Concussion in sport has been all over the news recently with Hugo Lloris; should he have played on? Is the manager (Andre Villas Boas) allowed to make a decision for him to play on instead of the highly skilled medical staff that saved Fabrice Muamba’s life 2 years ago? Nemanja Vidic coming off with concussion against Arsenal, Graeme Smith being pulled out of South AFrica’s ODI team due to post concussion symptoms and the recent documentary aired in the USA ‘The league of Denial’ which has exposed the truths about the impact that repetitive concussions has had on former NFL players affecting their memory, behaviour, causing permanent brain damage and even leading to suicide. This post will go through what concussion’s are, the evidence based assessment, management and their return to play considerations.
Concussion is latin for shake violently!
Sometimes concussions are easy to diagnose!!!
Other times they are extremely difficult and require gathering a lot of information to either confirm or deny. The appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode and that concussion should be seen as an evolving injury in the acute stage.
Jahvid Best is currently a free agent due to ongoing post-concussive problems
What is a concussion?
A concussion is defined as a traumatically induced transient disturbance of brain function and is caused by a complex pathophysiological process. Concussions are a subset of mild traumatic brain injuries, on the less-severe end of the brain injury spectrum and are generally self-limited in duration and resolution.
- Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’ force transmitted to the head.
- Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
- Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
- Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged (AMSSM, 2013).
Bradley Davies injury profile http://www.physiowizz.co.uk/injury-analysis-physiotherapy/injury-analysis-bradley-davies/
Currently, there is no known biomechanical threshold for a clinical concussion. A demonstrated cellular process, the ‘neurometabolic cascade’ underlying the clinical presentation of a concussive injury describes a complex cascade of ionic, metabolic and pathophysiological events that is accompanied by microscopic axonal injury. This disruption of ionic balance and normal metabolism requires energy to re-establish homeostasis. However, the need for increased energy occurs in the presence of decreased cerebral blood flow and ongoing mitochondrial dysfunction, resulting in an imbalance of energy supply and demand. Until normal brain cellular function is restored there is increased post concussive vulnerability, showing that a second injury before the brain has recovered results in worsening cellular metabolic changes and more significant cognitive deficits. Evidence suggests the concussed brain is less responsive to physiological neural activation. Thus, excessive cognitive or physical activity before complete recovery may result in prolonged dysfunction. Some of these pathophysiological perturbations are more pronounced in youth, raising concerns that the immature brain may be even more susceptible to repeat concussions before complete recovery (Shaw, 2002).
Concussion rate per 1000 playing hours
Horse racing (Amateur)
Horse racing (Jumps)
Horse racing (Flat)
Australian football (professional)
Rugby union (professional)
Ice Hockey (NHL)
Rugby union (amateur)
Soccer football (FIFA)
NFL football (NFL)
(McRory et al, 2013)
Second Impact Syndrome
Second impact syndrome (SIS) typically involves a person displaying post-concussive symptoms following a blow to the head. Minutes, hours or days later if a second head injury is sustained a cascade similar to that seen in the first injury can lead to diffuse cerebral swelling, brain herniation and death (Watjen et al, 2010). Although , extremely rare, it can be devastating, a death can result within a few minutes. Awareness of this condition in sport should be more widespread, and particularly those involved in pitch side return to play decisions.
