Concussion Guidelines

On the 4 Nov in a game against Everton the Spurs keeper was involved in a clash with an Everton player. When he got up he was obviously disorientated and initially wobbly on his feet. On the coaches decision and against medical advice he continued playing that game. The keeper stated he didn’t remember the incident and was possibly knocked out for a short period of time.

In the Sports Medicine media and the English press there has been much stated about the decision taken on the day. It is therefore a timely reminder of the consequences and management of concussions.

Firstly with regard to management, a concussion is a concussion. There isn’t a ‘mild concussion’ as everyone responds differently and symptoms are not necessarily related to the force of the initial knock. As a concussion is a mild (but temporary) brain injury it should be treated as such. The fact that the player can continue playing, or saving goals in the above mentioned case, does not mean they are OK.

A common misconception is that you need to be knocked out to suffer a concussion. If you have been knocked out you have sustained a concussion, but you don’t need to be knocked out to sustain one.  A concussion can even occur without a head knock as it is caused by a counter-coup force to the brain i.e. the brain bouncing back and forth in the skull. Any knock or jarring movement to the upper body can therefore cause one.

If a person has had a knock and there is any suspicion it may involve a concussion they should be taken from the field to be assessed. If the decision is made to assess them then they shouldn’t return to the field that day(1), even if they have been “cleared”, as symptoms may occur later.

Professional teams generally used computer based testing which compare the players to a base line measure taken at the start of the season. As most players won’t have base line tests manual assessments are undertaken to assess symptoms. The latest manual assessment tool is a SCAT3, of which there are child and adult versions. This assesses concentration, short term memory, and balance amongst other signs which are symptoms often seen in a concussed player. However no test is fool proof so “if in doubt leave them out”, and don’t let them play.

All athletes, especially children, with a suspected concussion should be check out as soon as possible by a medical practitioner, preferably one with a knowledge in concussion management. Before returning to play a medical clearance needs to be attained.

Many sporting bodies in New Zealand use to have a minimum stand down time following a concussion. To an athlete this seemed a long time and many therefore under reported symptoms so they could continue playing. Now set time frames have been largely replaced by a symptomatic recovery pathway. This is to make sure the brain recovers fully. Though rare, a second knock to the head before full recovery can lead to much more severe problems, including death.

As mentioned the management of a concussed athlete now follows a structured pathway which is independent of time. This should be supervised by a Sports Physiotherapist or Sports Doctor. Initially the athlete should rest until symptom free. Once symptom free they can return to light aerobic activity. If this is symptom free they can progress to more sport specific activities, then to non-contact drills. Finally after a medical clearance they can return to full contact training then their sport. If at any stage they have a re-occurrence of symptoms they must stop and rest, then return to the start of the pathway(1).

For concussion assessment or return to play advice contact me

(1)   Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258 doi:10.1136/bjsports-2013-092313