Practice Principal Dr George Pitsis is the Chief Medical Officer for the Cronulla Sharks NRL team. He is a highly qualified and respected doctor and is a specialist in adult and paediatric sport and exercise medicine.
In this article, Dr Pitsis takes a look at Concussion, what are they, how do they happen and the prognosis for those who suffer with this type of injury. With over 20 years’ experience as the team physician for many high calibre sports teams, locally and internationally, he’s certainly treated his fair share of such injuries.
What is it?
Concussion is a common type of brain injury typically resulting in rapid onset short-lived impairment of neurological function that resolves spontaneously. However occasionally clinical features may evolve over minutes to hours after impact.
How does it happen? (Mechanism of injury)
Concussion can occur in a number of ways. The most common is a direct blow to the head, either by another object impacting on the head (e.g. opponent tacking player), or the head impacting another object causing deceleration (e.g. player’s head hitting the ground hard, causing a contra coupe type injury).
Other mechanisms include “impulse” force transmission to the head via a blow to the neck or elsewhere on the body.
Symptoms reflect a functional rather than a structural disturbance of brain function. This includes disruption of concentration, memory, balance and coordination, as well as symptoms such as headaches, dizziness, light headedness, drowsiness, nausea, head feels like it’s in a fog, feeling slowed down, emotional, irritability, poor sleep, blurred or double vision, and sensitivity to light and nose.
In Rugby League the role of the Medical / Head Trainer (orange shirt) is to assess if a player may be concussed following injury to the head, neck, or body. If there is any loss of consciousness, seizures, confusion and disorientation (fails “Maddock’s” questions), balance disturbance, or memory or other cognitive dysfunction then the player is removed from field of play.
At that point the Team Doctor has 15 minutes to make an assessment using the Sports Concussion Assessment Tool (SCAT 3) protocols. This includes assessment of symptoms, memory, concentration, cognitive function, balance, coordination, neurological examination, and neck examination.
If the Team Doctor deems the player concussed then the player is unable to return to play that day. If the player is deemed not to be concussed then they may return to play, counting as a free interchange if done within 15 minutes.
Generally speaking a true concussive injury does not require any further investigations. If there are any clinical features that indicate the injury may be related to underlying structural neurological injury then the player is taken immediately to hospital for further evaluation by CT or MRI scan.
Early diagnosis is key to effective treatment. There is evidence demonstrating concussed players that continue to play are at risk of further significant injury both physically due to altered reaction time, coordination, balance and concentration, as well as further neurological deficit which may result in the fatal “second impact syndrome” as a result of loss of the ability of the body to properly regulate blood flow to the brain (auto-regulation).
Following a concussion event, once symptoms have completely settled, appropriate neuropsychological testing is performed. A couple of the current accepted tools are the “Sideline Concussion Assessment Tool 3 (SCAT3)” and “CogState” which tests the players’ cognitive state and ability to process information, memory, concentration, and reaction time.
When can I play again? (return to activity)
Once symptoms are clear and the player passes CogState the player is commented on a graded return to activity program. To begin with non-contact light aerobic activity is commenced which is graded up to be more intense, followed by introduction of light to heavier contact. If the player remains symptom free he may participate in normal training with the view to play. The minimum time to return to play is usually 1 week.
What about the long term? (prognosis)
The majority (80-90%) of concussions resolve within 7-10 days, although recovery may be longer for the younger child or adolescent athlete. A minority of patients have persisting symptoms and it is important to exclude structural injuries.
Mouthguards and helmets – there is no good clinical evidence to show they help prevent concussion. They can help reduce dental and facial injury, as well as head lacerations. On occasion use of protective gear may result in risk compensation and more dangerous play.
Rule change – as 50% of concussions occur with direct impact to the head, rules which minimise blows to the head will assist with reducing the rate of occurrence of concussion. Players should play in fairness and with respect to competitive aggression rather than violence.
Education – of players and staff for effective prevention and management.
Dr Pitsis and the team at Sports Medicine Institute are available to look after the injuries and medical needs of people of all ages and backgrounds, from amateur and professional athletes, to the man, woman or child in need of his expert advice.