Each year a number of deaths in young athletes are attributed to SIS, however it remains a controversial diagnosis. Statistical data for the occurrence of SIS does not exist and the prevalence of this condition is unknown. What separates SIS syndrome from other devastating brain injuries is the rapid deterioration in the absence of haematoma (Watjen et al, 2010). Here is a summary of what we do know that can help guide management of concussion and return to play decisions:
- A history of concussion is associated with a higher risk of sustaining another concussion (estimates at 2 – 5.8 times more likely)
- If a person does not lose consciousness this does not mean that concussion has not occurred
- Certain sports and positions within those sports are at greater risk of concussion
- Greater number, severity and duration of symptoms are a predictor of a delayed recovery
- Animal and human studies support the concept of post-concussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell
- There is no same-day return to play for an athlete diagnosed with a concussion
- Athletes suspected or diagnosed with concussion should be monitored for deteriorating physical or mental status
- A return-to-play progression involves a gradual, step-wise increase in physical demands, sports-specific activities, and the risk for contact
- If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step
(Kimberley et al, 2013)
Interestingly to note, cerebral swelling can occur without a second impact. Many players that have been reported to have suffered sport related catastrophic brain injury did not have a second impact, rather they collapsed during sporting activity or walked off and subsequently collapsed. In addition to this, the incidence of SIS should be in theory more prevalent in sports such as boxing, however, this is not the case (McCrory, 2001). My take on this is that rather than refuting SIS, I believe this observation actually strengthens the argument that athletes should cease from any activity following concussion, not only those at increase risk of head injury.
School Boy dies from second impact syndrome http://www.bbc.co.uk/news/uk-northern-ireland-12335547
The suspected diagnosis of concussion can include one or more of the following clinical domains:
Symptoms—somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability);
Physical signs (eg, loss of consciousness (LOC), amnesia);
Behavioural changes (eg, irritability);
Cognitive impairment (eg, slowed reaction times);
Sleep disturbance (eg, insomnia).
(McRory et al, 2013)
Below is a diagram showing a model for concussion management from the RFU, 2012.
Primary survey of the athlete if they have a reduced level on consciousness:
- Danger, Response, Airway, Breathing, Circulation (DRABC)
- Alert, Verbal, Pain, Unresponsive (AVPU)
The Glasgow Coma Scale (GCS) is commonly used to both assess the severity of brain injury and to serially monitor patients following TBI. The GCS is used to classify TBI as follows:
Mild: GCS = 13 – 15
Moderate: GCS = 9 – 12
Severe: GCS = <8
Assume associated cervical spine injury
Cervical Spine Examination
- Double vision, dizziness, slurred speech, severe headache, nausea
- pain in the neck, referred pain, pins and needles, numbness, tingling along upper limb
- Neurological exam (myotomes, dermatomes, reflexes)
- Palpation for the presence of neck tenderness and pain by posterior to anterior palpation of the spinous and transverse process’ of the cervical spine if there are no neurological deficits or complaints of pain or tenderness were elicited during palpation begin active movement testing, however if there are immobilise the athletes neck with a collar or manually and call the emergency services.
- Neck AROM (flexion, extension, rotation, side flexion)
If there are no neurological or painful symptoms during the objective exam then the cervical spine has been cleared of serious pathology and does not require immobilisation (Rose, 2012).
Maddocks Questions (Orientation)
- What ground are we at?
- Which half is it now?
- Which side scored last?
- Which team did you play last week?
- Did you win last week?
Balance Error Scoring System (BESS) is a clinical balance assessment for assessing postural stability that can be completed in about 5 minutes. The BESS assessment tool is likely to identify concussion with low to moderate diagnostic accuracy (sensitivity 34%-64%, specificity 91%)(Giza et al, 2013).
The BESS provides a portable, cost-effective, and objective method of assessing static postural stability. In the absence of expensive and sophisticated postural stability assessment tools, the BESS can be used to assess the effects of mild head injury on static postural stability. Information obtained from this clinical balance tool can be used to assist clinicians in making return to play decisions following mild head injury.
Before testing, instruct the individual to remove shoes and any ankle taping if necessary. Socks may be worn if desired.
Scoring the BESS
Each testing position is held for a maximum of 20 seconds with the athlete instructed to keep their hands on their illiac crests and eyes closed. The BESS is scored by counting the errors, or deviations from the proper stance, accumulated by the subject. The examiner will begin counting errors only after the individual has assumed the proper testing position.
An error is credited to the subject when any of the following occur:
moving the hands off the illiac crest
- opening the eyes
- step, stumble or fall
- abduction or flexion of the hip above 30°
- lifting the forefoot or heel off of the testing surface
- remaining out of the proper testing position for more than 5 seconds
The maximum total number of errors for any single condition is 10.
