“But I feel fine…”

Concussion is a brain injury caused by a knock to the head or anywhere on the body, where force is transmitted to the head. All concussion is serious and the effects of concussion appear to be cumulative. This means that recovery from each subsequent knock can be slower, so each and every episode needs to be managed well, even if you look and feel normal.

The brain is really complex and every brain injury is different. To make things even trickier, some symptoms will appear right away, while others may not appear for days or weeks after the injury. Because the brain is effected, the nature of the injury also makes it hard for players to recognise that they are having problems. This means we need to rely on clear assessment signs rather than player reporting.

The signs of concussion can be subtle so knowing exactly what to look for is key.

The four R’s of concussion management

In the initial stages of injury, it is often unclear whether you are dealing with a concussion or if there is a significant underlying head injury. Recognising concussion can sometimes be difficult, but recognising the signs of concussion can prevent further injury and allow you to implement the best management plan for recovery.

I’m going to take you through some of the ways in which you can recognise concussion and the most appropriate way to manage concussion. You may have heard this being referred to as the 4 R’s.

RECOGNISE concussion

Not all concussions result from a hit to the head and a hard knock is not required to sustain a concussion. Any injury resulting in a knock to the head or body that transmits force to the head can cause concussion, and therefore concussion should be considered in this scenario. A few ways to identify signs of concussion are listed below.

The athlete may;

• Appear normal apart from appearing vacant, dazed or stunned
• Be disoriented and unable to recall information such as scores, opponent, location, time
• Ask repeatedly about what happened or what the score is
• Have difficulty concentrating and answering specific questions
• Loss of consciousness, seizure, balance difficulties are clear signs of a more significant injury. In this circumstance, urgent medical attention is required.

The athlete may also report they “do not feel right”- a common occurrence in concussion. They also may experience;

• Visual disturbances
• Feeling ‘foggy’, lethargic or slow
• Sensitivity to light or noise
• Dizziness or nausea
• Headache.

If the athlete has reported any of the above symptoms or you have observed any obvious signs of concussion, the athlete must be removed from play.

REMOVE the player from the game

In order to do so safely, it is necessary to screen for any neck pain and/or loss of consciousness before moving the athlete from the field. In the case that a player is unconscious, or experiencing neck pain, urgent medical attention is required.

In the absence of neck pain and loss of consciousness, the concussed player is required to be assisted off the field for appropriate monitoring and assessment.

During this time, medical staff will undertake appropriate nerve and brain function tests (SCAT5 test for athletes over the age of 13). If these resources are not available, the athlete will be monitored for any signs of worsening.

Signs of worsening

• One pupil larger than the other.
• Drowsiness or inability to wake up.
• A headache that gets worse and does not go away.
• Slurred speech, weakness, numbness, or decreased coordination.
• Repeated vomiting or nausea, convulsions or seizures (shaking or twitching).
• Unusual behaviour, increased confusion, restlessness, or agitation.
• Loss of consciousness (passed out/knocked out). Even a brief loss of consciousness should be taken seriously.

If there is any doubt about whether an athlete is concussed, that athlete should not be allowed to return to sport until cleared by a medical practitioner.

REFER the player for medical assessment

There should be an accredited first-aider at every game and the basic rules of first aid should be used when dealing with any player who is unconscious or injured.

Any player who has suffered a concussion or is suspected of having a concussion must be medically assessed as soon as possible after the injury and must NOT be allowed to return to play in the same game/practice session.

REST, then Return to Play

Athletes should not be allowed to return to play until they have recovered completely from their concussion. In the first few days post concussion, it is important to;

• Give yourself physical and mental rest
  • Avoid activities that can cause or increase symptoms – physical activity increasing heart rate.
  • Reduce the amount of time on tasks using focused attention such as computer work, written work, reading, watching TV, using a phone.
  • Avoid riding a bike or driving a car – reaction time and vision may be impaired during this time.
  • Sleep during the night, rest during the day
• Complete light daily activities
• Avoid taking pain relievers such as aspirin or ibuprofen

The decision to return to play can vary between athletes, hence the importance of an individualised return to play program. A medical practitioner can make the judgement to return to play after considering;

• A period of cognitive and physical rest
• Monitoring of post-concussion symptoms and signs
• The use of specific tests to estimate recovery of cognitive function
• Graded return to activity with monitoring for recurrence of symptoms.

A question some may ask either on prevention of concussions or return to play post concussion is “shouldn’t players be wearing more protective gear to protect their heads?” The current research available suggests that there is no definitive evidence that helmets prevent concussion or other brain related injuries in AFL. Helmets may have a role in the protection of players for specific injuries or recovering from specific injuries such as face or skull fractures. While female football is still in its youth, women and girls have had less of an opportunity to understand the nature of the game and how to best use your body from a safety and performance perspective. Women and girls have also had less of an opportunity to develop head and neck strength as the age involved in participation in contact sports is relatively high. Despite these claims, females should instead, be encouraged to participate in a variety of sports, both contact and non-contact from a young age to develop global strength, varied movement patterns and skill-based exercises.

The reasons for an increased incidence of concussion amongst the female population, particularly in football is unknown. There is some research to suggest that young girls have less neck strength than their male counterparts, as well as the ability to control the rotational force of the neck. Females are also more likely to suffer ongoing post concussive symptoms and take an extended time to recover, therefore the importance of early recognition and appropriate management is vital.

In addition, it might be useful for coaches, trainers and players to recognise concussion as a significant injury in females who play football, and that it may take longer for females to fully recover and return to play.

As an athlete, it is important to acknowledge that concussion can present itself in a number of different ways and over an extended period post impact. It is vital to trust in the medical staff or bystanders when a concussion is suspected, for your own health, safety and playing career- even if you do feel “fine.”

References

1. AFL Community Club, Concussion (http://www.aflcommunityclub.com.au/index.php?id=66)
2. Brain Injury Australia (https://www.braininjuryaustralia.org.au/5r-concussion-logo/)
3. Concussion in Sport Australia (https://www.concussioninsport.gov.au/athlete)
4. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Concussion Recognition Tool 5th Edition (CRT5). Br J Sports Med 2017 doi: 10.1136/bjsports-2017-097508
5. Emery CA, Black AM, Kolstad A, et al. What strategies can be used to effectively reduce the risk of concussion in sport? Br J Sports Med 2017 doi:10.1136/ bjsports-2016-097452
6. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017 doi: 10.1136/bjsports-2017-097699