As a growing public health issue in Australia, sports-related concussion (SRC) is an area of immediate concern and there is a need for easily accessible up to date and trusted information.
An important milestone in the development of the risk reducing approach to concussion for Australia was achieved last week with the official launch of the Concussion in Sport Australia website and position statement. Funded by the Australian Government and developed through the collaborative efforts of the Australian Institute of Sports (AIS), Australian Medical Association (AMA), Australian College of Sports and Exercise Physicians (ACSEP) and Sports Medicine Australia (SMA); the website provides a trusted and valuable resource for all Australians across all levels of sports from grassroots right through to the professional level. This is an important resource especially at the grassroots level, where field side medical care is not always present nor easily accessible.
We will examine the highlights and major take home points from the updated Concussion in Sport Australia position statement in the following blog. Major highlights of the website include easy to follow visual flow charts on return to sport (RTS) for adults and children as well as on and off field management charts for both non-medical individuals (coaches, parents, teachers etc) and medical practitioners along with definitive care centers.
Presented in key categories, the position statement provides an up to date overview of the current evidence on SRC. The goal of the statement is to:
- Provide improved safety and health outcomes
- Assist sporting organisations and clubs to align policy and procedures with up to date evidence
- Protect the integrity of sport through the consistent application of best practice, and
- Provide a platform to support the development of national policy for concussion
What is a concussion?
The definition of a concussion has not changed much over the past few years, with the most recent consensus statement from Berlin stating that “concussion is a traumatic brain injury (TBI), induced by biomechanical forces to the head, or anywhere on the body which transmits an impulsive force to the head”1,2.
A key point of note is that the recognition of concussion is extremely difficult. This stems from the issue that the appropriate management of concussive injuries relies heavily on athlete reporting of symptoms for recognition and removal from play. Recognition is the first and most important step in the management of the injury. Any suspicion of a concussion should be assessed and diagnosed appropriately by a medical practitioner.
A useful tool to help with this difficult task is the Concussion Recognition Tool (CRT), designed to help non-medically trained individuals in the identification of the suspicion of a concussive injury1.
Medical Assessment of Concussion
The next major take home point surrounds the clearance of concussive injuries prior to returning to training and play. The statement calls for all injuries to be cleared by a medical practitioner prior to returning to sport. This is extremely important due to the lack of correlation between symptom resolution and full recovery. It is imperative that all athletes be taken through a graduated return to learn and sport protocol by a healthcare professional with experience and training in concussion management, followed ultimately by a final assessment and clearance for return to play.
Key points for medical practitioners also focus heavily on the subtly surrounding concussive injuries. Whereby diagnosis should be based on a range of domains included in a thorough clinical history and exam (ie. mechanism of injury, signs and symptoms, cognitive function, neurology and balance assessments).
Predictors of Clinical Recovery
Concussions are not a straight forward injury and every person and/or injury will respond and recover in a different and individualised way. There have been suggested predictors of clinical recovery in recent literature, however clinical judgement remains the cornerstone for management1.
The statement discusses the specific steps that should be taken following the diagnosis of a concussive injury; see the key points as summarised below. It is important to remember however that every concussion is different, and these steps are a guideline for management that should be applied and guided by a healthcare professional with training and experience in concussion.
- Head injury advice should be provided to all athletes with concussion and their career
- Physical and cognitive rest is advised in the first 24-48 hours
- Early activation follows – with the commencement of symptom limited light physical activity
- Graduated return to sport stages are followed symptom free
- Sporting organisations need to review and update policy as appropriate to maintain best practice
- High risk sports (ie. Professional collision sports) need to ensure medical personnel are appropriately trained in concussion diagnosis and management
Children and Adolescents
There is a growing body of evidence supporting slower rates of recovery from concussion in both children and adolescents3-7. This has led to the more conservative approach to the management of children and adolescents in recovery; with a focus on a full and unmodified “Return to Learn” prior to returning to sport. The statement recommends that schools may need to provide accommodations in this process and children should NOT return to contact and/or collision activities any less than 14 days post resolution of ALL symptoms.
General knowledge about concussion remains sub-optimal, despite improvement in recent years. This is an important issue where athletes, parents and coaches, and sporting and medical organsiations need to continue to improve awareness and understanding of the injury. This in turn will help with understanding the importance of self-injury reporting, recognition on the sidelines in community sport as well as the continued development of recommendations.
Long Term Consequences
Finally, the statement addresses the current issues around the evidence of potential long-term consequences of concussion. There has been much media coverage of the studies around Chronic Traumatic Encephalopathy (CTE) of late attempting to draw a link between concussive injury or sub-concussive impacts and cognitive deficits in later life. Despite the magnitude of research and media coverage, there is currently no reliable evidence showing a causation linkage between SRC and CTE.
In conclusion we would like to commend this group for their joint effort in the creation of such a great resource for Australian sport. Excellent work to all those involved and we look forward to the continued progress to ensure our athletes receive the best possible concussion information and care.
The mandate of Complete Concussion Management is to deliver evidence-based care through our clinical network, and as such we analyse and disseminate the latest research to our network on a monthly basis so we are always delivering the most effective care to our patients. If you are in search of some help in the recovery/rehab space as a patient or would like to find out more about clinical network membership as a clinician, contact us through our website at www.completeconcussions.com
For access to the full Concussion in Sport Australia position statement follow this link: www.concussioninsport.gov.au/__data/assets/pdf_file/0005/683501/
- McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., Cantu, R.C., Cassidy, D., Echemendia, R.J., Castellani, R.J., Davis, G.A., Ellenbogen, R., Emery, C., Engebretsen, L., Feddermann-Demont, N., Giza, C.C., Guskiewicz, K.M., Herring, S., Iverson, G.L., Johnston, K.M., Kissick, J., Kutcher, J., Leddy, J.J., Maddocks, D., Makdissi, M., Manley, G., McCrea, M., Meehan, W.P., Nagahiro, S., Patricios, J., Putukian, M., Schneider, K.J., Sills, A., Tator, C.H., Turner, M., Vos, P.E. (2017). Consensus statement on concussion in sport: the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine. 0:1–10. doi:10.1136/bjsports-2017-097699
- McCrory, P., Feddermann-Demont, N., Dvorak, J. et.al. (2017). What is the definition of sports-related concussion: a systematic review. British Journal of Sports Medicine, 51(11): 877-87.
- Iverson, G.L., Gardner, A.J., Terry, D.P. et.al. (2017). Predictors of clinical recovery from concussion: a systematic review, British Journal of Sports Medicine, 51(12), 941-48.
- Manzanero, S., Elkington, L.J., Praet, S.F., Lovell, G., Waddington, G., Hughes, D.C. (2017). Post-concussion recovery in children and adolescants: a narrative review, Journal of Concussion; doi: 1:2059700217726874.
- Davis, G.A., Anderson, V., Babi, F.E., et.al. (2017). What is the difference in concussion management in children as compared with adults? A systematic review. British Journal of Sports Medicine, 51(12), 949-57.
- Field, M., Collins, M.W., Lovell, M.R., Maroon, J. (2003). Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. Journal of Paediatrics, 142(5), 546-553.
- Crowe, L., Collie, A., Hearps, S. et.al. (2016). Cognitive and physical symptoms of concussive injury in children: a detailed longitudinal recovery study. British Journal of Sports Medicine, 50(5), 311-16.