What is concussion?

Concussion is an injury to the brain that occurs as a result of an impact to the head or body. Any impact to the head of sufficient force can cause structural brain injury, which can be seen with the naked eye on brain scans. Or the impact can cause concussion, which is an injury to brain nerve cells that does not necessarily show up on brain scans. Concussion is a disturbance of brain function which manifests in different athletes or players in many different ways.

The fundamental change to the concussed brain is a slower speed to take in and processes information. The delay in reaction time that occurs is caused by damage to nerve cells (neurons). Therefore, the message signal that is transmitted along the damaged nerve, transmits much slower.

The nerve cells can be damaged by a direct blow to the head, which causes the brain to rotate and/or move forward and backward. Indirect impact to the body can transfer an impulsive force to the brain and have a similar outcome.

Looking at how the brain nerve cells dysfunction in a more detail gives further understanding into the condition. The brain rapidly decelerates in the skull with impact causing changes to the pattern of neuron conduction, glucose metabolism, membrane protein expression and brain blood flow. The net effect of these changes is an energy shortage for the brain. An indirect marker of the brain’s energy balance is N–acetylaspartate (NAA). NAA is measured using proton magnetic resonance spectroscopy (MRS) and can be used as an index of metabolic recovery after concussion in athletes.

NAA levels have been found to be decreased for up to 30 days after concussion - long after the athlete reports to feel well and most likely has returned to sport. This phenomenon may put the brain at further risk of a second concussion if a second head impact occurs during this window of vulnerability.

Loss of consciousness is uncommon and occurs only in 10 - 20% of concussion cases. If managed correctly, recovery from concussion may take 10 - 14 days. 10 - 15% of athletes or players may take longer to recover (weeks to months). The group of athletes or players who take longer to recovery should be managed by a multidisciplinary team of concussion specialists.

Can concussion be prevented?

Parents, coaches and athletes have a vested interest in concussion prevention. In the competitive world of professional sports, it is now common practice to have a well-rehearsed action plan in place to deal rapidly and effectively with concussion. An effort has been made to prevent concussion in sport. At school level, where younger athletes are particularly vulnerable to concussion, these efforts are important.

Education & awareness
Increased awareness of subtle behaviour changes in children can alert parents to possible concussion. Mood swings, heightened emotions, restlessness, irritability, poor school performance and lethargy are common symptoms of concussion in children that should be identified as soon as possible.

Rule Changes
A number of sporting codes have introduced rules to avoid dangerous play. In 2012 the NFL banned players from using their helmets to impact players on the head or neck, whereas in rugby, spear tackles, where a player lifts and dumps a player on his head, is deemed a red card offence.

Is baseline screening important?

A baseline computerised screening is a brain function assessment that is routinely used to establish normal thinking ability in an athlete or player. The results of a baseline screening can be compared to the results of an after-injury computerized brain function test to assist in the diagnosis of concussion and plan recovery.
A computerised baseline screening typically evaluates the athlete or player:

• Simple reaction time
• Learning and memory skills
• Ability to pay attention or concentrate
• Problem solving capacity

Baseline computerised brain function testing is important for the following reasons:

• Is readily available and cost effective
• Can be done in the quiet of your own home (remote administration)
• Detects when impaired brain function lasts longer than the athlete has symptoms
• Precisely measures reaction time
• Provides objective information about the player’s recovery
• Has in built sophisticated software checks that detect when a player is purposefully performing poorly, especially on baseline testing
• Provides extra information in players with multiple concussions
• Helps to find those players with delayed brain function recovery who need more detailed testing with a neuropsychologist
• Is a useful add-on to clinical assessment and judgement
• Provides added assurance for fast tracking return to play decisions in professional sport
• Is easy to administer and takes a short time
• Helps when athletes under reports their symptoms in order to keep playing
• Younger players may not recognise the symptoms of concussion
• Athletes may be overly anxious
• Liability mitigation benefit for schools and clubs

Concussion outcomes can be unpredictable. Athletes and players participating in contact and collision sport should have a CogState baseline test before injury. This practice improves the ability of doctors to manage athletes back to sport safely. Objective information about the athlete’s brain function is one part of the overall care.

