Position statement summary
Emergency medicine General medicine Neurology Child health Sports medicine
Volume 206 - Issue 1

Australian Institute of Sport and Australian Medical Association position statement on concussion in sport

Authors:  Lisa J Elkington and David C Hughes

Med J Aust 2017; 206 (1): 46-50. || doi: 10.5694/mja16.00741
Published online: 16 January 2017

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Summary

Sport-related concussion is a growing health concern in Australia. Public concern is focused on the incidence and potential long term consequences of concussion. Children may be more prone to concussion and take longer to recover. The Australian Institute of Sport and the Australian Medical Association have collaborated to present the most contemporary evidence-based information in a format appropriate for all stakeholders. This position statement aims to ensure that participant safety and welfare is paramount when dealing with concussion in sport.

First aid principles apply in the management of the athlete with suspected concussion, including protection of the cervical spine. Tools exist for use by members of the community, allowing identification of key symptoms and signs that raise the suspicion of concussion. Medical professionals should use the Sport Concussion Assessment Tool 3, in conjunction with clinical assessment for the diagnosis of concussion. Clinical assessment includes mechanism of injury, symptoms and signs, cognitive functioning, and neurological assessment including balance testing. In any situation where concussion is suspected, the athlete must be immediately removed from sport and not be allowed to return to activity until they have been assessed by a medical practitioner. “If in doubt, sit them out.”

A diagnosis of concussion requires immediate physical and cognitive rest, followed by a structured, graduated return to physical activity. Children require a longer period of recovery from concussion. Algorithms are provided for use by medical and non-medically trained stakeholders in the recognition and management of concussion.

Sport-related concussion is a growing health concern in Australia. It affects athletes at all levels of sport from the recreational athlete to the full-time professional.1,2 Concerns about its incidence and possible health ramifications for athletes have led to an increased focus on safe and appropriate diagnosis and management.3-6 Parents, coaches, athletes, medical practitioners and others involved in sport are seeking information regarding the best management of sport-related concussion. Participant safety and welfare is paramount when dealing with all concussion incidents.

The Australian Institute of Sport (AIS) is Australia’s peak high performance sport agency. The Australian Medical Association (AMA) is the peak membership organisation representing the registered medical practitioners (doctors) and medical students of Australia. Both have a clear and unequivocal focus on ensuring the safety and welfare of Australians participating in sport.

Funded by the Australian government, this position statement aims to:

  • provide improved safety and health outcomes for all people who suffer concussive injuries while participating in sport;

  • assist all sporting organisations and clubs to align their policy and procedures to the most up-to-date evidence;

  • protect the integrity of sport through the consistent application of best practice protocols and guidelines; and

  • provide a platform to support the development of national policy for concussion management in Australia.

 

Concussion is a type of brain injury induced by a force to the head or anywhere on the body that transmits an impulsive force to the head. It commonly causes short-lived neurological impairment and the symptoms may evolve over hours or days after the injury. The symptoms should resolve without medical intervention. Rest, followed by gradual return to activity, is the main treatment.2 Evidence from animal and functional imaging studies indicates a series of interrelated biochemical and physiological changes that impair neuronal function.7-15 Recognising concussion can be difficult as the symptoms and signs are variable, non-specific and may be subtle. Onlookers should suspect concussion when an injury results in a knock to the head or body that transmits a force to the head. A hard knock is not required; concussion can occur from relatively minor knocks.

The signs of concussion may be obvious, such as loss of consciousness, brief convulsions or difficulty balancing or walking, or more subtle. The Sport Concussion Assessment Tool – 3rd Edition (SCAT3; http://bjsm.bmj.com/content/47/5/259.full.pdf) identifies 22 possible symptoms (Box 1).1,16,17

Recommendations

Recognising concussion

Recognising concussion is critical to correct management and prevention of further injury. The Pocket Concussion Recognition Tool (http://bjsm.bmj.com/content/47/5/267.full.pdf), developed by the Concussion in Sport Group, has been designed to help those without medical training to detect concussion symptoms.1

When concussion is suspected, first aid principles still apply, including a systematic assessment of airway, breathing, circulation, disability and exposure. Cervical spine injuries should be suspected if there is any loss of consciousness, neck pain or a mechanism that could lead to spinal injury. Manual in-line stabilisation should be undertaken and a hard collar applied until a cervical spine injury can be ruled out.

A medical practitioner should review any athlete with suspected concussion, but if a medical practitioner is not available, or if there is any doubt about whether an athlete is concussed, the athlete must not be returned to sport on the same day. An athlete with suspected concussion should be reassessed for developing symptoms and cleared by a medical practitioner before returning to sport. Due to the evolving nature of concussion, any athlete cleared to return to sport after a suspected concussion should be monitored closely during the game or competition for developing symptoms or signs.

