Concussion in Sport- A Headache of a Problem

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.

Screen Shot 2018-09-24 at 19.12.51

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!

 

Final Words

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.

 

Links

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-

https://www.rcem.ac.uk/docs/Local%20Guidelines_Audit%20Guidelines%20Protocols/12hi.%20Head%20Injury(Barts%20Health,%202014)%20NOTE%20NICE%20Head%20Injury%20guidance%20was%20updated%20Jan%202014%20(CG176).pdf

Insights into Sport Medicine

Thanks for joining me!

Let’s start by way of introductions. I am a junior doctor based in Manchester, UK. I graduated from Cardiff University a few years back and I am now working towards a career in Sport and Exercise Medicine (SEM). It’s not the first career people think of in medicine, and people are always a bit surprised when I say that’s what I want to do. Many don’t even know that it is a branch of medicine, even some of my own colleagues! I quite like surprising people though, it usually leads to an interesting conversation after and people are always keen to tell me about their painful knee or sore shoulder when they find out what I want to do. I don’t mind, but there is more to a career in SEM than just musculoskeletal injuries.

Yes MSK problems are a big part of it, and pitch side (or track side in my case- I love athletics!) management of injuries is an essential skill of any sports physician, but there is so much more than just managing a twisted ankle- management of major trauma, head injuries, cardiac problems, respiratory problems… to name just a few. We carry out invasive procedures including intubation, ventilation and central venous access. We deploy a whole host of pharmaceuticals to manage the acutely unwell and the patient in severe pain. We offer coaching and advice in areas of performance and research. Pitchside is only one part of it, there are a few more avenues a future SEM doctor can venture down.

Rehabilitation. Occupational health. Respiratory conditions in sport. Cardiac conditions in sport. Endocrine conditions in sport. Drug and IPED misuse. Advisory roles for IOC and other regulating bodies. Research and academic roles.

Not to mention the performance side of things- just think about the number of different events you see in the Olympics every 4 years- at Rio 2016 Great Britain took home 67 medals. Behind each of those medals is an entire host of specialists, including doctors, trying to get the best performance possible out of the athletes that win them. As to what that involves, well I often compare SEM to intensive care medicine, but while the intensivist is trying to get a patient with incredibly poor physiology to normal physiology and function, a SEM doctors aims to take someone with normal physiology to supranormal- in other words, we literally create superheroes. Just sayin.

My interest? All of the above. I am still learning so much about my future as a doctor and I haven’t fully decided where that might take me. That may change soon and I’ll be sure to let you know if it does… or you may just start to see my blog posts favour one area of SEM over another!

Anyway- this blog aims to offer up to date information for clinicians and others working in this field about the latest research and practical applications of practising SEM. We will look at new papers, consensus decisions, offer revision aids and basically anything else I can think of related to this field.

Why am I doing this? The amount of training we get at medical school about sport and exercise medicine is pretty much zero. Nada. Zilch. So this blog will (hopefully) go some way to fill that gap in knowledge and maybe even be a little bit interesting!

I am not an expert. This is as much a learning experience for me as it is for anybody else and I openly encourage differing points of view, debate, contradictions and generally just telling me I am wrong if I am. Educate me when I am. Thats the only way we learn and grow. Lets just keep it friendly yeah?

 

We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do. — Atul Gawande