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Concussion, the invisible injury

BY Richard Moodie - NDIP, BMEC


What is a concussion
Concussion can be defined as a “traumatically induced transient disturbance of brain function which involves a complex pathophysiological process” (1). Concussions can occur as a result of rotational and angular forces and it can it occur without a direct blow to the head (2). Concussions may occur commonly with impact sports and are difficult to recognise. Due to risks associated with secondary concussion is important that players, coaches and parents or family members are familiar with the assessment and treatment of concussion.
How to asses for and diagnose a concussion
Ensuring that standardised assessment of concussion is performed along with education of players, coaches and parents may be some of the most important implementations that are needed to manage concussions at the side-line (1).
The definition already describes concussion as a complex pathophysiological process and the assessment of concussion cannot include a cognitive assessment only (3). The concerns regarding assessment is that there is misconception that concussion can only be diagnosed with brain imaging (1). The concern with this is that parents and coaches may not believe that the player has a concussion and may insist that the player return to play. It is therefore important to have a standard assessment for concussion that can be done on the field or side-line that involve more than a simple cognitive assessment. The assessment of concussion on the side line can be done by making use of assessment tools such as the Sport Concussion Assessment (SAC) or the Sport Concussion Assessment Tool (SCAT) of which the 5th edition was recently published (2). Although the SAC was validated in Emergency department it is not ideal for use in children under 12. Years. (2). The child SCAT 5 can be used to assess children aged 5 – 12 years (4).
The SCAT5 is a comprehensive assessment tool and include the use of the Glasgow Coma Scale (GCS) and addition of a rapid neurological screen that include cervical spine assessment (4).
Considering the current evidence on concussion and assessment tools available for side-line assessment the medical services should be set up in such a way that the player can be removed from the field to an area where an assessment tools such as the SCAT5 can be performed. The evaluation from medical services at the field can be done as follows:
Medics should be taught to screen for any “red flags” as described by SCAT5 and the player should be removed from the field immediately and safely (4).
The assessment described in SCAT5 should be performed by a trained medical professional that ideally received training on the use of the SCAT5. It is important that the player, coach and referee be informed that the assessment will likely take more than 10 minutes to complete and that the player must be substituted on the field. The SCAT5 assessment should not be done in less than 10 minutes and should ideally be performed in a resting state (4). It is important that the player is moved to an area where this can be achieved without undue pressure to return to play.
The patient should be evaluated based on the SCAT5 and a neurological examination if the attending healthcare professional is able to perform such an exam (2). Physical examination of the patient should include cranial nerve examination, balance testing and standard reflex testing along with strength testing (3). The evaluation should be aimed at determining if the patient might have a concussion and whether the patient require referral and/or transport to an Emergency Centre (EC) for further evaluation and neuroimaging. If a neurological examination cannot be performed at the field that may be the only reason to refer the patient to the EC and the value of this should be carefully considered. Neuroimaging should not be a routine reason for referral to the EC, as it is unlikely that obtaining neuroimaging will affect the management of the concussion (2). The EC may also utilise a decision-making algorithm such as the Canadian CT Head Rule to determine if Computed Tomography (CT) is indicated and the patient with a concussion may be excluded from requiring CT (3). CT may be valuable in excluding more serious injuries such as skull fractures, spinal injury or cerebral hemorrhage and any player in which these injuries are suspected must immediately be referred to the EC (2).
Once the diagnosis of concussion is made the player should not be allowed to return to play and the parents and/or coach should be informed of the diagnosis and the steps that must be followed before the player can return to play. The following information is important for parents and players:
Rest: The patient will require both physical and cognitive rest, physical rest may be needed for 3 to 5 days and thereafter the patient can gradually return to physical activities (3). Cognitive rest may be more difficult to explain but it involves avoiding activities that require intense concentration (3). The patient may want to play video games or use a computer during the time that they cannot do physical activity, but these should rather be avoided. It may be necessary to adjust the patient’s schedule to avoid prolonged periods of concentration.

