A sports-related concussion is an injury to the brain that occurs through a collision with another person or object, resulting in a disturbance of brain function. This can cause symptoms like headaches, dizziness, memory disturbance and balance problems. While most concussions resolve over hours or days with relative rest followed by gradual return to activities, some neurological impairments can be persistent and prolonged. If activity is not stopped after a concussion it can significantly increase the risk of prolonged recovery and complications.  It is important to understand that many concussions don't show identifiable signs, or present with fleeting symptoms or signs. Awareness of the presentation of concussions is therefore essential to recognise the condition.

A concussion can happen from a direct blow to the head, but can also occur from a forceful blow to another part of the body that results in rapid acceleration and deceleration of the head e.g., whiplash type injuries

Health Risks of Concussion
Concussions typically resolve within 1-2 weeks. However, serious risks can arise if an athlete continues playing after a concussion, especially if they experience another blow to the head.

• Short-term: The most severe short-term complication is Second Impact Syndrome (SIS), causing life-threatening brain swelling.
• Medium-term: "Persisting symptoms" indicated prolonged symptoms such as headaches, dizziness, memory problems, sleep issues, and mood swings that last weeks or months.
• Long-term: Repeated concussions can lead to Traumatic Encephalopathy Syndrome (TES), causing early-onset neurodegenerative syndromes such as dementia, Parkinson’s disease or other brain problems.

Performance Risks
Concussions can impair balance, agility, reaction time, and decision-making, all crucial for athletic performance. Playing with a concussion can lead to poor performance and increase the risk of losing competitions.

Increased Risk of Other Injuries
Athletes with a previous concussion are more likely to suffer other injuries, especially to the lower body, within the following year. They are often more concussion-prone in the future, experiencing more severe and prolonged symptoms.

Who is Most at Risk?
Concussions can occur at any age, but children and adolescents (under 18) are:

• More susceptible to brain injury
• Slower to recover
• More likely to experience memory and mental processing problems
• At higher risk for rare, fatal complications

Women in football seem to have higher concussion rates than men. A history of concussion increases the risk and potentially lengthens recovery time for future concussions.
 

Reducing Concussion Risk

• Rule Changes: Limiting high-risk contact, reducing playing time for young athletes, and modifying tackling techniques can all help lower concussion rates.
• Protective Equipment: Mouthguards were associated with a 28% reduced concussion rate in ice hockey across all age groups, indicating that mouthguards should be mandated in child and adolescent ice hockey and supported at all levels of play. Evaluation of headgear in non-helmeted contact and collision sport requires more research to inform headgear recommendations. Helmets and soft-shell headgear have shown mixed effectiveness in preventing concussions. Research on improved equipment design and materials is ongoing.
• Neck Strengthening: Studies suggest stronger neck muscles might reduce concussion risk. Athletes in contact sports can benefit from neck strengthening exercises.
• Neuromuscular training:  Participation in on-field neuromuscular training (NMT) warm-up programmes completed at least three times per week has been associated with a lower rate of concussion in Rugby Union (rugby) across all age groups. NMT warm-up programmes are recommended in rugby to reduce concussion rates. The effect of NMT programmes to reduce concussion rates specifically has not been assessed in other sports. While extensive evidence exists to support the effectiveness of NMT warm-up programmes in reducing all injuries and lower extremity injuries, more research is needed for NMT warm-up programmes in women and other team sports specifically targeting exercise components aimed to reduce concussion rates.
• Removal from Play and Recovery: Following a suspected concussion, athletes must be removed from play and undergo a supervised recovery program before returning to play, to prevent further complications. Stand-down times are increasing, especially for younger athletes. Early return to play increases the risk of further injury.
• Education and Awareness: Educating athletes, coaches, and parents about concussion risks and the importance of proper concussion management is crucial for preventing long-term health problems.
   

Remember: When in doubt, sit them out. If you suspect a concussion, an athlete should be removed from play and evaluated by a healthcare professional before returning to activity.

Concussion is a brain injury that can occur from a blow to the head or a jolt to the body. It's important to note that loss of consciousness happens in less than 10% of concussions. Someone with a concussion may still be alert and want to continue playing, making it difficult to diagnose.

Signs and Symptoms

Visible Signs (What you may see):

• Dazed appearance
• Slow to get up after a fall
• Unsteady on feet, poor balance, or falls
• Confusion or disorientation
• Grabbing head
• Seizures
• Increased emotional or irritability

Symptoms (What you may hear from the injured person):

• Headache
• Dizziness
• Feeling foggy or slowed down
• Difficulty concentrating
• Nausea or vomiting
• Fatigue
• Sensitivity to light or noise

When in Doubt, Sit Them Out

If you suspect someone has a concussion, it's crucial to remove them from play immediately. We recommend these guidelines for removal from play:

Mandatory Removal (No return to play that day):

• Loss of consciousness
• Lying motionless for more than 5 seconds
• No attempt to protect oneself during a fall
• Seizure
• Confusion, disorientation
• Inability to answer questions properly
• Memory problems
• Balance issues or incoordination
• Significant concussion symptoms
• Dazed appearance or not acting themselves
• Unusual behavior changes

Discretionary Removal (Further assessment needed):

• Clutching head
• Slow to get up after a fall
• Suspected facial fracture
• Possible balance problems
• Behavior changes
• Other concerning signs

Red Flags (Immediate Medical Attention Required):

• Neck pain
• Increasing confusion, agitation, or irritability
• Repeated vomiting
• Seizures
• Weakness or numbness in arms or legs
• Worsening headache
• Loss of vision
• Skull deformity
• Unusual behavior changes
• Double vision

Remember: Early recognition and proper management are crucial for concussion recovery. If you suspect a concussion, seek professional medical advice.