The reliability of the BESS ranges from moderate (< 0.75) to good (> 0.75) while some studies report reliability coefficients below clinically acceptable levels (< 0.75). The same individual should administer the BESS for serial testing to improve reliability (Bell et al, 2011).
The average number of BESS errors in healthy controls depends on the stance and surface. Very few errors (range, 0-3) are associated with the double-limb stance on either thefirm or foam surfaces. Tandem stance average 1 error on the firm surface (range, 0-6) and 3 on foam (range, 0-8). The single-leg stance is responsible for adding 2 errors to the total BESS score on the firm surface (range, 0-8) and 6 errors on foam(range, 0-13 errors). Averaging the 20-39 year old data and the healthy controls results in a BESS score of 10.93 errors in. This agrees with normative data indicating an average BESS score of 10.97 in 104 community-dwelling adults (Bell et al, 2011).
Sport Concussion Assessment Tool (SCAT 3)
The SCAT 3 is a standardized tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older and includes the above testing procedures and should be completed on the sideline. The above testing procedures form part of the SCAT 3 which should be completed once first aid, primary and secondary surveys have been completed. It should be used by medical professionals and can be accessed here http://bjsm.bmj.com/content/47/5/259.full.pdf for children aged under 12 the Child SCAT 3 should be used and can be accessed here http://bjsm.bmj.com/content/47/5/263.full.pdf.
Cranial Nerve Testing
Although complete disruption of one or more cranial nerves is rare in the sporting world, the cranial nerves may be impaired as a result of the concussive blow. The assessment of many cranial nerves is imbedded throughout the concussion assessment (eg, CN VIII is evaluated during the BESS test), but the integrity of the remaining nerves should be completed as part of the sideline assessment. A cranial nerve assessment revealing functional deficits may indicate a more severe injury and so would warrant a timely assessment from the emergency services (Broglio and Guskiewicz, 2009).
Baseline pre-season evaluation using the assessment tools above can be useful to determine post concussion scores and how symptomatic they are. Assessment tools are most beneficial when baseline measurements are available for comparison.
Neuropsychological assessment has been described as an important ‘cornerstone’ of concussion management. Concussion management programmes that use neuropsychological assessment to assist in clinical decision-making have been instituted in professional sports, colleges and high schools (Enchemedia et al, 2013).
Traditional pen and paper tests are reasonably reliable, valid and sensitive to the effects of sports concussion (Randolph et al, 2005). Examples are in the table below:
(Randolph et al, 2005)
Computerized neuropsychological tests such as the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT), Axon Sports, the Automated Neuropsychological Assessment Metrics (ANAM) and CogSport can be rapidly adminstered to individuals or groups. Computerised batteries are portable and efficient for the collection, synthesis and storage of large amounts of data.
Appropriate use of neuropsychological test data can be very useful in the evaluation and management of athletes diagnosed with concussion. Neuropsychological testing should be a central element of concussion management programmes and both traditional pen and paper tests along with computerised testing used to ensure optimum assessment and resolution of the players symptoms (Enchemedia et al, 2013).
Pitch Side Concussion Assessment in Rugby (PCSA)
First trialled last year, the PSCA allows players to return to match action five minutes after a head injury as long as they have been cleared of concussion by medics. IRB chief medical officer Dr Martin Raftery, alongside IRB chief executive Brett Gosper on Monday (18/11/13), stressed the PSCA was designed to be a step-by-step or ‘multi-modal’ tool to help assess cases in which concussion was not immediately apparent.
The PSCA process confiming concussion leading to immediate removal from play
Confirmed Loss of Consciousness (LOC)
LOC can only be confirmed by a medically trained person attending the player following an assessment that shows that the player is not responding to orders and not moving apart from reflex movements such as tonic posturing or convulsions – this is equivalent to a player being assessed as P (pain) or U (unresponsive) on the AVPU scale
Tonic posturing as confirmed by the team doctor
Traumatic convulsion as confirmed by the medically trained person assessing / attending player
The player should leave the field for < 5mins for further evaluation using the PSCA tool if his team doctor or referee believe that he has sustained a suspected concussion.
