What is concussion?

A Sport-related concussion (SRC) is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain (1).

In 2017, Aspetar Hospital launched the “The Aspetar Sports Concussion Program”. The purpose of the program is to raise public and athlete awareness, educate medical staff, and facilitate early recognition and management of concussed athletes. The program also maintains a specialist referral network and advanced sports concussion clinic to offer excellent concussion care.

Aspetar hospital provides a multidisciplinary approach from the time of injury to return to sport. Our approach is based on the Consensus statement on concussion in sport: the 6^th International Conference on Concussion in Sport–Amsterdam, October 2022 bearing in mind the eleven Rs of SRC: Recognize, Reduce, Remove, Re-Evaluate, Rest, Refer, Rehabilitate, Recover, Return to learn/sport, Reconsider, Retire and Refine.
 

How to recognize sport-related concussion?

The recognition of SRC is challenging. Symptoms and signs of SRC may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged. SRC results in a range of clinical symptoms and signs that may or may not involve loss of consciousness. Anyone who is suspected of having SRC should be examined by a doctor on the same day. During the evaluation, the doctor will ask questions about the injury and how it occurred, how severe the force was, whether there was loss of consciousness or memory loss after the blow. It is especially important that the doctor is also made aware of any previous concussions. A neurological exam will then test balance, coordination, vision, hearing, and reflexes. A brain scan is only needed to exclude bleeding around or in the brain.  A normal brain scan does not rule out SRC.

There are many symptoms of concussion, the presence of one or more of the following may be a sign:

• Headache
• Dizziness
• Mental clouding, confusion, or feeling slowed down
• Visual problems
• Nausea or vomiting
• Fatigue
• Drowsiness/feeling like ‘in a fog’/difficulty concentrating
• Feeling of pressure in head
• Sensitivity to light or noise

These symptoms may appear immediately, whilst some may be delayed for hours or days after injury, such as:

• Concentration and memory complaints
• Irritability and other personality changes
• Sensitivity to light and noise
• Sleep disturbances
• Psychological adjustment problems and depression
• Disorders of taste and smell

The Concussion Recognition Tool (CRT6) is a free available resource to individuals without medical background, to help identify concussion.
 

How to REDUCE concussion?

The goal of concussion prevention is to mitigate the burden of injury, risk of recurrent injury and minimizing potential for persisting symptoms. While complete prevention of the risk of concussion in sports might not be possible, implementing rule changes can significantly decrease the risk of head impacts. Examples of successful rule changes are reduction of body checking in ice-hockey, and safer tackle rules in rugby. Safety gear such as  mouthguards can reduce the risk of a brain injury. The inclusion of neuromuscular training in warm-up drills has been shown to reduce concussion risk in rugby and is worth pursuing further. Sports organizations should adopt and apply policies to ensure optimal concussion care to prevent complications. Implementing primary prevention of SRC across all levels of sport is a priority that can have a significant public health impact. Aspetar is managing the concussion policy of the Qatar Stars League, the professional football league in Qatar and provides concussion support to all clubs and federations in Qatar.
 

When to REMOVE a player with concussion from play?

The recognition of concussion is the first step to initiate the management of SRC. Removal of a player from the field of play should be done if there is suspicion of a concussion to avoid aggravation of the injury. This may be based on a player’s symptoms or signs observed by other players, medical staff, or officials (on the field or video from a concussion spotter). Signs that warrant immediate removal from the field include actual or suspected loss of consciousness, seizure, tonic posturing, ataxia, poor balance, confusion, behavioral changes, and amnesia.

The concussion recognition tool (CRT6) is a guide for non-medical people to recognise suspected concussion, and should be available to all stakeholders in sport, including coaches, referees, and parents. Players exhibiting these signs should not return to a match or training that day, unless evaluated acutely by an experienced Healthcare Provider with a multimodal assessment, to confirm or exclude concussion. Serial assessment over the first 24 hours is necessary for full assessment, to allow for assessment of late-onset symptoms and signs.

The general rule for suspected concussion remains “When in doubt, sit them out”.
 

When to RE-EVALUATE the concussion?

When the athlete has been removed from play, close monitoring of the evolution is crucial. A Healthcare Provider should record symptoms and signs and re-evaluate using the Sport Concussion Assessment Tool (SCAT6), and followed up in a clinic setting with the Sport Concussion Office Assessment Tool (SCOAT6)

The following is recommended to be included in the evaluation of SRC.

• Injury history and medical history
• Symptom count and symptom score
• Immediate words recall and digit backwards test.
• Measure of systolic and diastolic blood pressure.
• Evaluation of cervical spine, muscle spasm and palpation of segmental or midline tenderness.
• Neurological examination
• Balance testing, including timed tandem gait.
• Vestibular Ocular Motor Screen (VOMS)
• Delayed words recall.
   

REST

Following a SRC relative cognitive and physical rest is recommended for optimal recovery. This does not equate to complete inactivity. In the early stage it may mean limiting activities that increase symptoms (physical and cognitive). It includes restriction reduced activities of daily living and screen time. Physical activity and cognitive exertion should be minimized if concussion symptoms exacerbate more than mild and daily activities and cognitive work may be progressively resumed once symptoms have returned to the prior level or increase as tolerated.

