Concussion is a traumatic brain injury resulting in a temporary disturbance in brain function, caused by a direct or indirect force to the head. It is considered a subset of mild traumatic brain injury that is at the less severe end of the brain injury continuum. It is characterized by a set of neurological symptoms and signs that usually arise rapidly and resolve spontaneously over a course of time, however that course varies from person to person and injury to injury.
Signs and Symptoms of a Concussion:
A concussion following head trauma can present with a range of symptoms that vary substantially from case to case; they include: loss of consciousness, headaches, dizziness, motor and convulsive responses, pain in the neck, nausea, vomiting, loss of balance, coordination problems, poor concentration, confusion, amnesia, feeling in a fog, blurred or double vision, seeing “stars”, irritability, mood swings, ringing in ears, vacant stare, drowsy, sleep problems.
Some of these symptoms may not occur for 24-48 hours or even up to a week after the initial injury.
There is also a range of modifiers that affect how an individuals initial and on-going response to a concussion occurs and progresses.
- Initial assessment using standard emergency first aid principles (airway, breathing and circulation) and paying particular attention to possibility of a cervical spine injury
- Removed immediately from the activity for further assessment (often assessed with tools such as the Concussion Recognition Tool or Sport Concussion Assessment Tool)
- If a concussion is suspected then monitor closely and referral for medical for assessment. If there is any doubt, transport to hospital by ambulance.
- Those with a suspected concussion should not be left alone after the injury and closely monitor for several hours.
- Always err on the side of safety. The mantra is often: “when in doubt, sit them out”.
- If a concussion is diagnosed or suspected, the sports participant must not be allowed to return to participation on the day of injury.
- Follow the guidelines or policies of the relevant organization (most sports bodies and related organizations have policies on this that do vary somewhat, but should be followed)
Physical and cognitive rest until initial symptoms have improved then a graduated increase in activity and cognitive load.
Pharmacological management of headaches (paracetamol or NSAIDs); sleep disturbances may also need pharmacological management.
Physiotherapy for cervicogenic headaches.
Creatine kinase supplements suggested to help, but data limited.
Return to Play Policy:
Return to sports participation (and training) after a diagnosed concussion should only occur once all symptoms are resolved and with clearance from a medical practitioner who has appropriate experience in the management of concussion. Most plans follow a graduated return to play and need to follow the policy of the relevant organization or governing body.
Often start with low-level aerobic activity as symptoms allow.
Long Term Consequences:
- Increased risk for lower extremity problems
- High risk for neurodegenerative diseases later in life such as chronic traumatic encephalopathy (CTE)
- Mental health issues
- Athletes should consider retiring if have multiple concussions, especially in a shorter period of time or if less force is needed to produce a concussion.
Second Impact Syndrome (SIS):
This is rare and occurs when there is a second concussion before the symptoms from the first concussion have resolved. This is potentially very dangerous and is often fatal and almost always causes disability if not fatal. The brain swells rapidly after the second impact due to what is considered the brains lack of an ability to auto-regulate the diameter of the arterioles following the first concussion. This results in a significant cerebral edema leading to a rapid and severe increase in intracranial pressure which needs immediate intervention to lower. The risk of SIS is the reason for not returning to sports following an initial concussion until all symptoms have resolved.
- Rule changes (eg assessment of the tackling in contact sports to see if appropriate rule changes can lower the risk; red card or 'sending off' of players who engage in activities that put other players at risk)
- Training and education (eg placement of head during tackling in sports like rugby)
- Equipment (most consider headgear is not effective at preventing concussions)
- Dissemination of guidelines and policies (some evidence that not getting through to community sports coaches and sports trainers)
- Screening (eg pre-season testing to identify any mild impairments)
Relevance to Podiatry:
- Public health issue that all health professionals should be concerned with
- Increased risk for lower extremity problems
- Podiatrists are part of the team that could make them a first responder to an on-field incident
- Involvement in community level sports, help increase awareness of and disseminate policy's and guidelines
- Suggested that heading the ball in soccer can lead to long-term neurological impairment similar to a concussion.
- Historically some sports were played hard by "hard men" and those with a concussion during those times may have often play on. See the Lonergan Shuffle.
Concussion and the lower limb and as a public health issue (Podiatry Arena)
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