If there is a yes in any of the columns the player is removed from the game!
Dr Martin Raftery re-iterated that if a player was clearly displaying signs of concussion, he shouldn’t play on in that same match. The ‘multi-modal’ approach has been trialled in leading tournaments as England’s Premiership and France’s Top 14 but has met resistance from the Celtic League. “The Six Nations have not signed on to it yet and we are certainly putting pressure on them to adopt it,” said Gosper.
The new scheme has had many critics with the PSCA’s most prominent critic beinbg former Ireland international Dr Barry O’Driscoll, the uncle of Irish great Brian. O’Driscoll resigned from the IRB’s medical board 18 months ago, claiming the issue of concussion was being “trivialised”. However, Raftery insisted Monday the PSCA was leading to a reduction in the number of concussed players remaining on the field. “Before with the single modal assessment it was based only on memory and that picked up just 32 percent of concussed players,” he said. “In the past 56 percent of concussed players stayed on the pitch, now with PSCA it is down to 13 percent.”
The scheme gives medical professionals more time to fully assess athletes then the traditional no minutes which is a good thing, but the jury is still out on its proficiency as a tool.
Referral to A + E
- GCS <13
- No medical personnel present
- Fractured skull or penetrating skull trauma
- Deterioration in conscious state following injury
- Focal neurological signs
- Confusion or impairment of consciousness > 30 mins
- LOC > 5 mins
- Persistant vomiting or increased headache post injury
- Any convulsive movements
- All children with head injuries
- Inadequate post injury supervision
Graded Return To Play
Athletes must be symptom free for 24 hours before proceeding to the next stage. Immediately following the concussion the athlete should undertake cognitive and physical rest:
- Rest: bed rest
- Cognitive rest: no reading, no computer, sitting in a dark room
Activities that do not exacerbate their symptoms.
24 hours at each stage once asymptomatic (RFU, IRB, 2012)
Unlike musculoskeletal injuries, few strength and conditioning methods will help prevent further concussions. However, that does not mean no preventive measures can be taken to minimize recurrence of concussions and other head injuries. Athletes sustaining a concussion are at a 3-fold increased risk for future concussions, and that risk increases with each successive injury.
In order to prevent recurrence, it is necessary to determine how the concussive incident occurred. No new valid, conclusive evidence was provided to suggest the use of headgear in rugby, or mouth guards in American football, significantly reduced players’ risk of concussion. No evidence was provided to suggest an association between neck strength increases and concussion risk reduction. There was evidence in ice hockey to suggest fair-play rules and eliminating body checking among 11-years-olds to 12-years-olds were effective injury prevention strategies. Reviewing game or practice films may provide an opportunity to see the mechanism of injury: a direct blow, a blow from hitting the ground, or even a rotational component. More importantly, the film may help reveal poor techniques, such as leading with the head to tackle or block or heading a soccer ball incorrectly. Reviewing the tape with the athlete and the coach may be useful in improving the athlete’s technique or changing the coach’s teaching methods. Preventing another concussion may be the difference in an athlete’s ability to return to participation during the season (Benson, 2013).
Concussions and Long Term Problems
Brett Farve played quarterback for the Green Bay Packers for over 20 years. He was heralded for his durability and longevity. In Farve’s last game, at the ripe old age of 42, he was unable to play because he failed the NFL mandated post-concussion tests. Of the numerous records he holds, two stand out; most sacked and most consecutive starts, so basically he got hit the most by opposing defenders and he played on in spite of this. Consider that when you read this next quote…
‘I don’t remember my daughter playing soccer, playing youth soccer, one summer, I don’t remember that. I got a pretty good memory….This was pretty shocking to me that I couldn’t remember my daughter playing youth soccer… So that’s a little bit scary to me. For the first time in 44 years, that put a little fear in me’ – Brett Farve, 2013
There is increasing concern that repeated concussions contribute to long term cognitive and motor declines, and that the risk of severe neurodegenerative conditions is magnified in this population (De Beaumont et al, 2013). The sporting world is finally taking note; the NFL recently paid £475 million to the families of former players who have either died or are suffering from early onset dementia, and the IRB recently recognised a potential link between concussion and Chronic Traumatic Encephalopathy, a condition associated with dementia.
