In the first of this 2 part series on concussion, we looked at the definition of concussion and the reason it has become such a crucial subject in sport. The research is showing us that the effects of concussion can be cumulative, and can cause issues later in life – so every concussion must be treated with absolute respect, no matter how mild it may be seem the time!
This time, we’ll take a look at how to recognise concussion on the sporting field, the important signs and symptoms to be aware of, management strategies, and the difficult decision on not just return to sport, but more immediately important – a safe return to school!
One of the great things about the TV coverage of AFL footy is we can clearly see the seriousness with which concussion is treated! The player is taken immediately from the field, down to the rooms, taken through a battery of tests (to compare with baselines measurements taken from the pre season), the vision is looked at on the TV to help determine degree and extent of trauma, and a qualified medical practitioner makes a decision on return to sport! What a fabulous system – certainly beats the old fashioned way of a bit of a slap on the cheek, a bit of advice (“I thought you were tough”) and a bit of assistance (the magic “smelling salts”) before rushing them back onto the ground before the footy has reached the other end of the ground!
But what about the majority of us who act as volunteer trainers/medics/coaches, or who are simply standing on the sidelines watching your kid play sport – what do we do? That’s where it all gets a little more difficult, and therein lies even more reason why our decisions need to be very conservative.
Recognising Concussion
There’s no definitive set of signs and symptoms for concussion – each case can be variable, and often any displayed signs and symptoms are subtle. Remember that large forces are not required to sustain a concussion, nor is loss of consciousness necessary for a concussion diagnosis. In essence, and particularly with junior athletes, we should suspect a concussion (until proven otherwise) for all injuries that involve a transmission of force to the head. Whilst concussion recognition isn’t always easy here are three categories to be aware of*1:
1. Symptoms indicating potential concussion
| headache | dizziness | irritability |
| ‘don’t feel right’ | confusion | feeling slowed down |
| ‘pressure in the head’ | blurred vision | sadness |
| difficulty concentrating | drowsiness | feeling like ‘in a fog’ |
| neck pain | balance problems | nervous or anxious |
| difficulty remembering | sensitivity to light | trouble falling asleep (if applicable) |
| nausea or vomiting | more emotional | |
| fatigue or low energy | sensitivity to noise |
2. Clear signs that a concussion has been sustained
| Loss of consciousness | Balance or movement disturbance |
| No protective action by athlete in fall | Significant, new or deteriorating symptoms |
| Impact seizure or tonic posturing | Dazed, blank, vacant stare |
| Confusion, disorientation | Atypical behaviours |
| Memory impairment |
3. Features of a more serious injury requiring immediate medical intervention
| Neck Pain | Deteriorating conscious state |
| Confusion, agitation, irritability | Severe of increasing headache |
| Repeated vomiting | Unusual behaviour change |
| Seizure or convulsion | Double vision |
| Weakness/tingling/burning in limbs |
There are a few validated sideline questions*2 which can be used to give you an idea of if a concussion has been sustained and these questions include:
- What venue are we at today?
- Which half is it now?
- Who scored last in this match?
- Which team did you play last week?
- Did your team win the last game
If In doubt, sit them out!!
Whilst it is important we are able to recognise the signs of a concussion or potential concussion, the diagnosis of concussion should only be made by a medical practitioner. Certainly in the latter two categories listed above, immediate medical attention should be sought and you should never hesitate to ring 000 at the very least to seek advice on what to do.
Managing Concussion
First and foremost, any athlete suspected of having a concussion should be immediately removed from the field and not allowed to return to sport for the rest of the day. And when we’re dealing with children this should be an absolute “non negotiable”!
After removing from the field, a decision needs to be made on the necessity of seeking medical assistance. If in doubt, err to the side of caution and send directly to a medical clinic/casualty, or call 000 in the more serious cases. If a player has suffered a head knock but you are certain that no concussion has been sustained, that player should be carefully monitored in case they begin to show delayed signs.
In particular, in the case of head knocks and concussions, players should be advised to:
- Remain in the company of a responsible adult
- Refrain from driving home from their sporting activity
- Avoid alcohol
- Not take aspirin, “anti inflams”, sleeping tablets or other medication without the advice of a medical practitioner.
- Rest during the acute period (considered 24-48 hours post injury), and then gradually introduce cognitive/mental activity, followed by physical activity.
A NOTE ABOUT CHILDREN: younger brains are in a rapid development phase and there is a good body of evidence that tells us that children and adolescents recover from concussion at a slower rate than adults. Thoughts are that a different neural make up, less developed neck muscles, and a higher head: neck ratio may contribute to their vulnerability. The immediate priority with children (after you have determined a medical management strategy) should be based around a “return to learn” plan, not simply a “return to sport” plan. Whilst a topic in itself, the general recommendations for children include the following:
- Rest, in a darker, quieter, less stimulating environment than usual.
- Avoid bright lights and devices in the first 24-48 hours. Rest does not mean “go home and spend the next 24 hours on your phone, or watching Netflix”!
- If concussion symptoms persist, school may not be the best place for them – seek the advice of your doctor.
- Notify the child’s teacher, and if issues with concentration, memory, behaviour, headaches are noted, the child should be sent home for further rest.
- In more severe cases, a graduated return to school program may be necessary, just as we have a graduated return to sport program!
Whilst different sporting codes have slightly different policies regarding concussion, the “Concussion in Sport Australia, Position Statement” says that:
Children should not return to contact/collision activities before 14 days from complete resolution of all concussion symptoms*1
Note that this policy says “after complete resolution”, meaning that even if an athlete shows symptoms only the day of their injury, it is recommended they miss the next 2 weeks of collision/contact activity!
We could keep going on about concussion for a lot longer, but hopefully this gives a basic idea of the definition, recognition, initial management, and care that needs to be taken especially with children.
As a final take home message, there is a great tool called the Concussion Recognition Tool3. This simplified concussion summary has been designed for use by any member of the community and lists the key signs and symptoms that should raise concerns about a possible concussion.
We strongly recommend that anybody involved in community sport downloads a copy of the Concussion Recognition Tool and keeps it handy in your team’s first aid kit.
For any further information, take a look at your own sporting code professional/national websites and see if they have a sport specific concussion policy: the following organisations certainly do –
• Australian Football League
• Australian Rugby Union
• Basketball Australia
• Boxing Australia
• Football Federation Australia
And finally, ensure your sporting organisation has a Concussion Policy that is relevant to your sporting code, even if it means officially adopting the policy of your National Body!
Anthony Lance
SSPC Physiotherapist
References
*1Concussion in Sport Australia – Position statement
*2The Sport Concussion Assessment Tool (SCAT5)
*3 Concussion recognition tool
