Evolving best practice for concussion in sport

CONCUSSION in sport is causing concern in Australia and internationally. Rarely a week goes by without a high-profile media exposé on this topic.

Attention on concussion is accentuated by dramatic, multidirectional video replays of concussion incidents, media interest in high profile concussion stories and the recent Concussion movie, alluding to long term neurodegenerative disease linked to sport-related concussion.

All stakeholders are concerned. Athletes and parents are worried about the health ramifications of concussion. Coaches and teachers find themselves supervising children who have suffered concussion and are understandably apprehensive about this responsibility. Sporting organisations are focused on duty of care and the legal and financial risk exposure.

Concussion commonly presents as short-lived neurological impairment. The symptoms of concussion evolve over hours or days following injury, necessitating monitoring of the concussed individual. In the vast majority of cases, concussion will resolve without medical intervention and without significant post-concussive sequelae. Immediate and deliberate rest for a period of 2–3 days, followed by a graduated return to sport, underpins the management of uncomplicated concussion.

Medical practitioners are frequently asked to assess an athlete following a suspected concussion incident, most commonly not witnessed by the practitioner. The history is often vague and there is little to find on physical examination. There is no blood test or medical imaging examination that can definitively diagnose or exclude concussion. Providing evidence-based advice in this situation can be fraught with difficulty, especially when there is subtle or overt pressure from the athlete, parents or coach to allow rapid return to sport.

The diagnosis and management of concussion may be challenging for medical practitioners, even for those with a great deal of concussion management experience. The symptoms and signs are variable, non-specific and may be subtle. In some cases, there are obvious signs of concussion, such as loss of consciousness, brief convulsions or difficulty balancing or walking. In many cases, however, the symptoms are quite subtle, presenting as a change in personality, difficulty concentrating, fatigue or low energy, emotional lability or other non-specific indicators.

When an athlete is suspected of having concussion, first-aid principles apply together with a systematic approach to assessment of airway, breathing, circulation, disability and exposure. If there is any loss of consciousness, cervical spine injury should be suspected and appropriate spinal care instituted until spinal injury can be excluded.

Several sports have instituted protocols that indicate the clinical features requiring immediate and permanent removal from the sporting environment. These clinical features include loss of consciousness, lack of protective action when falling to the ground, impact seizure or chronic posturing, confusion or disorientation, memory impairment, balance disturbance, progressive concussion symptoms, a blank or vacant stare or atypical behaviour of the athlete. Immediate referral to the nearest emergency department is appropriate where there is neck pain, increasing confusion or irritability, repeated vomiting, seizure, peripheral nervous system symptoms or signs, deteriorating conscious state, severe or increasing headache, disturbed vision or behavioural change.

The diagnosis of concussion is based on clinical assessment across a range of domains, including mechanism of injury, symptoms and signs, cognitive function and neurological assessment, such as balance testing. The Sport Concussion Assessment Tool, 3rd edition, is an internationally recommended assessment tool and covers the clinical domains mentioned – it is likely that this tool will be updated shortly.

Managing concussion in children involves special considerations. It is unclear whether children are more susceptible to concussion than adults, as the evidence on this question is conflicting and inconsistent.

There is however reliable and compelling evidence that adolescents take longer to recover from concussion than adults. In approximately 90% of adult concussion, symptoms will completely resolve by 10 days after the injury. With adolescent concussion,  as many as 50% of patients will continue to have symptoms at 10 days, and up to 10% will remain symptomatic at 4 weeks. A more conservative management approach is therefore required when dealing with individuals with concussion who are aged 18 years and under.

There is vigorous debate about the potential long term consequences of concussion. The problem of chronic traumatic encephalopathy (CTE) has received much attention in the media. While the concern is understandable, it is important to note that a clear causative link between sport-related concussion and CTE has not been established. Current published evidence is limited to case reports, case series and retrospective analyses, which cannot adequately determine causality. There is significant selection bias in many of the reported cases.

While case presentations of degenerative disease in ex-athletes makes compelling Hollywood, it is not possible to draw definitive scientific conclusions. Properly structured, prospective epidemiological studies are required with control of potential confounding variables, such as genetic predisposition to psychiatric illness and alcohol and drug use.

The diagnosis and management of concussion in sport has improved significantly over the past decade. All of the major sporting codes are concerned about the ramifications of concussion and have significantly tightened management protocols. It is now universally accepted that individuals who have concussion should be removed from the sporting environment and should not be allowed to return to sport until they have been medically cleared to do so.

In May 2016, the Australian Institute of Sport and the Australian Medical Association launched a Concussion in sport position statement, which is freely available online. The position statement is a “living resource” and has been updated twice since its launch – most recently in December 2016 – in response to rapidly changing evidence being published in the medical literature. The website provides a range of downloadable resources and up-to-date information for athletes, parents, coaches, teachers and medical practitioners. The position statement and the website will be continually updated as indicated by contemporary evidence.

Sport provides significant physical, psychological and emotional benefits to Australians across the boundaries of gender, age and socio-economic status. Ensuring best practice in the diagnosis and management of concussion is essential to optimise participation, while ensuring the safety and welfare of all involved in sport.

Dr David Hughes is Chief Medical Officer at the Australian Institute of Sport in Canberra. He is a former President of the Australasian College of Sport and Exercise Physicians. He was Medical Director of the Australian Olympic Team for Rio 2016.

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