Sports-Related Concussions in the Emergency Department

Context

There is an increasing interest amongst healthcare professionals and the public regarding the possible long-term effects of repetitive concussive and sub-concussive impacts.

Although concussions are possible in many contact sports, there has been particular focus on injury caused by repetitive heading in football and within rugby after several retired professional players have been diagnosed with neurodegenerative diseases. The approach to concussions has significantly changed following the introduction of new strict Head Injury Assessment (HIA) protocols into the professional game by World Rugby. This shift in attitude has subsequently influenced the management of concussions in grassroots (non-elite) sports.

Figure 1: Group of Men Playing Rugby – image via Pexels

Following a parliamentary inquiry, in 2023 the UK Government published new nationwide concussion guidelines for grassroots sports to improve the safety of participants. Now, following the “if in doubt, sit them out” mantra, players at all levels must be immediately removed from play if a concussion is suspected. If concussed, players must then follow the stepwise return to activity timeline.1

Whilst there are a vast number of validated resources developed for pre-hospital on/off pitch use, such as the Standard Concussion Assessment Tool 6 (SCAT6), there is currently no well-accepted standardised guideline or tool specifically validated for use in the Emergency Department (ED).

There is also a widespread lack of familiarity within healthcare with the new UK guidance, specifically surrounding the new gradual return to activity timelines. Therefore, despite concussions being a relatively common presentation to the ED, they are often poorly recognised and there is a lack of clinical consistency in management and discharge advice given.2

Appropriate patient education and discharge advice is essential to reduce the risk of further injury. Repetitive concussive or sub-concussive impacts can have severe neurodegenerative consequences (such as chronic traumatic encephalopathy) and long-term mental health conditions (such as depression). There is also a possibility of fatal outcomes such as second impact syndrome. Therefore, the effects of concussions are not only limited to sports but can impact many aspects of life.2

This is particularly important as many grassroots players will not have access to medical specialists and the ED clinician may be the only healthcare professional they see for this injury.

Figure 2. UK Concussion Guidelines for Non-Elite (Grassroots) Sport1

Learning bite

Accurate discharge advice and following the gradual return to activity timeline is essential to reduce the risk of further serious injury.

Definition and Pathophysiology

A sports-related concussion (SRC) is a form of mild traumatic brain injury (mTBI) that causes a disturbance in brain function. SRCs account for approximately 15-20% of all mTBIs.2

According to the 2022 Consensus Statement on Concussion in Sport,3 SRCs:

• Are caused by a direct blow to the head, face, neck or body resulting in an impulsive force transmitted to the brain that has occurred during a sporting activity.
• Present with a range of evolving clinical signs and symptoms that may or may not include loss of consciousness (LOC).
• Present with symptoms immediately, or after minutes or hours. These commonly resolve within days but may be prolonged.

SRCs are caused by a complex pathophysiological process where neurotransmitter release, blood flow changes and inflammation impact brain function. This is a functional disturbance, not structural, therefore no structural damage is seen on standard neuroimaging e.g. CT head.2-4

Figure 3: Athletes Playing Grass Hockey – image via Pexels

Learning bite

SRCs are a common type of mild traumatic brain injury.

Patients with SRCs can present with a wide range of signs and symptoms. This can make diagnosis challenging for clinicians, with up to 50% of concussions being missed in the ED.5 It is important to listen to the concerns of those close to the patient including accompanying family members, friends or coaches to identify non-obvious signs such as subtle personality changes.

Symptoms of concussion may present immediately following the head injury, or over the following hours-to-days. Most patients improve within 2-4 weeks but some may experience a prolonged recovery period with approximately 10-20% experiencing symptoms for months to years.

Symptoms are likely to evolve over this recovery period and can have a huge impact on many areas of life including work, school and relationships.

Concussion is a clinical diagnosis. To aid the recognition of a SRCs there are 4 main categories to consider1,2,5:

It is important that these signs and symptoms cannot be explained by other causes, such as drug use, alcohol use, medications, pre-existing mental health conditions or other injuries e.g. cervical spine injuries.