International team physicians find baseline and after-injury computerised testing very helpful. Individualized comparisons of brain function improved the accuracy of return to play decisions. Players self-reporting of their symptoms is subjective. The team physician is therefore relying on the honesty of the player when asked to answer questions about having concussion symptoms. The objective data that the CogState test provides is an invaluable piece of the return to play puzzle.

When to start school or work?

Students or workers recovering from concussion can worsen their symptoms by attempting full school or work days, normal homework and testing too early in their recovery. A delay in testing, less school hours and frequent breaks between classes, would be appropriate. Wait until the learner has minimal symptoms and near normal concentration before increasing the load on the brain. Limiting the use of computers, mobile phones and television viewing soon after concussion, can allow recovery at a normal speed. A similar approach to managing the load on the brain in children can apply for adults returning to work after concussion. However, no studies have yet provided guidelines on a clear return to work progression for adults. Remember, it’s not possible to speed up brain cell recovery beyond the normal healing rate, but you can slow it down.

HeadSmart™ members receive individualised school and work progression guidelines.

Who should you see?

An athlete or player with a head injury must see a medical doctor as soon as possible to make an accurate head injury diagnosis of concussion.

It is important to bear in mind that concussion cannot be diagnosed at one point in time. Symptoms can evolve over time and serial assessments must therefore be performed over time, and other conditions that can mimic concussion should be ruled out.

Should I use medicine?

One of the most prevalent symptoms of concussion, present in almost 90 percent of cases, are headaches. Pain relief in the early stages post injury is known to assist a normal recovery process by making the athlete or player feel better. The only analgesic medication recommended by health care professionals for the safe and effective treatment of early concussion headaches is paracetamol.

• Only use paracetamol to treat concussion headaches in the early stages of the injury.
• Avoid ibuprofen, aspirin and other anti-inflammatory drugs, especially within the first 24 to 72 hours, as they are associated with rebound headaches and can thin the blood, leading to bleeding of the brain.
• Athletes or players should be vigilant when using anti-inflammatories to prevent muscle pain and stiffness before playing sport. The use of NSAIDs prior to head injury increases the risk of brain bleeding.
• Do not use sleeping tablets or any other recreational, prescription or over the counter drug that can affect cognitive function and neurological recovery.

An initial period of rest (24-72 hours) combined with safe, effective pain relief is the best first aid for the symptoms of concussion.

What to do in first 48 hrs?

The first 48 hours post-concussion are vital in minimizing health risks from concussion and ensuring an optimal recovery timeframe.

During this period parents, coaches, teachers and other responsible adults are encouraged to monitor the athlete or player as closely as possible for the onset of signs of more severe complications.

The risks of epidural hematoma and subdural hematoma may manifest hours or even days after the head trauma.

If the athlete or player is unconscious, basic first aid principles apply. Protect the player’s neck and secure an open airway. Urgent hospital referral is necessary for any player who has lost consciousness as a result of a blow to the head or body.

Do’s

• Consult a medical doctor as soon as possible
• If discharged from hospital, ensure the athlete or player is under the supervision of a responsible adult
• Monitor and record any symptoms of concussion such as headaches, dizziness, nausea, fatigue, sleep disturbances, memory lapses, mood swings, poor concentration and any other unusual feelings
• After being discharged from the emergency department, make an appointment with your medical doctor to plan your full treatment and recovery plan

Don’ts

• Consume alcohol
• Take anti-inflammatory medication and aspirin
• Exposure to excessive bright light and loud noise
• Spend long periods of time playing games on computers and television
• Exercise, until cleared by a medical doctor
• Use mobile devices for longer than one to two hours each day
• Driving a motor vehicle

Head trauma red flags

• When to Go to Hospital
• Visit a hospital immediately if:
• The skull is fractured
• The trauma has penetrated the skull
• The athlete has lost consciousness
• There is a deterioration in the conscious state after the injury
• Confusion levels increase
• The headache becomes more severe as time passes
• Persistent vomiting is present
• Convulsive movements are present
• Develops weakness of upper or lower limbs
• The player has sustained additional concussive injuries in a match or training session
• The athlete is a child
• The athlete is at higher risk (hemophiliacs, users of anticoagulant medicine)
• The injury was high-risk, such as a high velocity impact or a missile injury
• The athlete received inadequate supervision following the injury