I’m going to end this article by talking about Bert Trautmann. For those of you who are unacquainted with Bert, he was a goalkeeper who entered footballing folklore in the 1956 FA cup final after completing the game with two fractured cervical vertebrae; an injury he sustained from a collision 17 minutes into the game. More recently Hugo Lloris, another goalkeeper, played on despite losing consciousness on the field of play. Both Lloris and Trautmann were commended for their bravery, one played with a broken neck and the other with a concussion, both deserved better. Attitudes toward concussion need to change; Lloris and Trautman were both brave but it is up to parents/coaches/medical staff to be brave and the athletes health comes first. There is a lot of work to be done, firstly to collect more long term evidence on the impact/predisposing factors of concussion but also to change beliefs. Misconceptions with respects to concussion are so eloquently summed up by Eorl Crabtree, Professional Rugby League player and BBC pundit.
Yes…very good Eorl!
‘Letting a concussed player return to sport is not validated by how the player performs later in that game’ (Karim Khan, 2013). It comes back down to that simple mantra, if in doubt sit them out!
I would like to thank Michael Cottom (twitter:@mikecottom77) for his input to this article.
AMSSM, (2013). American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15–26. doi:10.1136/bjsports-2012-091941
Bell, D.R, Guskiewicz, K.M, Clark, M.A and Pauda, D.A. (2011) Systematic Review of the Balance Error Scoring System, Sports Health: A Multidisciplinary Approach, vol. 3 no. 3 287-295.
Benson, W.B, McIntosh, A.S, Maddocks, D, Herring, S.A, M, Raftery, Dvořák, J. (2013) What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med 2013;47:321–326. doi:10.1136/bjsports-2013-092216
Broglio, S.P and Guskiewicz, K.M. (2009). Concussion in Sports: The Sideline Assessment, Sports Health: A Multidisciplinary Approach, 1: 361.
De Beaumont, L., Tremblay, S., Henry, L. C., Poirier, J., Lassonde, M., & Théoret, H. (2013). Motor system alterations in retired former athletes: the role of aging and concussion history. BMC neurology, 13(1), 1-10.
Giza, C.S, Kutcher, J.S and Ashwal, S. (2013). Summary of evidence-based guideline update: Evaluation and management of concussion in Sports, American Academy of Neurology, 10 (4), 100-121.
McCrory, P. (2001). Does second impact syndrome exist?. Clinical Journal of Sport Medicine, 11(3), 144-149.
McCrory, P, Meeuwisse WH, Aubry M, Cantu RC, et al (2013) Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zurich. J Athl Train, 48(4):554-75. doi: 10.4085/1062-6050-48.4.05.
Randolph, C, McCrea, M and Barr, W.B. (2005) Is neuropsychological testing useful in the management of sport related concussion? Journal of athletic training, 40 (3), 139-154.
Rose, M.K, Rosal, L.M, Gonzalez, R.P, Rostas, J.W, Baker, J.A, Simmons, J.D, Frotan, M.A and Brevard, S.B. (2012). Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth. J Trauma Acute Care Surg, 73(2):498-502.
Shaw, N.A. (2002). The neurophysiology of concussion. Prog Neurobiol. 67(4):281-344.
Wetjen, N. M., Pichelmann, M. A., & Atkinson, J. L. (2010). Second impact syndrome: concussion and second injury brain complications. Journal of the American College of Surgeons, 211(4), 553-557.