Learning bite

Loss of consciousness only occurs in approximately 10% of concussions. Many symptoms of concussion are not physical; the patient may just “not feel right.”

There is currently no validated tool or national guideline for the management of concussions in the ED.

There are a vast number of validated resources and recognition tools developed for pre-hospital on/off pitch use. One widely used example is the SCAT6. Several studies have assessed its use in the ED but concluded that it is a relatively long assessment and not ideal for in-hospital use.2,3,5

There are three main aspects to cover when approaching an SRC in the ED:

1. Identify cerebral injury requiring imaging or other serious injury;
2. Identify concussion early by recognising signs and symptoms;
3. Prevent further injury by giving appropriate discharge advice.

The initial step is to assess the need for neuroimaging or neurosurgical input following the NICE Head Injury Guidelines.4 Most patients with an SRC do not require imaging but it must always be considered. It is also important to consider other serious injuries such as cervical spine or maxillofacial fractures.

Below is a summary of the NICE Head Injury guidelines for those aged ≥ 16 who have sustained head injury4:

Figure 4. From NICE Head Injury Guidelines4

Figure 5. From NICE Head Injury Guidelines4

Further important aspects of the ED assessment include2,5:

A comprehensive history that should cover:

• The events around the injury i.e. timings, mechanism, whether they continued continue to play
• Current symptoms and symptoms trajectory (i.e. whether they are worsening or improving) – this is especially important in delayed presentations
• Identification of premorbid factors that may lead to prolonged recovery and worse outcomes such as previous concussions or pre-existing mental health conditions

There are key aspects to consider when examining a patient with a concussion. It should be noted that this may vary based on the clinical picture:

• Baseline GCS
• Full neurological examination:
  • Vision and eye movements
  • Balance e.g. Romberg’s test
  • Coordination
  • Gait
  • Peripheral nervous system
• Mental status and cognitive function i.e. alertness, memory, concentration
• Neurophysiological assessment

It is important to note that the absence of symptoms in the ED does not rule out concussion.

To aid assessment some clinicians may find it useful to use aspects from the SCAT6. For example, if concerned about balance one could use the Balance Error Scoring System (BESS) section.

Notably, vestibular testing (eye movement and balance) is often a missed component. Clinicians may find it helpful to use the Vestibular/Ocular-Motor Screening (VOMS) tool.6 A summary of this assessment can be found via this link: VOMS-explicit-directions.pdf

Learning bite

When assessing an SRC, a clinician must first rule out serious cerebral or cervical neck injury.

Patients with SRC usually only require supportive treatment e.g. simple analgesia, fluids and rest. If experiencing dizziness, some papers suggest the use of the Epley’s manoeuvre if the c-spine has been cleared.2,5

For those who do not require imaging or have normal brain imaging, the NICE Head Injury Guidelines4 can be used to assess the need for admission and observation. After ruling out other serious injury, the mainstay of management is appropriate discharge advice and safety netting.

Learning bite

Most patients with SRCs require supportive treatment only and do not need to be admitted.

Appropriate discharge advice is essential to optimise recovery and prevent further injury. Ideally this advice should be given in written and verbal formats to both the patient and person responsible for their care after discharge.

Explanation of injury and safety netting2,5:

• Explain the common symptoms of concussion
• Explain that recovery varies for each individual but most make a full recovery in a short period of time (approximately 10-14 days)
• Monitor symptoms and educate patient and caregiver on red flags – if symptoms do not improve in 14 days or worsen, seek medical advice i.e. NHS 111 or ED
• Some may experience prolonged recovery (post-concussion syndrome). If symptoms have not resolved within 28 days, the patient should see their GP as they may require specialist referral and review

Educate patients on long-term consequences of repetitive concussive or sub-concussive impacts2,5:

• Ensure patients are aware a concussion is a form of brain injury
• Explain that the greatest risk of further injury is in the first 7-10 days after the primary concussion
• The effects of concussion are not limited to sport and can impact many aspects of life such as education and work
• Repeated concussions increase the risk of neurodegenerative diseases e.g. chronic traumatic encephalopathy and possibly long-term mental health conditions e.g. depression
• Explain that the brain is in a vulnerable state and is at a higher risk of reinjury. Second impact syndrome is a rare, severe and possibly fatal injury where a subsequent head injury occurs whilst the brain is still recovering from the initial concussion.