Importantly, athletes should be advised to avoid the risk of re-injury (contact, collision or fall) until determined to be safe for higher risk activities. Sleep disturbances within 10 days after SRC is linked with an increased risk of persisting symptoms and may warrant evaluation and treatment.
 

REFER

Community settings should have a concussion protocol and consider appointing a "concussion officer" who can help cases of suspected SRC and facilitate referral to more specialized healthcare. In Aspetar, every athlete who experiences a concussion will be met by a multidisciplinary team with specialized knowledge and skills in concussion management. Your physician will be the overall case-manager and will make sure to REFER you to all related expertise such as physiotherapy, nutritionist, radiology, psychologist and neurosurgeon. The team will collaborate to provide multi-disciplinary care.
 

REHABILITATION

Aspetar has a dedicated team of concussion physiotherapists who customise rehabilitation programs to address a concussed athlete’s specific symptoms. The rehabilitation also includes an overall focus on recovery, aiming to return individuals to their desired activity level before being discharge by your physician and return to sport or your club. The treatments also typically target persistent issues like dizziness, neck pain, headaches, with cervico-vestibular rehabilitation, as well as addresses heart rate thresholds for safe reintroduction of aerobic exercise.

Growing evidence supports the involvement of physiotherapists in concussion assessment and management. Physiotherapists are often present at sporting events to identify suspected concussions and remove athletes from play. They can act as primary care providers in community sport settings and monitor athletes in high-performance environments. Physiotherapists play a vital role in managing complex cases with prolonged symptoms and recovery issues. In Aspetar, our physical therapy team work closely together with the medical team to provide the best service for our athletes emphasizing the importance of interdisciplinary care.
 

RECOVERY

Our recovery outcomes include a varying symptoms rating, specific clinical tests, dynamic balance, vestibulo-ocular reflex test with eye tracking, cardiovascular test, and threshold of physical exertion, as well as a group of functional tests required to return to your sport. The first goal is to resolve symptoms at rest followed by a complete symptom resolution with no return of symptoms during or after physical or cognitive exertion.

In Aspetar, we are constantly educating medical providers in using the Sport Concussion Assessment Tool (SCAT6) for sideline assessment and Sport Concussion office Assessment Tool (SCOAT6) to diagnose and monitor the post-concussion symptoms and recovery.
 

RETURN TO LEARNING AND RETURN TO SPORT

After a concussion it is recommended to follow a stepwise return to learn and return to sport strategy.

The return to physical activity protocol includes:

• Step 1: The first 24-48 hours following the concussion. This step begins with an initial period of relative rest and symptom limit activities with an incremental increase in cognitive load. Daily activities should not result in mild exacerbation of concussion-related symptoms. The goal is to gradually return to typical activities.
• Step 2: Light aerobic exercises can gradually be introduced with exercises not exceeding heart rate up to 55% maxHR (low intensity) and then progress to activities up to 70% maxHR (moderate intensity). Typical activities could be stationary cycling, walking, or jogging.
• Step 3: Introducing individual sport-specific drills without contact. This typically occurs away from the team environment and includes activities such as running and change of direction.
• Step 4: Progress to non- contact training drills with increasing intensity including more challenging training drills like passing or multiple players integrated into the team.
• Step 5: Full contact practice with normal activities.
• Step 6: Return to sport. (It typically takes at least a week to reach this stage. Twenty-four hours should elapse without symptom aggravation before progressing to the next stage).

The return to learning protocol includes:

• Step 1:  Daily activities that do not result in more than a mild exacerbation (more than 2 points on a ten-point scale) of symptoms related to the current concussion. Typical activities during the day (e.g., reading) while minimising screen time. Start with 5–15 min at a time and increase gradually.
• Step 2: Home-based school/work activities, as tolerated.
• Step 3: Return to school /work part-time, as tolerated.
• Step 4: Full return to school/work activities.

Importantly, children and adolescents recover slower and require a more conservative approach. A history of multiple concussions may indicate a longer recovery period and might need a specialist assessment. The athlete and the healthcare team should spend at least one week to complete the full rehabilitation strategy, but it typically takes more time.
 

RECONSIDER

Always reconsider the long-term effect of concussion on the athlete. There has been increasing concern for later-in-life issues like mental health problems and neurogenerative diseases. Ongoing research is crucial to better understand the long-term effects of concussion on brain health.
 

RETIRE

Athletes with repetitive concussions, prolonged recovery and lowering concussion thresholds may face complex decisions on retirement due to head injuries. Multifaceted medical guidance is crucial and should involve clinicians with expertise in concussion. All athletes should be encouraged to continue non-contact or low impact physical, cognitive, and social activities after retirement, and have the health benefit of exercise explained.
 

REFINE

Aspetar is always working on improving the concussion care and updating and refining our protocol and approach based on the recent evidence and clinical experience.