Sometimes there are clear signs that an athlete has sustained a concussion. Medical practitioners covering sporting events should immediately remove an athlete from sport with any of the following clinical features:

  • loss of consciousness;

  • no protective action taken by the athlete in a fall to ground directly observed or on video;

  • impact seizure or tonic posturing;

  • confusion, disorientation;

  • memory impairment;

  • balance disturbance (eg, ataxia);

  • significant, new or progressive concussion symptoms reported by the athlete;

  • dazed, blank or vacant stare, or not their normal selves;

  • behaviour change atypical of the athlete.

 

Some features suggest more serious injury and athletes displaying any of these signs should be immediately referred to the nearest emergency department:

  • neck pain;

  • increasing confusion or irritability;

  • repeated vomiting;

  • seizure or convulsion;

  • weakness or tingling/burning in the arms or legs;

  • deteriorating conscious state;

  • severe or increasing headache;

  • unusual behavioural change; and

  • double vision.

 

Medical assessment of concussion

Concussion should be diagnosed by a medical practitioner after a clinical history and examination covering several domains including mechanism of injury, symptoms and signs, cognitive functioning, and neurological assessment including balance testing.16,17 These domains are covered by the internationally recommended SCAT3,1 which should not be used in isolation but as part of the overall clinical assessment. Computerised neurocognitive testing can be used for assessment but should not be used in isolation. Baseline neurocognitive testing can be useful in the pre-season period for comparison with post-injury scores, but in its absence many programs have reference ranges that can be applied.

Blood tests are not indicated for uncomplicated concussion as there are currently no serum diagnostic biomarkers. Medical imaging is not indicated in the diagnosis or management of uncomplicated concussion, but may be indicated where there is suspicion of more serious injury.1

Where resources allow, sporting organisations could use modern technology such as pitch-side instant video replay to enhance concussion detection.

Modifying factors

While a medical practitioner assessing a suspected concussion should make optimal use of available tools, clinical judgement remains a cornerstone of concussion diagnosis and management. Concussion modifiers are factors that may affect a clinician’s management of a concussed athlete.1 They can be associated with a more protracted recovery time,18-23 and include:

  • a high number of concussive symptoms;

  • high severity of concussive symptoms;

  • prolonged loss of consciousness (greater than one minute);

  • post-concussive seizure;

  • previous history of concussion;

  • age of the athlete (a more conservative approach is indicated in children);

  • history of depression, anxiety, migraine, learning disability, attention deficit hyperactivity disorder or sleep disturbance; and

  • use of medications, especially psychoactive or anticoagulant medications.

 

Managing concussion

Head injury advice should be given to athletes with concussion and their carers. Any athlete with suspected or confirmed concussion should be accompanied by a responsible adult and not be allowed to drive. Athletes should be advised to avoid alcohol and check medications with their doctor. Specifically, they should avoid aspirin, non-steroidal anti-inflammatory drugs, sleeping tablets and sedating pain medications.5

Once a concussion has been diagnosed, immediate management is physical and cognitive rest.24,25 This may include time off school or work, and relative rest from cognitive activity. The majority of symptoms should resolve in 7–10 days. After a minimum of 24 hours without any symptoms, the patient can return to cognitive and physical activity.1,26 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 symptoms have not recurred during that time. If symptoms recur, there should be a “step down” to the previous level for at least 24 hours (after symptoms have resolved).1 The activity steps are:

  • light aerobic activity to begin with (at an intensity that can easily be maintained while having a conversation);

  • basic sport-specific drills that 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; and

  • normal competitive sporting activity.

 

Sporting organisations need to continually review their policies for best practice, and high risk sports such as professional collision sports need to ensure that medical personnel are appropriately trained in concussion diagnosis and management. The potential benefits of changes such as introduction of independent “concussion doctors” require careful consideration against possible unintended negative consequences. Those who know the athlete may be best equipped to detect some subtle signs of concussion. Removing the team doctor entirely from the assessment and decision making processes could compromise the ability to detect subtle concussions. A compromise could be a model that allows team doctors to assess concussions, with independent doctors overseeing the process and signing off on any athletes returned to sport (Box 2).

Children and adolescents

Athletes aged 18 years and under may be more susceptible to concussion and take longer to recover, requiring a more conservative approach.27-32 Return to learning should take priority over return to sport. School programs may need to be modified to include more regular breaks, rests and increased time to complete tasks. The symptom-free rest period and the graduated return to sport protocol should be extended so the child’s return to contact training, sport or play happens not less than 14 days after symptoms are fully resolved (Box 3).

Long term consequences

Potential long term consequences of concussion are concerning.33,34 There is currently no reliable evidence linking sport-related concussion with chronic traumatic encephalopathy (CTE).35-39 The evidence supporting a link consists of case reports, case series and retrospective analyses. Due to the nature of the studies, and the reliance on retired athletes volunteering for autopsy diagnoses, selection bias is common. The studies to date have not adequately controlled for potential confounding variables such as alcohol and drug misuse, genetic predisposition and psychiatric illness.35,40,41

Given that concussion is common and the number of cases of CTE reported is extremely small, the link between them remains tenuous. However, it raises concerns that call for well designed prospective epidemiological studies accounting for potential confounding variables.

