Part 2- Management
So we’ve looked at pitch-side assessment of concussion (if you haven’t then see my previous post) and hopefully I’ve got the point across that this can be very difficult, however, I would say the most important take home is that if you are in doubt, remove from play and monitor. Repeat assessments will give you a better idea of any changes, and if you later decide there is no evidence of concussion then no harm done.
If you decide an athlete is showing signs of concussion however, what do you do?
REMOVE FROM PLAY
This is the most important step, this allows for further assessment and also eliminates risk of further injury.
Second most important point- any RED FLAGS as outlined in the previous post require an immediate trip to the Emergency Department- don’t try and be a pitch side hero when you don’t even have access to simple x-rays.
The athlete should then be advised to rest to reduce metabolic load on the brain, and is also the initial basis of most head injuries for the exact same reason- in severe head injuries this can be achieved further through sedation on an intensive care unit but that is a whole other subject!
Now how much rest the player should have is still up for debate- the consensus statement suggests that 24-48hours is usually sufficient before a graded rehabilitation plan can be introduced, however I would suggest a caveat to this is that worsening symptoms in this time requires urgent assessment and likely cranial imaging (CT/MRI) to rule out underlying pathology such as a bleed.
Following a rest period, an individualised rehabilitation can be introduced. At this point I feel it is important to outline that symptoms of concussion can persist for up to 2 weeks in adults, and even longer in children, and that continued symptoms are not a contraindication to rehabilitation, however they need to be considered when tailoring rehabilitation to an individual.
With well-structured rehabilitation the majority of athletes can expect to return to play within 10 days, however everybody is different, and no two injuries are ever quite the same. Some patients report symptoms persisting many months after the initial injury, as a general rule often the worse the initial symptoms, the worse the prognosis and road to full recover. It is important not to focus on time to recovery, but rather on response to recoveryin athletes undergoing rehabilitation.
Rehabilitation will always be individualised, depending on the individual, the sport they play and the symptoms experienced as part of their concussion, so it is impossible to outline what a ‘gold-standard’ programme would look like as it simply doesn’t exist, but should be carried out with a team of experienced professionals, and under close supervision.
Some common factors however may include-
- Sufficient rest period.
- Detailed analysis of symptoms and deficits sustained, so these can be monitored throughout recovery.
- Sub-maximal exercise that does not elicit symptoms, slowly built up over the course of recovery.
- Use of graded return-to-sport (RTS)- more on this later.
- Targeted physical therapy focussed on any specific injuries sustained.
- Treatment of associated cognitive/psychological deficits such as depression with specialist input, such as through cognitive behavioural therapy or counselling.
There is a consensus theory that athletes that return to play too early, and without sufficient rehabilitation, may be exposed to additional risk factors that play a role in persistence of cognitive deficit, long after the initial symptoms of concussion have passed. However, there is no gold standard of investigation that can say fro sure how long the roads to full recovery, and so as clinicians we must be vigilant to changes in behaviour, and most importantly seek advice of specialists when needed.
Graded return-to-sport (RTS)
This describes a well-structured, individualised rehabilitation programme that gradually builds up intensity of activity from complete rest to full activity. This is designed to allow sufficient time to recover following concussion and is performed under guidance of a specialist team to allow continued assessment throughout this period. The general rule is that athletes can progress through each stage as long as the level of activity does not elicit any further symptoms- the theory behind this being metabolic load on the brain is built up slowly to allow full recovery to occur- if symptoms occur during any stage then the athlete should return to the previous stage of rehabilitation to allow further recovery time.
Each stage of RTS should be carried out over a minimum of 24 hours, and may take longer depending on the individual.
The following table is taken directly from the consensus statement on concussion in sport and is designed to serve as an example of what the RTS programme could look like. As stated before however, this should be individualised and undertaken with a team of experts.
IMPORTANT NOTE- CHILDREN WITH CONCUSSION REQUIRE A DIFFERENT APPROACH TO MANAGEMENT NOT COVERED IN THIS POST AND EXPERT ADVICE MUST ALWAYS BE OBTAINED
Prevention of Concussion
This is a complex area that is still highly debated, and is not as simple as wearing a helmet, where evidence for their benefit is limited at best. This is a subject that I will return to at a later date… once I’ve had chance to update myself on the latest evidence and guidance!
Concussion is a complex and difficult subject. There are no gold standards for diagnosis, no gold standards in assessment, and no gold standards for treatment.
So much work still needs to be done to understands the pathophysiology that underlies this disease process, and how we manage this will undoubtedly change over the years.
My most important take home from all of my ramblings is to have a low threshold of suspicion, always ask ‘could it be concussion?’ and if there is any niggling in those instincts of yours that say it could be then assess off the field of play. Seek advice from experts, those with more experience, and then when you gain that experience yourself, pass it on to others. We still do not have all the answers, so as always, be prepared to change practice if and when the time comes- this is true for all of medicine of course.
No doubt we will come back to the subject of concussion in the future, but in the meantime I still encourage you all to read the full consensus status that I linked to in my previous post.
Not directly mentioned above but here are the current Bart’s NHS Trust and College of Emergency Medicine guidelines on head injury which are a good resource for red flags to look out for-