I am very grateful to be asked to write this guest blog for Janet and Naomi regarding the recent #physiotalk debate on concussion. Being my first blog, bear with me, it could be a little bumpy but we’ll get through it.
On Monday the 18th of August 45 participants were involved in a rigorous #physiotalk discussion on the definition, diagnosis and long term affects of concussion as well as current protocols, effectiveness, and barriers to implementation. You can read a transcript of the chat here.
Definition of concussion
The definition of a concussion was rigorously debated, focusing on the signs and symptoms experienced by patients. Various participants highlighted that changes both functionally and structurally are key aspects in the diagnosis of concussion. However, functional changes to the player seemed to be more predominant in the identification of concussion. Variability also lies in the use of imaging for diagnosis; many participants concluding that minimal shift of 3-5mm in the brain would be hard to differentiate unless regular access to imaging was available to the players.
The Zurich Conference on Concussion in 2012 highlighted that concussion can be defined as a pathophysiological process affecting the brain, induced by either a direct blow to the head, neck or face. However, definitions of concussion vary and include mechanistic, pathophysiological, and clinical features. Concussion typically results in the sudden onset of temporary impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours, although it is important to note that in some cases symptoms may be prolonged for up to 4-6 weeks.
Common features that incorporate clinical, pathological and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury. These symptoms may include:
- Difficulties in subjective concentration
- Intellectual difficulties
- Loss of consciousness
- Behavioural changes
- Cognitive impairment
Clinically, concussion is defined by neurological deficits, cognitive impairment and somatic symptoms. Participants in the chat discussed the identification of possible blood tests to diagnose concussion comes with recent literature (Davies, 2009), recognizing a pathophysiological sequence chracterized by the release of amino acids, an ionic flux and a brief period of hyperglycolysis. Following this pathological sequence, a persistent metabolic instability and mitochondrial dysfunction. These physiological changes could possibly be monitored in elite athletes where access to previous blood results could give a more accurate reading to pre season assessment.
Second impact syndrome
The importance of identifying a suspect concussion was seen in 2011 with the tragic loss of Ben Robinson at the age of 14. Having examined the game footage, Professor Jack Crane concluded the Ben had played a full half of rugby with clear signs of concussion. With a minute remaining in the game, Ben lost consciousness and passed away days later. The harrowing tale that occurred to this young talent means death is a realistic consequence of concussion. It was later discovered Ben’s cause of death is Second Impact Syndrome, possibly the first recorded case of this in the UK.
A patient who sustains an initial concussion may develop cerebral edema, accounting for possible loss of consciousness, memory impairment and confusion. However, the brain’s auto regulatory mechanisms compensate for this mechanical and physiologic stress and protect against massive swelling. This reaction is possibly achieved by acutely limiting cerebral blood flow, which leads increase build up of lactate and intracellular acidosis. A state of altered cerebral metabolism then occurs and could possibly last for up to ten days, involving a reduction in protein synthesis and decreased oxidative capacity. Research suggests that the loss of consciousness after head injuries, the development of secondary brain damage, and the enhanced vulnerability of the brain after an initial trauma can be explained largely by possible ionic fluxes, metabolic changes, and cerebral blood flow variation that occur immediately after cerebral concussions (Giza and Hovda, 2001).
Other long-term symptoms may include:
- Chronic traumatic encephalopathy
- Memory loss
- Chronic headaches
- Emotional changes
- Increase risk of other injuries
Role of physiotherapy
The role that physiotherapy plays in the application of concussion evidence and guidelines were again a topic widely discussed with many variable aspects considered. The general consensus provided during the chat was that the role of assessment lies with the physiotherapist at amateur level due to the lack of access to a doctor. Competencies in vestibular and musculoskeletal assessment and pitchside management are therefore needed for physiotherapists to effectively identify and act on suspected concussion.
The Zurich Conference on Concussion highlighted the use of SCAT 3 (sport concussion assessment tool) as the most up to date outcome measure to effectively identify a concussion. The SCAT 3 incorporates a Glasgow coma scale, Maddock’s Score, symptom evaluation, cognitive and physical evaluation as well as a neck, balance and co-ordination examination. Orientation questions to time and place have been shown to be unreliable in the sporting situation when compared with a comprehensive memory assessment. However, the Zurich Conference on Concussion highlight that abbreviated assessments, such as the SCAT3, are designed for rapid concussion screening on the sidelines and are not meant to be a replacement for comprehensive neuropsychological testing nor should they be used as an individual tool for the ongoing management of sports concussions.
Any deterioration in symptoms as the game progresses, or days later, should result in immediate referral to A&E. Also any player suspected of a possible concussion, or removed from a game due to a positive test on the SCAT 3, should be followed up 24-48 hours later with a possible appointment/visit or if unfeasible, a Skype assessment.
Education and awareness
Although the identification of concussion is a key aspect of a pitch side physiotherapist, education is also vital when preventing the long-term side effects of repetitive concussions. The application of concussion education from a grass roots level, including coaches, athletes and parents, can highlight the short and long-term affects of concussion. Coaching education was predictive of the ability to recognize signs and symptoms of sport-related concussion. As well as coach’s education, athletes with post concussion training have been shown to be more likely to notify their coach of concussion symptoms, potentially reducing their risk for further injury. However, research shows that coach’s education does not necessarily result in an increase in the awareness of athletes presenting with concussion. Several studies highlight the possible shadowing of health professionals as an appropriate education method rather than DVD or quiz like methods, although these modalities have been proven to be significantly more effective then no education.
There was also a call for a possible concussion replacement (much like a blood sub) in team sports. However, the chat highlighted that abuse of such a policy for a free substitution could result in a “bloodgate” type abuse and further harm the drive for increased awareness of concussion. As well as the concussion substitute, the application of a concussion champion who would regularly provide players with up to date information on current policies. The concussion champion would also make sure their clubs are following current protocols.
Challenges for Physiotherapists
Obstacles physiotherapists encountered with concussion widely vary from relationships with management and coaches to players falsifying pre-season markers and under reporting of symptoms. The relationship between practitioners and coaches has a huge impact on the implementation of assessment and current protocols. During the chat a number of practitioners stated on various occasion’s coaches or players had over ruled their decisions to remove a player from the competitive environment. Many reported the player attaining an injury shortly after returning to the pitch to play.
The under reporting of symptoms from players can be as a result of multiple external and internal factors. The most common reasons for concussion being unreported included a player not knowing the possible short and long term affects, the injury not serious enough to warrant medical attention, and motivation not to be withheld from competition. The misconception of an automatic three-week ban in some contact sports has lead to an increase in pressure not to report possible concussions and diagnoses such as “traumatic migraine” or “loss of consciousness without concussion.” However the International Rugby Board has since dissolved this criterion as long as a neurologist has cleared the patient.
Overall the limitation of clear evidence on concussion was highlighted during the chat, with the lack of a concise definition reported by the participants in the discussion. More awareness is needed on the potentially fatal outcomes and long-term affects of repetitive concussion from grass roots right up to professional level. Although reporting of concussion is continually rising, showing a positive outcome for current intervention, a statistically significant prevention program is yet to be completely identified.
@Robbielillie, with thanks to Andrew Cuff @AndrewVCuff for proofing this blog post for me.