Dizziness, headache and sleep disturbances: These may occur following concussion(3). Dizziness may occur as a result of a vestibular injury that is benign and will improve without management. The patient may also complain of light-headedness when getting up from a seated position and symptoms should improve with time (3). There is little value in pharmacological management of the dizziness and if symptoms persist for longer than 6 weeks after the concussion the patient should consult their doctor to perform comprehensive balance assessment (3).
Headache may occur and may be aggravated if the patient suffered from migraine type headaches prior to the concussion (3). Patients may want to consult their doctor and/or neurologist to evaluate a migraine type headache to ensure early effective management of the headache. Another cause of headache may be due to whiplash with resultant cervical strain (3). It is best to avoid medication that may mask symptoms such as codeine containing agents, like Mybulen that can cause drowsiness (2). It is safe to use medication such as Panado for headache according to the recommended daily dose. Sleep disturbances may occur, but tablets such as benzodiazepines should rather be avoided (3). Rather take a more conservative approach such as limiting caffeine intake, avoiding naps and consider the addition of melatonin as medication (3).
Patients and family members should be aware that people that had depression or anxiety prior to a concussion may have exaggerated symptoms after the concussion (3). The patient may also complain of photophobia and phonophobia (2).
It is important to monitor the patient for any signs of deterioration within first 24 - 48 hours and the patient should not be left alone during this time (4). Signs and symptoms to monitor for is valuable and can be found on the SCAT5.
Patients and family members must be aware of the risks associated with multiple concussions and second impact syndrome if the player return to play before the concussion is fully resolved (2). Second impact syndrome may be associated with cerebral oedema and raised intracranial pressures that can result in seizures, coma and/or death (2). The SCAT5 can provide guidance on how the player should return to sports and ideally the player must be evaluated by a medical professional before returning to play (4). There may also be long term cognitive deficits when a player suffer multiple concussion and there is evidence that those with previous concussion has an increased risk of suffering from another concussion (2).
With evidence suggesting that players of a sport such as rugby having an increased risk of suffering from a concussion whilst they also display unsafe practices around concussion management and return to play, more focus must be placed on educational campaigns (1). It may not be ideal to explain and counsel the players, coaches or parents of an injured player on the side of the field on all the dangers related to concussion. This may be a tense and emotional stage and common misconceptions such as only neuroimaging can diagnose a concussion still exist (1). Having educational and awareness campaigns to educate coaches, players and parents may be more beneficial to clarify misconceptions around concussion and the diagnosis thereof. Another important concept that must be explained and implemented is the use of standardised assessment tool such as the SCAT5 to assess concussion on the field and identify immediate “red flags” on the field.
With the ever-increasing risk of injuries occurring in sports played at school Emergency Medical Services (EMS) are almost always requested to provide medical standby services for school sports days and has become to a degree a legal requirement. These services are normally provided by Basic Life Support (BLS) practitioners and often by people trained in first aid. The diagnosis of concussion must include an assessment as described in the SCAT5 and the medics must be familiar with this assessment. Neuroimaging such as CT scans and MRI is only valuable to exclude more serious injuries but is not required to diagnose a concussion. It is important to ensure that the service provider that provide medical standby services at the event is adequately trained and equipped to perform the SCAT5 to diagnose a concussion.
1.          Viljoen C, Schoeman M, Bandt C, Patricios J, van Rooyen C. Concussion knowledge and attitudes among amateur South African rugby players. South African Journal of Sports Medicine. 2017;29:1-6.
2.          Scorza KA, Raleigh MF, O'Connor FG. Current concepts in concussion: evaluation and management. Am Fam Physician. 2012;85(2):123-32.
3.          Stillman A, Alexander M, Mannix R, Madigan N, Pascual-Leone A, Meehan WP. Concussion: Evaluation and management. Cleve Clin J Med. 2017;84(8):623-30.
4.          Echemendia RJ, Meeuwisse W, McCrory P, Davis GA, Putukian M, Leddy J, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med. 2017;51(11):848-50.

 May 31, 2019
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