How to identify and treat a concussion

Anyone involved in rugby, including players, parents, coaches, referees, teachers and administrators, needs to understand the importance of identifying and managing concussion. In Concussion Identification & Management Guidelines by Dr Jon Patricios of Morningside Sports Medicine, this is how to identify and manage a concussion.

It is important to note the following trends in international concussion protocol:

• Every individual case of concussion is treated on its own merits using as many objective criteria as possible; there is no specific guideline defining how long the player needs to rest, although a minimum period may be recommended.
   
• The potential consequences of returning a player to sport too soon after a concussion include prolonged neurological symptoms, disturbed concentration and associated decrease in classroom performance, and even death.
   
• All players suspected of suffering a concussion are to be assessed by a medical doctor.
   
• Best clinical practise dictates that medical doctors include a neuropsychologist as part of the multidisciplinary team making return-to-play decisions, particularly where computerised screening tests reveal significant, persistent or recurrent discrepancies in psychometric function.

Further educational information can be obtained from www.BokSmart.com.

How to identify a concussed player
 
Concussion refers to any alteration in mental state as a result of a direct or indirect blow to the head. A player does not have to lose consciousness or have amnesia (memory loss) to have suffered a concussion.

Suspect concussion in a player if he or she:

• Loses consciousness (blacks out) for any period of time
• Has memory loss
• Appears confused
• Does not understand calls or plays
• Complains of any of the following symptoms – headache, nausea, dizziness, sensitivity to light or noise, excessive tiredness, numbness or tingling.

On the field, use the following questions to identify confusion in a player:

• What venue are we at?
• Which half is it?
• Who scored last?
• What team did we play last week?
• Did we win last week?

An incorrect answer to any of these questions should indicate that the player should be removed from the field for further assessment. The injured player should not be left by himself, but should be monitored by a responsible adult for a period of up to two to three hours.

How to manage a concussed player

Any player suspected of having suffered a concussion should be removed from the game or practise immediately.

Any player who loses consciousness, is unsteady on his feet or is in any way suspected of having a suffered a neck injury, should have his head and neck stabilised with a neck collar, spider harness and head blocks and removed on a stretcher or spinal board.

The injured player must be monitored at all times. Players suspected of having suffered a neck injury or whose level of consciousness or condition deteriorates should be taken to hospital immediately.

Telephone ahead and preferably arrange for a CT scan and neurosurgeon on standby. If no transport is available, contact the BokSmart Spineline on 0800 678 678 for assistance.

Signs to watch out for

The following are important signs of a serious or deteriorating head injury:

• Headaches that worsen
• Increasing drowsiness
• Player cannot recognise people or places
• Deteriorating consciousness
• Increasing confusion or irritability
• Repeated vomiting
• Seizures
• Slurred speech
• Enlargement of one or both pupils of the eyes
• Unusual behaviour change
• Severe neck pain
• Weakness or numbness in the limbs.

Players who are suspected of having a serious or deteriorating injury should be referred to a hospital with facilities for brain scanning and a neurosurgeon on call. Players who are stable and improving can be monitored and assessed on the side of the field, preferably in a quiet room.

All players suspected of having suffered a head or neck injury should be assessed by a doctor as soon as possible. Assess and record the player’s symptoms according to the modified Sports Concussion Assessment Tool (SCAT2).

The symptom analysis should be recorded and presented by the player or an accompanying person when next undergoing a concussion assessment.

No return to play until assessment done

No return to play decisions should be made on the side of the field.

All players suspected of suffering a concussion should be reassessed later by a doctor, who may consult a neuropsychologist where possible. Preferably transfer the injured player to the nearest Emergency Department, Sports Physician or Neurology specialist for further assessment. At this stage decisions may be taken to perform a brain scan, admit the patient for neurological observation, or discharge under the care of a responsible adult.

A normal brain scan is not an indication that a player has not suffered a significant concussion.

The first 48 hours

Whether admitted or discharged, the following advice is appropriate for the player in the first 48-72 hours:

• Always make sure that you are in the presence of a responsible adult for 48 hours.
• Record and monitor the symptoms of concussion including headache, nausea, dizziness, fatigue, sleep disturbances, memory lapses, mood swings, poor concentration or any other feeling that concerns you.
• Complete rest and sleep will help recovery; this includes rest from exercise and class.

What NOT to do:

• Consume alcohol
• Take excessive amounts of painkillers (follow doctor’s orders)
• Place yourself in an environment of loud noise and excessive light
• Study
• Work at a computer
• Exercise until re-evaluation by a doctor
• Drive a car until evaluated by a doctor.

When to contact a doctor

If you experience any of the following you should contact an emergency service immediately:

• Any of the symptoms deteriorate
• The headache becomes severe or does not respond to mild analgesics (e.g. Panado)
• You have a seizure (fit)
• You experience excessive irritability
• You experience visual disturbances
• You experience balance problems
• You or anyone else is concerned about your condition.

Decisions regarding returning to sport should be made over the following days and weeks taking into consideration individual circumstances including medical history, previous head injuries and current symptoms.

Follow-up assessments

Following the acute management in the first 48-72 hours after any head injury, all concussed players should undergo serial clinical assessments by a doctor that include the following:

• Post-concussion symptom analysis
• Verbal cognitive testing
• General examination including blood pressure and pulse measurements as well as assessment of neck and facial injuries
• Balance testing
• Neurological examination.

All findings should preferably be compared to previous results to determine a trend.

Returning to play

The return-to-play process should begin only once the following criteria are met:

• The player is asymptomatic (i.e. post-concussion symptom score 0/132)
• The neurological examination is normal
• Computerised neuropsychological tests, where available, have returned to baseline or are comparable to age-appropriate norms.

The player should be put through a step-wise exercise programme gradually increasing in both duration and intensity (see Return-To-Sport Programme). This is an essential part of medical clearance.

Players who become symptomatic at any stage during or in the 24 hours following exercise should return to the previous stage.

Particular caution necessitating a conservative return-to-play approach should be exercised in cases where the concussed player:

• is very young (under 13 years of age)

• has suffered three or more concussions

• has an associated neurological history (e.g. migraines, epilepsy, depression, sleep disorder)

• suffers from a learning disability.

Source: Concussion Identification & Management Guidelines by Dr Jon Patricios of Morningside Sports Medicine for SA Rugby.

(Health24, August 2011)