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  • Kris Krotiris

Concussions in Sport: Diagnosis, Recovery and Post-Concussion Syndrome

Updated: Sep 20, 2023

In the world of sports, where athletes push their limits, one injury was once dismissed but now carries substantial evidence of long-term consequences: concussions. These once-dismissed injuries have gained attention due to concerns about the well-being of athletes, both current and retired, experiencing ongoing symptoms likely linked to recurrent concussions.

Following decades of research, anecdotal evidence, and more recently concrete evidence of Chronic Traumatic Encephalopathy (CTE) related to repeated concussions through post-mortem brain dissection, the importance of understanding head injuries in sports and their potential long-term consequences is now unquestionable. There now exists a critical need to raise awareness, implement preventive measures, and establish proper management protocols. The evolving perception of concussions demands our attention and action to safeguard the well-being of athletes and promote a safer future for sports at all levels.

What is Concussion?

A concussion, often referred to as a mild traumatic brain injury, is a condition that occurs when the brain experiences a sudden jolt or impact, leading to temporary impairment of its normal functions. In the context of sports, concussions typically result from direct blows to the head or body that transmit force to the head. These incidents can happen in various sports, from football and soccer to boxing and even non-contact sports like gymnastics.

When an individual experiences trauma leading to a concussion, it can trigger a cascade of events in the brain. Initially, there's an increased demand for energy to support various repair and maintenance processes. However, following a concussion, the brain may experience difficulty in efficiently utilising the available energy. This state is often referred to as an 'energy crisis' within the brain, and is further exacerbated by reduced blood flow within the brain and neuro-inflammation. This combination of factors can disrupt the brain's normal electrical signaling, resulting in a range of symptoms. These symptoms can disrupt cognitive, emotional, and physical capabilities, impacting functions such as memory, balance, coordination, and mood.

Additionally, during this 'energy crisis,' the brain becomes more vulnerable, and the individual is more susceptible to a second concussion if another injury occurs during this initial period. This heightened vulnerability underscores the critical importance of accurately diagnosing and managing concussions promptly.

Diagnosing Concussion: An insight into on-field diagnosis and management

A concussion can exhibit a range of signs and symptoms, including:

  • Headache

  • Dizziness

  • Nausea

  • Sensitivity to light or noise

  • Confusion

  • Difficulty concentrating

  • Memory problems

  • Irritability

  • Mood swings

  • Balance issues

  • Unsteady gait

  • Impaired coordination

In the context of competitive sport, medical staff reaching the correct diagnosis immediately following a head trauma is crucial for the reasons described above. This task can be particularly challenging amidst the heightened emotions often experienced in the heat of competition. Reassuringly, there are protocols which most sporting organisations now enforce, knowing the potential severe ramifications of missed diagnoses. Although this may vary slightly between organisations, trained medical staff will consider the following:

‘Observable signs’ following head trauma

If the athlete displays any of these signs, they should be deemed to have a concussion, stopped from participating in any further competition and entered into strict concussion rehabilitation protocols:

  • Loss of consciousness

  • Falling to the ground without a protective mechanism (e.g., doesn’t put their hands out to protect themselves on impact)

  • Tonic posturing (e.g., limbs/arms become stiff immediately following head trauma)

  • Motor incoordination (e.g., player stumbles when trying to get up after impact)

  • Player looking dazed or is not their normal self

  • Player looking confused or disorientated

  • Player’s memory is impaired (e.g., forgets where they are, how they got to the game, what quarter/half they are in etc.)

Two athletes are concussed during an AFL game. An example of tonic posturing is seen in the athlete on the right

If no observable signs are recognised but there is still suspicion of possible concussion due to the injury mechanism or the athletes concussion history, they should then undertake a formal test call a SCAT5 (Sports Concussion Assessment Tool) by a trained sports doctor. This test involves a series of questions and physical tests. The player will be assessed and monitored over a period of 20 minutes or longer, as concussion symptoms can develop over time. If the results of this test suggest a diagnosis of concussion, the athlete will be stopped from participating in any further competition and entered into strict concussion rehabilitation protocols.

In amateur sport where trained medical staff may not be available, tools such as the Concussion Recognition Tool 5 can be an excellent resource for coaches to help in identifying concussion and informing on the necessary steps if a concussion is suspected. A link to this tool can be found by clicking here.

Recovery from Concussion

Recovery from a concussion is a multifaceted process that varies from person to person, and it involves both physical and cognitive aspects. All suspected concussions should be managed by a doctor trained in the area of concussion management. In the immediate aftermath of a concussion, rest is often prescribed as the primary form of treatment. This means avoiding physically and mentally demanding activities, including sports, work, and even excessive screen time. Rest allows the brain to heal without the added stress of stimulation. Gradually, as symptoms subside, a structured return-to-activity plan is initiated, typically under the guidance of a sports doctor and sports physiotherapist. This plan includes a stepwise progression back to normal activities, starting with light aerobic exercise and progressing to sports-specific drills and, ultimately, full contact if the athlete remains symptom-free. It is essential for individuals recovering from a concussion to listen to their bodies and adhere to the prescribed recovery plan, as premature return to physical and cognitive activities can increase the risk of re-injury.

