Concussion is the in-vogue medical term at the moment. Not only have concussion diagnoses been on the rise (the incidence of concussion in sport now at 0.1 to 2.5 per 1000 athletic exposures, Clay et al, 2013) but also the research around concussion has dramatically increased. The most recent Consensus Statement on Concussion in Sport (as a result of the 5th International Conference on Concussion in Sport in Berlin 2016) has included some of this new research and has outlined the best treatment protocols for concussion management in sport.
Changes to the Consensus Statement
FIFA release this Consensus Statement regularly using the latest research pertaining to sports’ concussions. The last Statement was released in 2012 in Zurich has had a number of changes made to it as outlined below:
Return to Play Protocols
As mentioned above there is a graduated return to play protocol outlined in the guidelines. Once an athlete displays no symptoms at a phase, they can move into the next phase of recovery. The current recommendations are:
Phase 1
Aim: Symptom-limited Activity
Activity: Daily activities that do not provoke symptoms
Phase 2
Aim: Light Aerobic Exercise
Activity: Walking / Stationary Cycling. No resistance
Phase 3
Aim: Sport-Specific Exercise
Activity: Running, adding movement
Phase 4
Aim: Non-Contact Training Drills
Activity: Harder training drills e.g. passing, drills that require thinking. Can also start progressive resistance training
Phase 5
Aim: Full Contact Practice
Activity: Following medical clearance, full normal training session
Phase 6
Aim: Normal Match Play
It’s important to note that the player must have no symptoms before progressing to the next phase
Criteria for Physiotherapy Post-Concussion
So now that physiotherapy is recommended in the guidelines, when is it appropriate to be seen by one and what will they do?
Firstly, whoever is on the sideline at the time of your concussion should do a full evaluation of your head injury. 4 out of 10 concussions are better by week 1 but if you’re unfortunate to be one of the remaining 6 whose symptoms last longer than a week, then you need to see a physiotherapist trained in vestibular rehabilitation.
Your neck, balance and vestibular functioning will be assessed and an appropriate exercise programme for your neck pain / decreased balance / dizziness will be started. The only time you should visit a vestibular physiotherapist immediately after your concussion is if you are suffering from vertigo (spinning sensation). Your therapist will assess the type of vertigo and treat accordingly.
Therefore it’s important to note that not all concussions require vestibular rehabilitation!
Concussion Assessment
So if there’s no healthcare professional available pitchside to assess a concussion what do you do?
Firstly, in order to assess a concussion both pitch side and fully, there are several assessment forms you can use and easily download. However if you’re not the most organised (like myself!) download the Concussion app from Acquired Brain Injury Ireland. This app will take you through a shortened and lengthy concussion assessment and is a must for any coach or parent.
Secondly, if you suspect a player has a concussion remove them from play immediately. You can see from the graduated return to play protocol that it’s important not to over-exercise with concussive symptoms as this can prolong your recovery. Let’s not forget that you’re dealing with a brain injury. Would you allow someone to play on if they had a stroke? Of course not, so why do it with a concussion? Don’t be negligent; if in doubt, sit them out!
References:
Changes to the Consensus Statement
FIFA release this Consensus Statement regularly using the latest research pertaining to sports’ concussions. The last Statement was released in 2012 in Zurich has had a number of changes made to it as outlined below:
- Rest for only 24-48 hours MAXIMUM:
- Originally rest was the first phase of recovery for concussion but now it has been removed and our first phase is symptom-limited activity. Recent research has shown that the longer you rest with no activity, the worse your outcome post-concussion.
- Return to Learn Guidelines now included
- For some of our younger athletes, it was unsure previously when they could return to school / learning but now we have a designated protocol for just that
- Neuropsychological Testing not Exclusive to return to play
- Where before cognitive testing (where are you? Whose the president? Etc.!) was the be all and end all, now it’s understood that more disciplines need to have input before an athlete is safe to return to sport.
- Physiotherapy and Vestibular Rehabilitation
- Physio is now acknowledged as beneficial in the assessment and treatment of prolonged concussion (> 7 days) and a physiotherapist trained in vestibular rehabilitation is recommended in the treatment of concussion
Return to Play Protocols
As mentioned above there is a graduated return to play protocol outlined in the guidelines. Once an athlete displays no symptoms at a phase, they can move into the next phase of recovery. The current recommendations are:
Phase 1
Aim: Symptom-limited Activity
Activity: Daily activities that do not provoke symptoms
Phase 2
Aim: Light Aerobic Exercise
Activity: Walking / Stationary Cycling. No resistance
Phase 3
Aim: Sport-Specific Exercise
Activity: Running, adding movement
Phase 4
Aim: Non-Contact Training Drills
Activity: Harder training drills e.g. passing, drills that require thinking. Can also start progressive resistance training
Phase 5
Aim: Full Contact Practice
Activity: Following medical clearance, full normal training session
Phase 6
Aim: Normal Match Play
It’s important to note that the player must have no symptoms before progressing to the next phase
Criteria for Physiotherapy Post-Concussion
So now that physiotherapy is recommended in the guidelines, when is it appropriate to be seen by one and what will they do?
Firstly, whoever is on the sideline at the time of your concussion should do a full evaluation of your head injury. 4 out of 10 concussions are better by week 1 but if you’re unfortunate to be one of the remaining 6 whose symptoms last longer than a week, then you need to see a physiotherapist trained in vestibular rehabilitation.
Your neck, balance and vestibular functioning will be assessed and an appropriate exercise programme for your neck pain / decreased balance / dizziness will be started. The only time you should visit a vestibular physiotherapist immediately after your concussion is if you are suffering from vertigo (spinning sensation). Your therapist will assess the type of vertigo and treat accordingly.
Therefore it’s important to note that not all concussions require vestibular rehabilitation!
Concussion Assessment
So if there’s no healthcare professional available pitchside to assess a concussion what do you do?
Firstly, in order to assess a concussion both pitch side and fully, there are several assessment forms you can use and easily download. However if you’re not the most organised (like myself!) download the Concussion app from Acquired Brain Injury Ireland. This app will take you through a shortened and lengthy concussion assessment and is a must for any coach or parent.
Secondly, if you suspect a player has a concussion remove them from play immediately. You can see from the graduated return to play protocol that it’s important not to over-exercise with concussive symptoms as this can prolong your recovery. Let’s not forget that you’re dealing with a brain injury. Would you allow someone to play on if they had a stroke? Of course not, so why do it with a concussion? Don’t be negligent; if in doubt, sit them out!
References:
- Clay, M. B., Glover, K. L., & Lowe, D. T. (2013). Epidemiology of concussion in sport: a literature review. Journal of Chiropractic Medicine, 12(4), 230–251.
- McCrory P, Meeuwisse W, Dvorak J, et al. Br J Sports Med 2018;51:838–847.
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