuries occurred during training rather than competition and most were new injuries rather than recurring ones. They found the incidence of concussion was comparatively low.

Equestrian Concussion – Michael Whitlock

Horse Racing and Point-to-Point is controlled by the British Horse Racing Authority, who have been aware of the effects of concussion for many years. One of the problems for doctors is that they have to make a decision within minutes to decide if the jockey is fit to ride in the next race. Many jockeys will have 6 horses to ride in one day. Because minor concussion is difficult to detect in an immediate care setting the SCAT questionnaire and examination is used to check riders after any fall. All doctors involved need to be recognised by British Horse Racing and to have completed relevant trauma courses. Any jockey who fails the SCAT is prevented from riding until declared fit by the senior jockey club doctor.

All jockeys have psychometric tests before each season to establish a baseline and they cannot compete again after a fall until the tests have returned to normal.

Event riders who jump over fixed obstacles such as in the Badminton Horse Trials need to be assessed by a doctor after any fall. Doctors are encouraged to use the SCAT system in determining if the rider can compete on another horse. Minor concussion involves a suspension for seven days, but in practice most doctors will suspend the rider for 3 weeks. Any rider sent to hospital with suspected concussion is suspended for minimum of 3 weeks. All riders will need a GP or another recognised doctor to sign them fit again. Many professional event riders will use psychometric testing so they can avoid the 3 week rule.

Race course, Point-to-Point and event riders must wear an approved helmet – a measure which has reduced rates of concussion. There is debate over the hardness of the shell required. With a fall on a soft surface a softer shell is better at reducing concussion, but a kick or a horse falling on top of the rider would benefit from a hard shell.
Other disciplines such as show jumping and dressage are more relaxed over concussion rules because head injuries are less common. In show jumping it is mandatory to wear an approved safety helmet, but in dressage it is not. The winner of the London Olympics did wear an approved helmet and this caused some controversy as most riders wore a top hat.

Much research is being undertaken regarding concussion in riders. Investigation of the use of biochemical markers in detecting and monitoring concussion, including their use to determine if a rider is fit to ride, is shortly to be published. There are some enhanced CT scanners in the country which can detect minor contusions that most CT and MRI scanners cannot. Work is being undertaken on the effect on the neck vessels causing a temporary lack of oxygenation to the brain and the effect of electrical impulses after a head injury. Some riders have been found to have pituitary dysfunction associated with concussion and this still needs further work to determine any link.

There is a good twitter thread around forces involved in equestrian concussion here from @jopo_dr. 

Concussion in Sailing – James Davies

You might not automatically consider head injuries as being a sailing related injury. But look carefully at a boat – at the bottom of the sail is often a metal pole, connected to the sail. This is called the boom – some say because that’s the noise it makes when it hits your head. Hard. Generally, the bigger the boat, the bigger the boom. And the harder it hits. Mechanism of injury is very important, and being flung against the boat by a wave, flung across the boat by the boom, and falling from a height or at higher speeds can all be just as significant as a blow to the head itself. A helmet doesn’t necessarily protect you against concussion.

Sailors who sail near to land, are encouraged (required if working commercially) to complete the RYA first aid qualification, which covers head injuries as part of the syllabus. If sailors are likely to be travelling further away from help, a series of further qualifications can be obtained -including the STCW Medical Care Aboard Ship qualification.

The level of equipment carried depends on whether the boat is commercial or private pleasure only, and the length of the vessel. Dinghies (small boats) don’t have to carry anything, and nor do leisure cruisers (boats with a cabin) less than 13.7m. If you’re sailing on a commercial vessel up to 60 miles offshore, you must carry a category C kit, with a defined minimum contents. It would take at least an hour to get an injured casualty back to shore safely, so erring on the side of caution is recommended. There’s no chance of a “rest” when you’re on a sailing boat – even if you’re “off watch” and below deck, the boat moves, and you’re still constantly assessing the risk.

Why are we telling you this? Well, firstly, if you see a sailor, don’t underestimate the likely force involved. Sailors are used to bumps on the head and won’t attend ED unless they’re really worried. Secondly, if you work in a coastal area, you might be part of the team discussing injuries with a ship’s captain.

After any qualifying injury, and where concussion is suspected, sailors are advised to check for signs and symptoms, and if offshore, obtain early radio medical advice. Offshore, it is impossible to remove the seafarer from movement – putting them down below in a bunk is only half the battle.

Sailors are becoming more aware of the risks of concussion but there are no specific “return to sailing” rules.

Concussion in Cricket – 

Have a look at all of the advice from the ECB.

Concussion in Rugby – Rebecca Saunders

It won’t take any convincing to make you believe that concussion in Rugby League is a thing. However it isn’t always sustained in the usual way of a blow to the head. Many collisions are upright and involve a sudden deceleration causing contra-coup-type injuries and therefore can be quite hard to spot on occasion. It is mandated by the rugby football league (RFL), our governing body, that there are three doctors pitch-side (supporting both teams) as well as video footage for playback to review any suspicious looking tackles or behaviour from the players, in the hope to avoid missed concussions and therefore second traumatic impacts.

Concussion testing pitch-side includes a 5 minute period of mandatory rest, followed by 10 minutes to complete your examination and decide if the player is allowed to return to the pitch. We, like most sports, use the SCAT5 form to make our assessments. Anyone displaying category one symptoms, such as loss of consciousness or an ataxic gait, is removed immediately from the game without any other examinations or tests.  The rest are taken through the SCAT assessment, which is compared to a baseline SCAT which should have been done at the start of the season. This includes memory, concentration and critical thinking testing, as well as physical skill. Those who pass can return to the field of play. Those who don’t, remain off the pitch and go through a graded return to play protocol, as set out by the RFL. All SCAT forms are sent off to the RFL for governance reasons, to prove that testing was completed and the players remained safe.

Following a concussion players are made to rest for 48 hours starting the day after injury and must be asymptomatic at rest before any graduated return to sport protocols can begin.

The table below details an example of a return to sport strategy in adults after 48 hours of rest.

The players should only progress through each level if they are asymptomatic at the current level. If any concussion symptoms do occur, they should drop back to the previous asymptomatic level for at least a 24 hour rest period before attempting to progress again. Each step should take 24 hours minimum meaning it would take a week to get through the protocol.

If professionals take a week to recover from concussion, then maybe we should be giving similar advice to our amateurs in the ED hospital setting to help prevent longstanding issues and the risk of second impact syndrome.

England Rugby have some great resources for both clinicians and players including headcase and this fab video for younger players:

 

There’s lots of research happening about helmets. Check out these helmets! 

 

Now you’ve read the blog, why not test yourself on this (members access only!) SAQ.

For other interesting reading I’d recommend you (and your patients!) have a look at all of the resources available on headway, and don’t forget to listen to podcast one, two and three.