Part 1- Pitch-side assessment
Concussion has been, and remains to this day a hot topic amongst pre-hospital and sports medics. It is a notorious little bugbear in the healthcare system that does not play by the rules of well-established patterns that we often see in medicine. It is difficult to diagnose, which in turn makes it difficult to manage, and in the high pressured situation of pitch side assessment there is the added pressure of getting players back in the field of play, which can often lead to substandard assessment within a very limited timeframe. So I thought this would be a great topic to kick off my new blog with, and one that will no doubt come under serious scrutiny and backlash from the medical profession.
That’s okay, come at me bro. Just kidding, but I will admit that there is much divided opinion on the subject and I am sure that guidance on assessment and management will change dramatically over the net few years.
I am going to split this into two parts. First we will discuss pitch-side assessment, and then we will discuss further investigation and management, as both of these areas require a lot of discussion and I don’t want to bore you all too quickly.
First though let’s start with a bit of background.
It is important to note that concussion does not relate to the head injury itself, that is what it is- a head injury- but instead refers to the change in neurology that occurs alongside.
By definition concussion is temporary unconsciousness, confusion or other neurological symptoms that result from an injury to the head. I would go on to expand this further and say that it is an evolving pathology, with symptoms developing alongside the developing underlying injury, and as such is very difficult to identify and manage, a view that is mirrored by many experts including those of the 5thinternational conference on concussion in sport held in Berlin 20161, which is where much of the information in this post is drawn from. I will link in to this paper and any other sources at the end of the post, and would certainly recommend a read through this at some point.
Why is it a problem?
Concussion is a problem in any impact sport. Most commonly it is associated with rugby, American football, ice hockey and combat sports, but in reality almost any sport has potential for head injury to occur. It is estimated that in every three games played in the NFL, somebody suffers a concussion2, and that after playing 25 matches of rugby union, players are more likely to suffer a concussion than they are not3,4. This is not new data, but it is becoming an increasing concern as we look to the future of those suffering repeated head injury as a result of their sport, the biochemical changes in the brain that these cause and how these lead to increased rates of depression, suicide, types of dementia and other neurocognitive deficits. More research needs to be done but a nice summary of these long-term effects can be found in this paper5. Sufficed to say, we know it’s bad for you.
I am not going to outlined every nuanced detail about concussion management, I am not an expert and to be frank it would be an impossible task- as I have eluded to already there is still so much we don’t understand about the biomechanics of sports related head injuries and the resulting neurological defects these can cause, to say this is the only way to approach these injuries. What I will do though is try and give some practical advice on how to go about assessing and managing suspected concussion at pitch side and beyond.
This is not a one-stop guide- I will always encourage you to question why and do your own research. New evidence may change some, even all of what has been written and as clinicians it is our job to be open minded to new ideas and debunking of old ones, so please by all means if you feel you can give better advice or have new evidence please let me know, we can start a discussion and I will be happy to update with new evidence as we go along.
This is the hardest part. Imagine it. It’s the 2023 RFC World Cup Final. You are pitch side at the Stade de France in Saint-Denis. England are 12 points ahead of the All Blacks (I’m dreaming okay, let me have this moment) and fly-half George Ford has just taken a bit of a knock from his counter-part Beauden Barrett as he unsuccessfully attempts to break the defensive line. The crowd are disappointed, so are you, but then you notice George Ford stumble slightly to the left, seemingly off balance. It only lasts a second, and then he’s back in the game, full fighting form. What do you do?
Step 1- recognise a potential concussion.
Great, you’ve done that. George took a knock and you think something isn’t quite right. There is no one-size-fits-all pattern to concussion and although we talk about neurological deficits it can present with a number of clinical signs, or non at all. Often it may be experience that drives the decision for further assessment, but as a first point of call the 2017 Concussion in Sport Group (CISG) point out some clinical features that should be considered in diagnosing a suspected head injury.-
- Concussion may result from a blow to the head, neck or other part of the body that creates an impulsive force that travels to the brain- so always consider the mechanism of action, for example has a high tackle around the chest driven the head and neck forward at powerful velocity?