Beyond physical rehabilitation, cognitive recovery is also crucial. Concussion-related cognitive symptoms like memory problems and difficulty concentrating may persist for some time. Cognitive therapy and gradual reintroduction to mentally demanding tasks, such as school or work assignments, are often recommended. Emotional support and monitoring for symptoms of anxiety and depression are also important, as these conditions can sometimes arise or worsen during the recovery process. It's worth noting that recovery times can vary significantly, and some individuals may experience symptoms for weeks or months. Patience, proper medical guidance, and open communication with healthcare providers are key to achieving a successful and complete recovery from a concussion.

It's also important to note that in children or anyone under the age of 18, concussion management should be especially conservative. The immature brain that is still developing is especially susceptible to concussion and requires a cautious approach to ensure proper healing and minimise potential long-term consequences. Because young brains are in the midst of critical growth and development, any injury to this delicate process can have lasting effects on cognitive function and emotional well-being. Therefore, comprehensive evaluation, monitoring, and a gradual return to normal activities, including academic and physical pursuits, are imperative in younger individuals to support their recovery and safeguard their future neurological health.

Concussion in children should be treated especially conservatively due to their immature, developing brain

Post-Concussion Syndrome

Post-concussion syndrome (PCS) is a complex and often debilitating condition that can affect individuals who have sustained a concussion. It is characterised by the persistence of concussion-related symptoms beyond the expected recovery period, typically lasting for weeks, months, or even years after the initial injury. The exact mechanisms underlying PCS are not fully understood, but it is believed to involve a combination of factors, including ongoing neurological inflammation, changes in brain chemistry, and altered brain connectivity.

Rehabilitation from Post-Concussion Syndrome is a critical component of the recovery process, as it aims to alleviate symptoms, improve cognitive and physical function, and enhance overall quality of life for individuals struggling with the persistent effects of a concussion. Key aspects of rehabilitation for PCS include:

  • Individualised Treatment Plans: Each PCS case is unique, so rehabilitation plans should be tailored to the specific needs and symptoms of the individual. A comprehensive evaluation by a healthcare professional, such as a neurologist or neuropsychologist, helps determine the most appropriate interventions.

  • Rest and Gradual Activity: Like the initial concussion recovery process, rest is often prescribed initially. This may involve a break from school or work, as well as limiting screen time and physical exertion. As symptoms improve, a gradual return to daily activities is typically recommended.

  • Cognitive Rehabilitation: Cognitive symptoms are common in PCS, including memory problems, difficulty concentrating, and brain fog. Cognitive rehabilitation programs may include exercises and strategies to improve memory, attention, and problem-solving skills.

  • Physical Rehabilitation: For individuals experiencing balance issues, dizziness, or physical symptoms, physiotherapy can be beneficial. Exercises to improve balance, coordination, and vestibular function may be prescribed.

  • Mental Health Support: Emotional symptoms such as anxiety and depression can accompany PCS. Psychiatric or psychological support can help individuals cope with these issues and provide strategies for managing stress.

  • Medications: In some cases, medications may be prescribed to manage specific symptoms, such as headaches or sleep disturbances. These should be used under the guidance of a healthcare provider.

  • Education and Lifestyle Modifications: Providing education about PCS and lifestyle modifications, such as maintaining a consistent sleep schedule, managing stress, and adopting a healthy diet, can also play a significant role in recovery.

  • Regular Follow-Up: Continued monitoring and follow-up appointments with healthcare professionals are essential to track progress, adjust treatment plans, and ensure that the individual is on the right path to recovery.

Rehabilitation from PCS can be a lengthy and challenging process, but with the right support and a patient-centred approach, many individuals can experience significant improvements in their symptoms and quality of life over time. It's important for individuals with PCS to work closely with their healthcare team to develop and implement a comprehensive rehabilitation plan that addresses their specific needs and goals.

Chronic Traumatic Encephalopathy

Chronic Traumatic Encephalopathy (CTE) is a progressive neurodegenerative disease linked to repetitive head injuries, such as those commonly seen in contact sports like football and boxing. Unlike PCS, CTE is typically diagnosed post-mortem through the examination of brain tissue. Post-mortem findings in CTE cases often reveal an abnormal build-up of 'tau' protein in the brain, which is associated with neurodegeneration and cognitive decline. Symptoms of CTE can include memory loss, mood swings, and impaired cognitive function, and they tend to worsen over time. CTE has gained significant attention due to its association with the long-term health risks faced by athletes and individuals who have experienced repeated head trauma. This has prompted increased efforts in sports and medical communities to raise awareness, improve prevention strategies, and develop treatments for concussions and their potential long-term consequences, including CTE.

Concussion Management Moving Forward

Concussions are not mere transient injuries but rather complex and dynamic conditions that demand our attention, understanding, and proactive management. Post-concussion syndrome can extend the suffering of those affected, highlighting the need for continued research to unravel its mechanisms and develop more effective treatments. Furthermore, the sobering realities of CTE underscore the importance of preventing repetitive head injuries, especially in contact sports. As we move forward, it is imperative to prioritise the well-being of athletes, young and old, through rigorous protocols, better diagnostics, and a commitment to fostering a safer environment for all participants in sports. Only through these concerted efforts can we hope to mitigate the long-term consequences of concussions and pave the way for a healthier future in the world of sports and beyond. More information can be found on concussion and its management at the Concussion in Sport government website here.

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