Concussion is one of those topics in sport that has been increasing in prevalence over the last few years. It is most likely that concussion injuries have existed for a long time, however, the awareness of their symptoms, presentation and management have been largely hidden from the mainstream. High profile athletes who have shared their experience of concussion have helped to create a groundswell of awareness around the seriousness of concussion’s short term and long term effects on individuals, their sporting career and their everyday life. Researchers and medical professionals continue to study this phenomena to better understand concussion and recommend treatment and management practices. In October 2016 the Concussion in Sport Group reconvened for their 5th International Conference on Concussion in Sport and published in April, the 2017 Concussion in Sport Group (CSIG) consensus statement. The stated intention of the consensus document is to develop further conceptual understanding of sport-related concussion (SRC) and is meant for physicians and healthcare providers caring for athletes at all levels (recreational, elite, or professional).
While the full version of the consensus statement as well as the accompanying systematic reviews should be consulted for full understanding of the suggestions for clinical practice, some of the key points of this version of the consensus statement that have changed from the previous versions can be summarized as follows:
- Recognize and Remove – One of the most important factors for anyone involved in sport is supporting athlete health by erring on the side of caution, by recognizing (coaches, teammates, parents, support staff, etc.) situations where an athlete may have experienced head trauma and removing that athlete from practice or play to be further assessed by qualified medical professionals.
- Multifaceted Assessment – While there are many common symptoms of concussion, a multifaceted approach to assessment should be taken to evaluate the athlete’s condition. The updated Sport Concussion Assessment Tool – 5th Edition (SCAT5) is most effectively used by medical professionals immediately after injury to differentiate between concussed and non-concussed athletes. For children 12 years of age and younger the Child SCAT5 should be used. The CSIG also has provided a general tool, the Concussion Recognition Tool 5, that will help all those involved in sport identify concussion in children, adolescents and adults. Note that it is not intended as a diagnostic tool, but solely to identify suspected concussions.
- 24-48 Hours of Rest – The CSIG indicates that there is no evidence that complete rest until symptoms resolve is required. Rather rest (physical and cognitive) during the acute stage (24-48 hours) is necessary with gradual and progressive activity encouraged as long activity doesn’t bring on or worsen symptoms.
- Recovery – While individual circumstances and physiology result in diverse experiences of concussion, most adults generally recover in 10-14 days and most children in 4 weeks. The timeline for recovery for those who experience persistent symptoms is very difficult to predict. “The strongest and most consistent predictor of slower recovery from SRC is the severity of a person’s initial symptoms in the first day, or initial few days, after injury”. Those that have a pre-injury history or who are susceptible to migraines are at greater risk for a longer recovery time.
- Gradual Return to Learn/Work and Return to Sport Strategy – Return to school/work should precede return to sport. However, early research suggests that both protocols can be run concurrently as long as it is a gradual and progressive reintroduction of either cognitive or physical activity and as long as symptoms do not recur and/or worsen. Schools are encouraged to have concussion policies in place for teachers, staff, students and parents so that proper academic accommodations and support are available.
- Rehabilitation – Treatment and rehabilitation should address all facets of concussion recovery and may include physical therapy, cognitive therapy and/or behavioural therapy. Currently there is limited evidence to support the use of pharmacotherapy.
- Widespread, routine use of baseline testing is not supported – While baseline testing may have a role as one of many tools in evaluating concussions, research is still being conducted to validate its use.
- Long term consequences of concussion – Researchers admit that there is still much to be learned in terms of the long term problems such as cognitive impairment, depression, behavioural inconsistencies, etc. for athletes suffering both singular or repetitive brain traumas. Occurrence of chronic traumatic encephalopathy (CTE) is a real consideration for athletes, however, the cause-and-effect relationship has not been clearly established and more research is required.
- Concussion prevention strategies can reduce the number and severity of concussions in many sports – Evidence that helmets can reduce the risk of concussion is limited in many sports because of the differing regulations however, the reduction of overall head injuries in sports such as skiing and snowboarding is supported through evidence. Evidence of mouthguard use in preventing SRC is mixed, but there is a non-significant trend of a protective effect in collision sports. There is strong and consistent evidence that removal of body checking in youth ice hockey reduces the risk of concussion. Early evidence shows that there might be promise in the use of vision training to help reduce frequency of head contact. In general there needs to be more research done to examine the effectiveness of other concussion-reducing initiatives in sport (eg. Tackle training without helmets or shoulder pads, tackle training in rugby, red card rules for elbowing in soccer, fair play rules in hockey, etc.).
The body of evidence and evaluation around sport related concussions has increased over the last few decades and has distinguished itself from other sources of brain injury and concussion mostly since it provides a unique opportunity to study the phenomena. However, the study of all traumatic brain injuries advances the management of the field in general. Being educated and aware of sport related concussion is still the best way to help athletes continue to engage in safe sport.