Anyone with a suspected concussion must be IMMEDIATELY REMOVED FROM PLAY.

• Once safely removed from play they must not return to activity that day.
• Team-mates, coaches, match officials, team managers, administrators or parents who suspect someone may have concussion MUST do their best to ensure that they are removed from play in a safe manner.
• If a neck injury is suspected suitable guidelines regarding the management of this type of injury at pitch side should also be followed (see useful links).

If ANY of the following are reported then the player should be transported for urgent medical assessment at the nearest hospital emergency department (Red flags): (Acronym: NADAL SIT and Vomit)

• Neck pain
• Altered or deteriorating level of consciousness
• Double vision
• Agitated/confused
• Loss of consciousness
• Seizure
• Increasing or severe headache
• Tingling or weakness in legs
• Vomiting persistent.

In all cases of suspected concussion, it is recommended that the player is referred to a medical or healthcare professional on the same day for diagnosis and advice, even if the symptoms resolve.

ONGOING MANAGEMENT OF CONCUSSION

Rest the body rest the brain for 24-48 hours, or until symptoms start improving faster.

Rest means avoiding:

• Physical activities such as running, cycling, swimming or physical work activities etc.
• Cognitive activities (thinking activities), such as school work, homework, reading, television or video games. Students with a diagnosis of concussion may need to have allowance made • Cognitive activities (thinking activities), such as school work, homework, reading, television or video games. Students with a diagnosis of concussion may need to have allowance made for impaired cognition (memory and concentration) during recovery, such as additional time for classwork, homework and postponement of exams.

Anyone with a concussion or suspected concussion should NOT:

• be left alone in the first 24 hours.
• consume alcohol in the first 24 hours, and thereafter should avoid alcohol until free of all concussion symptoms.
• drive a motor vehicle and should not return to driving until provided with medical or healthcare professional clearance or, if no medical or healthcare professional advice is available, should not drive until free of all concussion symptoms.

A graded return to activity and play protocol (GRTP) should be used. It should be integrated with oculo-vestibular and cognitive rehabilitation. The minimum time in which a player can return to play in the standard care setting is summarized in Table 1, the ASPETAR concussion return to activity and sport protocol. Each day comprises a 24-hour period. The pathway begins at midnight on the day of injury.
Children should not return to contact/collision activities before 14 days from the complete resolution of all concussion symptoms.

FIGURE 1: THE ASPETAR RETURN TO ACTIVITY AND SPORT PROTOCOL

Under the GRTP Protocol, the individual can advance to the next stage only if there are no symptoms of concussion at rest and at the level of physical activity achieved in the current GRTP stage. If any symptoms occur while going through the GRTP program, the individual must return to the previous stage and attempt to progress again after a minimum 24-hour period of rest without symptoms (this is 48 hours for players under 19 years of age).
A medical practitioner must confirm recovery before an individual enters Stage 5 (full-contact practice).
Players will often want to return to play as soon as possible following a concussion. Players, coaches, management, parents and teachers must exercise caution to:
a. Ensure that all symptoms have resolved before commencing GRTP.
b. Ensure that the GRTP protocol is followed.
c. Ensure that the advice of medical practitioners and other healthcare professionals is strictly adhered to.

After returning to play, all those involved with the player, especially coaches and parents must remain vigilant for the return of symptoms even if the GRTP has been successfully completed.
If symptoms recur the player must rest from sporting activities and consult a healthcare practitioner as soon as possible as they may need a referral to a specialist in concussion management.

RETURNING TO WORK AND STUDY AFTER CONCUSSION
At the non-professional level, adults must have returned to normal education or work and students must have returned to school or full studies before starting physical activity (stage 2) in a GRTP program.
At professional level, return to normal cognitive function and return to play may be done at the same time, but both should be completed before returning to play.
The Return to Learning protocol is presented in Figure 2.

FIGURE 2: RETURN TO LEARNING PROTOCOL

HOW ARE RECURRENT OR MULTIPLE CONCUSSIONS MANAGED?
Any player with a second concussion within 12 months, a history of multiple concussions or players with unusual presentations or a prolonged recovery should be assessed and managed by a healthcare provider with experience in sports-related concussions working within a multidisciplinary team.
Outcomes in concussion are better if the injured player is well informed and understands what has happened. Measures to improve understanding and deal with emotional problems and anxiety should be included in the management of concussed players.