- Neurological symptoms usually have rapid onset and are self-resolving, but as we’ve already said, the pattern can be slow and evolving- have a low threshold for suspicion.
- Initial signs usually represent a functional abnormality, not a structural one. Therefore classic head imaging will likely not tell you much.
- Symptoms usually come on and then resolve in a sequential pattern- but this is not always the case.
- Signs and symptoms do not have another cause e.g. alcohol, drugs, co-morbidities etc.
Step 2- Pitch side assessment.
This should be performed on anybody with suspected concussion- and as a health professional you need to ignore any protests from the player/coach/manager- how much was your indemnity this year? Lets avoid any medico-legal problems shall we. At the end of the day you want to ensure that the player is safe to return to the field of play with no long-term consequences on their health.
Do you have access to video replay? USE IT. Identifying signs of concussion in the heat of play is incredibly difficult, so utilise the tools at your disposal and review video replay if you can.
It goes without saying that in the case of severe injuries you utilise you trauma assessment of the patient, with the classic ABCDE pattern and review of any potentially life-threatening injuries, including spinal cord assessment being performed first. We’ll assume you’ve done that.
I won’t go into the details of how to carry out a trauma assessment, that can be learnt on a number of expensive courses I am sure many of you will have done, but it is always important to cover red flags in head injury that anyone can recognise, and should prompt immediate removal of play and in most cases transfer to hospital. These are taken direct from CISG guidelines as well as from NICE guidelines6, but modified to be specific to sport, and are a good little summary to remember-
- Unconsciousness or lack of full consciousness, even if the person has now recovered.
- Seizure, vomiting or increasing headache.
- C-spine tenderness
- Evidence of CSF leak- clear fluid running from the ears or nose.
- Bleeding from one or both ears.
- Bruising behind one or both ears.
- Any signs of skull damage or a penetrating head injury.
- The injury was caused by a forceful blow to the head at speed- consider the mechanism of action, and in the context of sport being played.
- The person has had previous brain surgery.
- The person has had previous problems with uncontrollable bleeding or a blood clotting disorder, or is taking a drug that may cause bleeding problems (for example, warfarin).
- Increasingly restless, agitated or combative
Assuming there are no immediate concerns now comes the tricky part- concussion assessment.
There are many tools available for assessing likelihood of concussion at the pitch side. The Sport Concussion Assessment Tool (SCAT)7is standardised and is the one recommended by the CISG- caveat to this is that they designed it so there may well be a bias in its use.
You may find another tool that works better for you but the important thing to note is that these tools should never be used as a single tool to identify concussion. There is no single test. It is a clinical decision.
Having said that it can be a very useful aid to frame your clinical assessment around, so it is well worth a read in advance. Find a link to the full SCAT5 below.
Important points to consider are-
- It is recommended for use in anyone aged 13 or older. In younger children there is a Child SCAT, which I will not cover in this post.
- Healthcare professionals with appropriate training only should use it.
- It can be used in advance of play to create a baseline for your players- this is not essential, and there is debatable evidence on how effective this is, however I personally like to do this as it also gives me chance to get to know the player and how they answer questions, which can be useful for identifying a change.
The SCAT is divided into on-field and off-field assessment.
The on field assessment includes GCS score, the Maddock’s questions (these are similar to an abbreviated mental test score and are designed to assess immediate change in cognition and memory deficit), as well as assessment of C-spine and red flags.
At this point if suspicion of concussion continues then further assessment should be carried out off pitch, in a safe, quiet environment. The SCAT divides this assessment into 6 parts-
- Athlete’s Background
- Symptom Evaluation
- Cognitive Screening
- Neurological Screening
- Delayed Recall
- Clinical Decision
There is a tonne of useful advice on the SCAT, which is linked below, on how to carry out this assessment and I would recommend having a read through this.
Concussion evolves, I cannot emphasise this enough, and so serial assessments may need to be carried out and it is essential that the player is not left unattended during this period.
The final point I need to emphasise in this overly long post is that any player who you suspect has sustained a concussion should not be allowed to return to the field of play. They require further assessment, investigation and rest- this reduces metabolic load of the brain and allows the process of recovery to begin. Rehabilitation can then begin, but we will cover that in the next post.