Concussion is an injury to the brain following an injury to the head, resulting in a disturbance of brain function. There are many symptoms of concussion, common ones being headache, dizziness, memory disturbance or balance problems. It causes short-lived neurological impairment and the symptoms may evolve over the hours or days following the injury. The symptoms usually resolve without medical intervention. Rest, followed by gradual return to activity, is the main treatment. If activity is not stopped after sustaining a concussion, recovery is often be prolonged and the risk of complications is significantly increased.

Concussion can be caused by a direct blow to the head but can also occur when a blow to another part of the body results in rapid acceleration and deceleration of the head e.g. whiplash type injuries.

• Medical risks

The majority of concussions resolve within 7-10 days.  The risk of complications is increased if a concussed athlete continues playing/participating after sustaining a concussion, especially if they receive another blow to the head.  The most severe short term complication is the Second Impact Syndrome (SIS), which is a severe swelling of the brain after a second impact, resulting in severe metabolic dysfunction in the brain which is often fatal⁴. 

The most important medium term complication of concussion is prolonged symptoms of concussion, sometimes called “post-concussion syndrome”, presenting with persistent headache, dizziness, balance problems, inability to concentrate, anxiety, depression, and sleep disturbances which can last for weeks or months⁵.

In the long term, repeated blows to the head can lead to early degeneration of the brain, or chronic traumatic encephalopathy (CTE), causing early onset dementia (similar to Alzheimer’s disease) or other permanent brain dysfunction⁶.
 

• Performance risk

Concussion often affects balance, agility, speed of eye tracking, and response time, all important functions in most sports, including football⁷⁸.  Playing with concussion can result in poor decision making, slow reaction times, inaccurate execution of tasks, all of which cause poor performance.  Important competitions have been lost because of a key player being left on the field after sustaining a concussion⁹ 
 

• Risk of other injuries

There is a 50% increased risk of subsequent injuries of any other body part, especially lower limb injuries, in previously concussed athletes for a year after a concussion¹⁰,¹¹.  Furthermore, previously concussed athletes are more concussion-prone, sustaining future concussions more easily, and experiencing more severe and prolonged symptoms¹².
 

• Who is at risk?

Concussions can happen to players at any age.  However, children and adolescents (18 and under):

• are more susceptible to brain injury
• take longer to recover
• have more significant memory and mental processing issues
• are more susceptible to rare and dangerous neurological complications, including death caused by a single or second impact.

Studies indicate that concussion rates in women are higher than in men in football.

A history of previous concussion increases the risk of further concussions, which may also take longer to recover.

Loss of consciousness does NOT always occur in concussion (in fact it occurs in less than 10% of concussions). A concussed player may still be awake and upright, wanting to play on and signs of a concussion can be very subtle making it difficult to diagnose.

If any of the signs or symptoms listed below are present following an injury the player should be suspected of having a concussion and immediately removed from play or training and must not return to play that day. The Pocket Recognition tool may be used as an aid to the pitch side assessment (see Useful Links section).

The absence of loss of consciousness does NOT indicate a less severe concussion.

What you may see (Visible clues (signs) of concussion):

Any one or more of the following visual clues can indicate a concussion:

• Dazed, blank or vacant look
• Lying motionless on ground / slow to get up
• Unsteady on feet / balance problems or falling over / poor coordination
• Loss of consciousness or responsiveness
• Confused / not aware of play or events
• Grabbing / clutching of head
• Seizure (fits)
• More emotional / irritable than normal for that person

Questions to ask a player:

These should be tailored to the particular activity and event, but failure to answer any of the questions correctly may suggest a concussion. Examples with alternatives include:

• What venue are we at today? Or Where are we now?
• What team did you play last game? Or Where were you on this day last week?
• Which half is it now? Or Approximately what time of day is it?
• Did your team win the last game? Or What were you doing this time last week?
• Who scored last in this game? Or How did you get here today?

Symptoms of concussion:

What you may be told by the injured player:

Presence of any one or more of the following symptoms may suggest a concussion:

• Headache
• Dizziness
• Mental clouding, confusion, or feeling slowed down
• Visual problems
• Nausea or vomiting
• Fatigue
• Drowsiness / feeling like “in a fog“/ difficulty concentrating
• “Pressure in head”
• Sensitivity to light or noise

Video footage:

If video footage of the incident is available it may be of assistance in establishing the mechanism and potential severity of the injury and can be used to contribute to the overall assessment of the player. This may be viewed by the person assessing the injured player or can be commented on by a third party, such as the tunnel doctor in an elite professional setting. A coach or parent may have video footage that could be helpful in a non-elite setting. However, video evidence must not be used to contradict a medical decision to remove the player.

It is sometimes difficult to recognize concussion. In such a case, we follow the internationally accepted mantra:

“If in doubt, sit them out.”

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.