The risks and complications of concussion can be reduced or prevented if sports bodies adopt these guidelines, and ensure proper implementation thereof.

Because concussion is sometimes difficult to detect, easy to hide by eager players and easy to ignore by uninformed coaches and parents, the key to successful concussion care is widespread awareness and knowledge of this condition. Education of all stakeholders in sport is essential.

AWARENESS AND EDUCATION

General knowledge about concussion is low in Qatar. Education programs must target the various groups involved in sport-related concussion in order to effectively improve awareness and understanding in the community.  Effective targeted education should have the following goals:

Athletes – need to have a good understanding of concussion to appreciate the importance of reporting symptoms and complying with rest and return to sport advice.

Parents and coaches – must be able to recognise symptoms and signs of concussion to detect concussions at the community-sport level where there is no medical supervision present.

Sporting and medical organisations – need to continue to develop specific recommendations around concussion to educate their own participants.

Key points for athletes, coaches, parents, teachers and allied health practitioners

• Concussion is a brain injury that occurs from a knock to the head or body.
• Recognising concussion is critical to ensure appropriate management and prevention of further injury.
• The Concussion Recognition Tool 5 (CRT5) is recommended to help recognise the signs and symptoms of concussion.
• This can be downloaded at bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097508CRT5.full.pdf, or from the useful links.
• First aid principles apply in the management of the athlete with suspected concussion. This includes observing first aid principles for protection of the cervical spine.
• Any athlete suspected of having concussion should be removed from sport and not allowed to return to sport that day. This athlete should be reviewed by a medical practitioner.
• Features that suggest more serious injury and should prompt immediate emergency department referral include neck pain, increased confusion, agitation or irritability, repeated vomiting, seizure, weakness or tingling/burning in the arms or legs, reduced level of consciousness, severe or increasing headache, or unusual behaviour.
• When assessing a patient with suspected concussion, a medical practitioner will ask about details of the event as well as past medical history and then assess the patient, including asking about symptoms, signs, testing memory function and concentration, balance and neurological function.
• There is no single test that can determine whether someone has sustained a concussion. Your doctor may not order blood tests or medical imaging unless they wish to exclude other more serious injuries.
• Once a diagnosis of concussion has been confirmed, the main treatment for concussion is rest. After 24–48 hours of rest, light intensity physical activity is allowed as long as such activity does not cause a significant and sustained deterioration in symptoms.
• The activity phase should proceed as outlined below with a minimum of 24 hours spent at each level.
• The activity should only be upgraded if there has been no recurrence of symptoms during that time. If this occurs there should be a ‘step down’ to the previous level for at least 24 hours (after symptoms have resolved): light aerobic activity (at an intensity that can easily be maintained while having a conversation), until symptom-free basic sport-specific drills which are non-contact and with no head impact more complex sport-specific drills without contact (may add resistance training) full contact practice following medical review normal competitive sporting activity.
• Children and adolescents take longer to recover from concussion. A more conservative approach should be taken with those aged 18 or younger. The graduated return to sport protocol should be extended such that the child does not receive medical clearance to return to contact/collision activities in less than 14 days from resolution of symptoms.
• The long-term consequences of concussion, and especially multiple concussions, are not yet clearly understood.
• If in doubt, sit them out.

Key points for medical practitioners

• Concussion can be very difficult to detect. The symptoms and signs can be varied, non-specific and subtle.
• Athletes with suspected concussion should be removed from sport and assessed by a medical practitioner.
• When assessing acute concussions, a standard primary survey and cervical spine precautions should be used.
• Concussion is an evolving condition. Athletes suspected of, or diagnosed with, concussion require close monitoring and repeated assessment.
• The diagnosis of concussion should be based on a clinical history and examination that includes a range of domains such as mechanism of injury, symptoms and signs, cognitive functioning and neurology, including balance assessment.
• The SCAT5 is the internationally recommended concussion assessment tool and covers the above-mentioned domains. This should not be used in isolation, but as part of the overall clinical assessment.
• Computerised neurocognitive testing can be undertaken as part of the assessment but should not be used in isolation.
• Children and adolescents take longer to recover from concussion. A more conservative approach should be taken with those aged 18 or younger. The graduated return to sport protocol should be extended such that the child does not receive medical clearance to return to contact/collision activities in less than 14 days from resolution of symptoms.
• Blood tests are not indicated for uncomplicated concussion. Medical imaging is not indicated unless there is suspicion of more serious head or brain injury.
• Standard head-injury advice should be given to all athletes suffering concussion and to their carers.
• Once the diagnosis of concussion has been made, immediate management is physical and cognitive rest. This includes time off school or work and deliberate rest from cognitive activity for 24–48 hours. After this period, the patient can return to light intensity physical activity as long as such activity does not cause a significant and sustained deterioration in symptoms. Concussive symptoms usually resolve in 10–14 days. Once the symptoms have resolved the patient can proceed with a graduated return to sport protocol.
• Some sports have their own guidelines or recommendations around the management of concussion in sport which should also be considered.
• If in doubt, sit them out.