Synapse - reconnecting lives

Dr Ryan Kohler explains how to keep our athletes safe on and off the field from concusion - the mildest form of traumatic brain injury. 

Concussion is a disturbance in the ability of the brain to take in and process information. The slower function of the brain represents damage to nerve cells (neurons). The neurons can be damaged by a direct blow to the head, which causes the brain to collide with the skull. Indirect impact to the body can transfer an impulsive force to the brain and have a similar outcome.

The effect varies from athlete to athlete, producing signs that depend on which part of the brain has been affected. Concussion signs visible to others at the time of the collision include:

• Loss of consciousness / unresponsiveness
• Upper limb muscle rigidity
• Upper limb spontaneous movement
• Loss of overall body tone
• Loss of control of the neck ("rag doll effect")
• A fit / seizure soon after contacting the surface
• Balance difficulty
• Slow responses
• Vacant stare
• Confusion
• Disorientation
• Holding the head
• Facial injury
• Speech slurring.

After the impact injury, the athlete can start to feel unwell as a group of symptoms start to randomly present themselves. The athlete may complain of:

• Headache
• Nausea / vomiting
• Blurred vision
• Memory loss / difficulty
• Dizziness
• Tiredness
• Not feeling right
• Intolerance of bright light & loud noise
• Sleep difficulty
• Poor attention & concentration
• Sad or irritable or frustrated
• Fatigue
• Lethargic, low motivation
• Slow reaction time.

How common is concussion in sport?
1.6 to 3.8 million concussions occur in sport per year in the United States. Across football codes in Australia, the probability of concussion is approximately 1 in 10 across all sports.

The issue
It is recognised that most concussions get better in seven to 10 days. However, ignoring concussion signs and symptoms or not recognising them, can result in potentially catastrophic consequences. Acute brain swelling, traditionally referred to as "second impact syndrome" is usually fatal. Prolonged symptoms, recurrent concussion, learning difficulties, and personality problems have also been reported. A recent study showed how the recovery time from concussion became longer with each concussion.

What should parents, coaches and administrators do before the season?
Secondary prevention can be explained as effective preparation. Gathering baseline information on the athlete is able to provide the first step to effective post concussion treatment.

The important components of concussion screening are:

• Baseline brain function testing with Axon Sports
• Baseline symptom assessment
• Baseline balance testing.

What should parents, coaches and administrators do at the event?
Use available resources to recognise or suspect concussion. Any athlete with suspected concussion must be withdrawn from the event or training immediately. Furthermore, no athlete with concussion or suspected concussion should return to the same event or practice that day. ALL athletes with concussion or suspected of concussion need a formal medical assessment in the soonest possible time.

Before getting to a medical doctor, be on the lookout for signs of serious neck or head injury. Protect the athlete's neck and secure an open airway when the athlete is not responsive.

Urgent hospital referral is necessary for any athlete who has lost consciousness as a result of a blow to the head or body. Indications for urgent referral to hospital include:

• Fractured skull
• Penetrating skull trauma
• Loss of consciousness
• Deterioration in conscious state following injury
• Increasing confusion
• Worsening headache post injury
• Persistent vomiting
• Any convulsive movements
• Focal neurological signs
• More than one episode of concussive injury in a match or training session
• All children with head injuries
• High-risk patients (e.g. hemophilia, anticoagulant use)
• High-risk injury mechanism (e.g. high velocity impact, missile injury)
• Inadequate post injury supervision.

See a medical doctor as soon as possible
A concussed athlete should see a medical doctor with experience in managing concussion as soon as possible after the impact. The medical doctor should see the athlete on a number of occasions, performing serial assessments. At the first visit, the doctor will do a full neurological examination and document current symptoms.

It is recommended that balance testing and computerised brain function testing be repeated and compared to the baseline test report.

Recovery from concussion may take longer in younger athletes under 18 years of age, therefore a conservative approach to playing sport again should be followed in these cases.

How does the athlete get back to sport?
Athletes should only return to high intensity exercise when their symptoms have gone away and cognitive function has returned to normal.

Once the athlete feels better after about 72 hours, some low intensity exercise in the form of vision and balance training can begin.

Progression of exercise challenge can occur every 24 hours. If athletes start to feel unwell during or after exercise, they should rest for 24 hours and then attempt the same exercise challenge. Only when an athlete has completed all the stages of exercise challenge can they obtain written medical clearance from a medical doctor. The athlete should give this medical clearance to their coach.

Key messages about concussion 

• Two to three players in your team this season will have a concussion.
• An athlete does not have to lose consciousness to have a concussion.
• Suspected concussion? The athlete must stop playing, and not return to sport or training that day.
• Symptoms can evolve over time - keep monitoring the athlete for at least 72 hours.
• All athletes with suspected concussion should see a medical doctor as soon as possible.