What to do on the first night as a parent or guardian?
Uninterrupted sleep is thought to be the best medicine for concussion symptoms. The only time it’s recommended to periodically wake the patient to monitor symptoms is if there was loss of consciousness or amnesia at the time of the trauma, or the signs of concussion such as headaches, vomiting, dizziness or sensitivity to noise and light are still present. In this context, checking to see that the athlete or player is rousable once during the night, is sufficient.

When to start exercise?

Deciding when an athlete or player is ready to start exercise an art and not an exact science. Once an athlete or player is back to hours at school or work, start a balance and postural stability re-training programme. A progression to light aerobic exercise can follow the initial static balance and co-ordination re-training. 23 - 81% of persons report dizziness and balance problems in the first few days after concussion and 16 – 18% of concussed athletes may have ongoing dizziness for 3 months. Hence, the importance of balance training.

Concussed athletes also have an increased risk of lower limb injury following concussion. This finding in recent studies is proposed to be caused by impaired body position sense and awareness. Balance drills should continue for months after the athlete or player is back at sport. Physical Therapists are in an excellent position to supervise, individualize and adapt this form of rehabilitation. Balance training programmes are effective at treating dizziness and improving balance after head injury.

Once symptoms of concussion have disappeared and the athlete or player is feeling their normal selves, coping at full work or school and has progressed through an element of balance training, start light non-impact loading aerobic exercise and progress through a number of stages, ending with high intensity sports specific exercise activity.

It is very important that an athlete or player be evaluated by a medical doctor and cleared before starting high risk or contact training activity, and not simply return on their own time.

If scan is normal?

A normal brain scan does not exclude concussion. All that a normal brain scan indicates is that there is no structural injury to the brain. Concussion cannot be seen on a CT or MRI scan, therefore clearance cannot be given to a player to return to sport on the basis of a normal CT or MRI scan.

While baseline, side line and remote concussion tests can reliably assess brain function pre and post- concussion, they are not designed to detect structural damage within the brain. Instead, brain imaging can be used to assess whether there is swelling or bleeding of the brain.

Consider conducting brain scans if the athlete or player displays any of the following signs;

• Fractured skull
• Penetrating skull trauma
• Loss of consciousness
• Deterioration in conscious state following injury
• Increasing confusion
• Worsening headache post injury
• Persistent vomiting
• Any convulsive movements
• Focal neurological signs
• More than one episode of concussive injury in a match or training session
• High-risk injury mechanism (i.e. high velocity impact, missile injury)

In addition, the following groups of sportspersons are at heightened risk of brain injury;

• All children with head injuries
• High-risk patients (i.e. haemophilia, anticoagulant use)
• Athletes who had inadequate post injury supervision

There are several brain scans currently available based on different technologies and techniques.

CT Scans
A CT or computerised tomography scan is one of the best techniques to evaluate bleeding or swelling of the brain within the first 24 to 48 hours post-concussion. It is also preferred over an MRI to detect skull fractures, as it is faster, more affordable and easier to perform. A disadvantage is that it cannot show microscopic damage to neurons and brain function disturbance.

MRI Scan
A magnetic resonance imaging (MRI) scan is arguably the more appropriate imaging procedure 48 hours or longer after an athlete or player has suffered head trauma. It is particularly accurate in detecting traumatic lesions of the brain and does not expose athletes or players to radiation. Changes in white matter tracts, degraded blood products or small capillary bleeds around nerve cells can also be identified on MRI.

DTI Scan
Diffusion tensor imaging (DTI) is a magnetic resonance imaging technique which provides a calculable measure of the often subtle changes within the white matter tissue of the brain following concussion. These changes may provide clues as to why concussion manifests with certain neurological symptoms. Despite showing tremendous potential, DTI may not be applicable to the routine evaluation of concussion.