Definition

Many definitions for concussion.

  • "minor" traumatic brain injury
  • "A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces"
  • "a transiently induced alteration in mental status, (not necessarily with loss of consciousness)"

Only pathognomic feature is post traumatic altered short term recall

NB : Not limited to direct head impact

Symptoms usually start at time of impact but may be delayed for 24-48 hours.

Difficult to advise when to return to sport (minimise chances of catastrophic "second impact syndrome")

Symptoms may last up to 6 months

Standardised Assessment of Concussion (SAC) has been proposed as an objective, quantifiable assessment


Symptoms

  • Persistent low grade headache
  • Nausea or vomiting
  • Dizziness or light headedness
  • Poor attention / concentration
  • Memory dysfunction
  • Irritability, easily frustrated
  • Easily fatigued
  • Sleep disturbance
  • Anxiety / depression
  • Blurred or double vision
  • Photophobia
  • Phonophobia, tinnitus

Signs

  • Any LOC
  • Seizure
  • Disorientation
  • Amnesia
  • Observable incoordination
  • Emotional lability
  • Poor concentration
  • Slurred / incoherent speech
  • Delayed verbal / motor response
  • Vacant stare
  • Worsening sympts with exertion
  • Sadness/depression

Second Impact Syndrome

  • Typically seen when players who remain symptomatic from a previous concussion return to play and sustain a second blow to the head.
  • 2nd blow may be minor
  • Later rapid, fatal brain oedema
  • Thought o be due to loss autoregulation
  • All reported cases : victims returned to play before symptoms related to an initial concussion had resolved.

Repeated concussions

  • After a player has suffered a first concussion, the chance of incurring a second concussion is more than 4 times greater than for the non-concussed player (Ref)
  • Those who do suffer a second concussion have reduced cognitive functioning (reduced information processing ability) than those who had only been concussed once.

Concussive fitting

  • Convulsive episodes start within 2 seconds of impact.
  • Typically brief tonic stiffening followed by myoclonic jerking.
  • May be asymmetrical.
  • Transient or last up to 3 minutes (ref).
  • Not associated with structural or permanent brain injury and are non-epileptic.
  • All Ix (including EEG, CT and MRI) are normal.
  • No further treatment needed.
  • Can return to sport after 3 symptomatic weeks.

Graduated return to Play (GRTP) - IRFU

Players can only move on to the next stage once they have been symptom free during the full period of each stage.

Rehab stage Ecercise Objective of stage Adult U6 - U20s
Rest None Rest 14 days 14 Days
1. No activity Complete physical and mental rest without symptoms Recovery 1 day
2. Light areobic exercise

Walking swimming etc. Intensity <70% max HR (Max predicted HR = 220-Age)

↑ heart rate 1 day 2 days
3. Rugby specific exercise Running drills. No impact. Add movement 1 day 2 days
4. Non-contact training drills Progression to more complex drills e.g. passing. May start resistance training. Exercise, coordinationa and mental load 1 day 2 days
5. Following medical clearance, full contact practice May participate in normal training activities Restore confidence and assess functional skills by coaching staff 2 days 2 days
6. After 24hrs, return to play Player rehabilitated Recovered 21 days 23 days

Sports related concussion in children / adolescents

  • Girls have higher concussion rates than boys do in similar sports.
  • LOC is uncommon. If longer than 30 sec, it may indicate more significant intracranial injury.
  • Concussion can cause symptoms that interfere with school, social & family relationships, and participation in sports.
  • The signs and symptoms of a concussion typically resolve in 7 to 10 days in the majority of cases.
  • Cognitive and physical rest is the mainstay of management after diagnosis.
  • Imaging results are usually normal.
  • Neuropsychological testing is a helpful tool in the management of concussion.
  • Return to sport should be accomplished by using a progressive exercise program while evaluating for any return of signs or symptoms (rather than rigidly adhering to specific time intervals).
  • Athletes with concussion should rest, both physically and cognitively, until their symptoms have resolved both at rest and with exertion. Teachers and school administrators should work with students to modify workloads to avoid exacerbation of symptoms.
  • No patient (any age) should ever return to play while symptomatic at rest or with exertion.
  • Athletes also should not be returned to play on the same day of the concussion, even if they become asymptomatic.