Education

Several studies have demonstrated that general knowledge of concussion is inadequate. Education programs must target the various groups involved in sport-related concussion to effectively improve awareness and understanding. 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 the symptoms and signs of concussion for detection at the community sport level where medical supervision is absent.42-48 Sporting and medical organisations continue to develop specific recommendations regarding concussion in order to educate their participants.47,49,50

Concussion research priorities

There is a need for well designed prospective research to inform the diagnosis and management of concussion. Areas of priority include the biological processes underlying concussion, the impact of concussion on long term health, the role of concussion in special groups such as children, and the effectiveness of concussion education programs. Further research is needed to constantly improve clinical tools used in the diagnosis and management of concussion.

Key points for coaches, parents and athletes

 

  • Concussion is a type of brain injury that occurs from a knock to head or body.

  • Recognising concussion is critical to correctly managing and preventing further injury.

  • The Pocket Concussion Recognition Tool is recommended to help recognise the signs and symptoms of concussion.

  • First aid principles apply in case of suspected concussion, including those for protection of the cervical spine.

  • Any athlete suspected of having concussion should be removed from sport, not allowed to return to sport that day, and be reviewed by a medical practitioner.

  • Features that suggest more serious injury and should prompt immediate emergency department referral include neck pain, increased confusion 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 event details and past medical history and then assess the patient including symptoms, signs, testing memory function and concentration, balance and neurological function.

  • No single test can determine whether someone has sustained a concussion. Your doctor may not order blood tests or medical imaging unless they wish to exclude more serious injuries.

  • Once a diagnosis has been confirmed, the main treatment for concussion is rest. When symptoms have resolved for a minimum of 24 hours (longer for children) gradual return to sport can usually begin.

  • 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 symptoms have not recurred 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):

    • begin with light aerobic activity at an intensity that can easily be maintained while having a conversation

    • 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. They should have a longer rest period (48 hours) and the recommended minimum of 14 days from when symptoms cease before returning to full contact sport (after medical clearance).

  • The long term consequences of concussion and especially multiple concussions are not yet clearly understood.

  • If in doubt, sit them out.

 

For diagrams summarising the non-medical assessment of concussion on-field and off-field, see Appendix 1 and Appendix 2 at mja.com.au.

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 in a range of domains including mechanism of injury, symptoms and signs, cognitive functioning, and neurology including balance assessment.

  • The SCAT 3 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. The SCAT 3 includes a Concussion Injury Advice sheet (page 4), which can be filled in by the medical practitioner and handed to the injured athlete’s immediate carer for instructions on the early days following the injury.

  • Computerised neurocognitive testing can be used for assessment but should not be used in isolation.

  • Children and adolescents may be more susceptible to concussion and take longer to recover. A more conservative approach should be taken and the symptom-free rest period should be extended. The graduated return to sport protocol should be extended such that the child does not return to contact training, sport or play until symptom-free for at least 14 days.

  • Blood tests are not indicated for uncomplicated concussion. Medical imaging is not indicated unless a more serious head or brain injury is suspected.

  • Standard head injury advice should be given to athletes suffering concussion and to their carer.

  • Once concussion has been diagnosed, immediate management is physical and cognitive rest. This includes time off school or work and rest from all cognitive activity. The majority of concussive symptoms should resolve in 7–10 days. After a minimum of 24 hours without any symptoms, the patient can progressively return to cognitive and physical activity.

  • Some sports have their own guidelines or recommendations for the management of concussion in sport which should also be considered.

  • If in doubt, sit them out.

 

For diagrams summarising the medical assessment of concussion on-field and off-field, see Appendix 3 and Appendix 4 at mja.com.au.

Box 1 – Possible symptoms of concussion

Headache

Sensitivity to noise

Drowsiness

“Pressure in head”

Feeling slowed down

Trouble falling asleep

Neck pain

Feeling like “in a fog”

More emotional

Nausea or vomiting

“Don’t feel right”

Irritability

Dizziness

Difficulty concentrating

Sadness

Blurred vision

Difficulty remembering

Nervous or anxious

Balance problems

Fatigue or low energy

 

Sensitivity to light

Confusion

 

Source: Sport Concussion Assessment Tool – 3rd Edition (http://bjsm.bmj.com/content/47/5/259.full.pdf).

Box 2 – Return to sport protocol for adults over 18 years of age

Box 3 – Return to sport protocol for children under 18 years of age

Authors

  • Lisa J Elkington
  • David C Hughes
  • 1. Australian Institute of Sport, Canberra, ACT

Correspondence: david.hughes@ausport.gov.au

Competing interests

No relevant disclosures.

Acknowledgements

This is a summary version of the full AIS and AMA position statement on concussion in sport available at . We acknowledge the collaboration of the Australian Medical Association in the preparation of the position statement.

References

Linked content

  • MJA InSight: Evolving best practice for concussion in sport

Provenance: Not commissioned; externally peer reviewed.

View this article on Wiley Online Library

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