Children and adolescents may be generally more susceptible to concussions, take longer to recover and are more likely to have rare and dangerous neurological complications.1

Other Do’s and Don’ts:

Graduated return-to-activity guidelines1:

The new graduated return-to-activity guidelines aim to achieve a successful return to normal activity and to avoid further injury. After a short period of complete rest (24-48 hours), the patient should follow the gradual stepwise approach to normal activities and then sport. Progression through the stages is dependent on the activity not (more than mildly) exacerbating current symptoms or causing new symptoms. Patients should drop back to an earlier, asymptomatic level if this occurs.

Key points include:

• To return to training that has risk of head impact, patients must be asymptomatic for 14 days prior
• The shortest time in which patients can return to competitive sport is 21 days (only if asymptomatic at rest in previous 14 days and symptom-free during training)

Below is a summary of gradual return to activity guidance. More information is available in the UK Grassroots Concussion guideline (see below).

Figure 5: Adapted from UK Government Concussion Guidelines for Non-Elite (Grassroots) Sport1

Signpost

Some useful resources include:

• Headway Headway – the brain injury association | Headway
• UK Grassroots Concussion Guidelines (appropriate for patients) UK-wide Concussion Guidelines for Grassroots Sport
• ACORN  (After Concussion Return to Normality) offers advice for Paediatric patients
• Head On Health Home | HeadOn

Learning bite

Following a head injury, patients must not participate in competitive sport for at least 21 days.

There are several areas currently being researched for potential use in future practice.2,3,5 These include:

• An ED-specific, validated tool to be used alongside clinical judgement for the assessment and management of SRCs.
• Serum biomarkers that can potentially identify those with more severe concussions and therefore those at increased risk of prolonged recovery (post-concussive syndrome).
• Neurocognitive testing batteries which may have a role in assessing neurophysiological function in mild traumatic brain injuries.
• Advanced neuroimaging e.g. MRI that may identify brain damage that is not visible on standard CT imaging.

Although these show promise in the research setting, evidence is currently limited and they are not yet suited for routine use in clinical practice.

Learning bite

There are several upcoming areas of research surrounding concussions, but further research is required.

• Accurate discharge advice and following the gradual return to activity timeline is essential to reduce the risk of further serious injury.
• SRCs are a common type of mild traumatic brain injury.
• Loss of consciousness only occurs in approximately 10% of concussions. Many symptoms of concussion are not physical; the patient may just “not feel right.”
• When assessing an SRC, a clinician must first rule out serious cerebral or cervical neck injury.
• Most patients with SRCs require supportive treatment only and do not need to be admitted.
• Following a head injury, patients must not participate in competitive sport for at least 21 days.
• There are several upcoming areas of research surrounding concussions, but further research is required.

1. UK Government. UK Concussion Guidelines for Non-Elite (Grassroots) Sport. 2023 [accessed 1 Nov 2023].
2. Whitehouse DP, Newcombe VF. Management of sports-related concussion in the emergency department. Br J Hosp Med. 2023;84(9):1-9. doi: https://dx.doi.org/10.12968/hmed.2023.0171
3. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med. 2023; 57:695-711.doi: 10.1136/bjsports-2023-106898
4. National Institute for Health and Care Excellence (NICE). Head injury: assessment and early management. [NG232]. London: NICE; 2023 [accessed 1 Nov 2023].
5. Bazarian JJ, Raukar N, Devera G, et al. Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med. 2020;75(4):471-82. doi:10.1016/j.annemergmed.2019.05.032
6. Mucha A, Collins MW, Elbin RJ, Furman JM, et al. A brief vestibular and ocular motor screening (VOMS) assessment to evaluate preliminary concussion: Preliminary findings. Am J Sports Med. 2014;42(10):2479-86. doi: 10.1177/0363546514543775