With all the media attention on head injuries and concussion in sport, we thought it would be good to share with you what the current recommendations are from the FFA and the medical community regarding the assessment and medical management of concussions in football.
What is Concussion?
Concussion is a brain injury defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. It is caused by either:
- a direct blow to the head, face and neck; or
- a blow elsewhere in the body with an impulsive force transmitted to the head.
Concussion affects the way the brain acquires and processes information and reflects a functional injury rather than structural damage to the brain. You don’t need to lose consciousness (black out) to be diagnosed with a concussion!
Concussion facts
- The majority (80–90%) of concussions resolve in a short (7–10 day) period, although the recovery time frame may be longer in children and adolescents.
- Women are twice as likely to suffer concussion than men.
- Concussion symptoms can manifest immediately, hours and even days later.
- The risk of concussion is doubled if a concussion has occurred within the previous 12 months.
- In Australia, if you play Football (Soccer) and sustain a concussion, it is an FFA protocol that you must follow their recommended Graduated Return to Play Program (GRTP) in conjunction with a Medical (GP) Clearance.
What causes a concussion - the science behind it?
The brain is surrounded by a fluid called cerebrospinal fluid whose role is to act as a cushion for the brain within the skull. When the impulsive force applied to the body exceeds the amount of force able to be absorbed by the CSP, a concussion results.
The concussion itself results in changes to the speed at which the brain functions due to an energy deficit. These include changes to the pattern of nerve conduction, energy metabolism, and brain blood flow. The net effect of these changes is an energy shortage for the brain – which can last up to 30 days!
Symptoms
Common include but are not limited to:
- Loss of consciousness
- Increased irritability
- Dizziness and headaches
- Emotionally Labile
- Tonic posture - hypertonic posturing
- Short and Long term Memory Difficulties
- Unbalanced – ataxia
- “Rag doll” body – cervical hypotonia
- Double/blurred vision
- Drowsiness
- Amnesia
- Nausea
- Photophobia – sensitivity to light
- Hyperacusis – sensitivity to normal environmental sounds
If diagnosed with a concussion, the next 72 hours are of great importance and if any of the above symptoms present themselves or begin to deteriorate, you should head to the hospital.
What happens if I am suspected of suffering a concussion?
Any athlete with a suspected concussion should be immediately removed from play and should not return until they are assess by a qualified medical practitioner (General Practitioner; Sports Physician or Neurologist).
Players with a suspected concussion should not be left alone and should not drive a motor vehicle. Only qualified medical practitioners should diagnose whether a concussion has occurred, or provide advice as to whether the player can return to play.
Important: there should be no return to play on the day of a concussive injury.
A qualified Medical Practitioner should:
- Assess and Diagnose whether a concussion has occurred based on their clinical judgement
- Evaluate the injured party utilising a concussion tool
- Provide advice on appropriate medical management to the player and their parent or guardian
- Advise when the player can initiate the Graduated Return to Play Program (GRTP)
- Review & Clear the player to return to play following completion of the GRTP
Physiotherapist’s role
Physiotherapists cannot diagnose a concussion. However, we play a significant role in identifying concussions, arranging referral to appropriate medical practitioners and upon receiving a clearance from a medical practitioner we can be instrumental in guiding you through any associated injuries and facilitating the GRTP as per the FFA Guidelines.
Graduated return to play program
FIFA and the FFA both recommend the application of a GRTP Program following a diagnosis of concussion from a Medical Practitioner. This program provides a minimum of six (6) days from time of injury until return to competition.
| Rehabilitation stage | Functional exercise at each stage of rehabilitation | Objective of each stage |
|---|---|---|
| 1. No activity | Symptom limited physical and cognitive rest No activity for a minimum of 24 hours if being treated by a medical practitioner. This includes ALL electronic devices, TV, reading and Physical Activity to allow the Brain to Rest and Recover. | Recovery |
| 2. Light aerobic exercise | Walking, swimming or stationary cycling with intensity <70% maximum permitted heart rate No resistance training. Athlete must remain symptom free during full 24-hour period. | Increase heart rate |
| 3. Sport-specific exercise | Running drills only. No head impact activities. Athlete must remain symptom free during full 24-hour period. | Add movement |
| 4. Non-contact training drills | Progression to more complex training drills, eg, passing drills. May start progressive resistance training. Athlete must remain symptom free during full 24-hour period. | Exercise, coordination and cognitive load |
| 5. Full-contact practice | Following medical clearance participate in normal training activities. Athlete must remain symptom free during full 24-hour period. | Restore confidence and assess functional skills by coaching staff |
| 6. Return to play | Normal game play | Recovered |
The value of a baseline assessment
The easiest and most effective way to identify a concussion is to undertake baseline assessment - usually performed at the beginning of a sports pre-season. Such a baseline assessment includes a symptom checklist, balance assessment, and computer generated reaction time and memory assessment. If a concussion is sustained, the physician is able to retest the baseline measures and compare. This is also a very useful tool in observing how your rehabilitation is progressing!
What if you want to return to sport early?
It is of great importance that you follow the graduated return to play and do not return to contact sport until medically cleared by a doctor. In Australia, the FFA stipulates that you cannot return until you have completed the GRTP, and all coaches and club officials are aware of the FFA rules.
If a player returns prematurely, they risk sustaining second-impact syndrome – when the brain has not had sufficient time to settle and heal and the athlete receives a second head-impact injury causing diffuse cerebral swelling, brain herniation and death. Another risk which has come to research of late is Chronic Traumatic Encephalopathy (CTE), a chronic neurodegenerative disease seen predominantly in people with a history of repetitive brain trauma. Such a disease causes memory loss, confusion, impaired judgement, impulse control problems, aggression, depression and dementia.
Although both rare in occurrence, CTE and Second Impact Syndrome are significant injuries that should be taken into consideration when determining when to return to sport.
More Information
For further information the FFA Concussion Guidelines may be of interest to you.
If you are seeking management or a baseline assessment for a concussion, please Physioworks:
- Clayfield – 38624544 – clayfield@physioworks.com.au
- Ashgrove – 33664221 – ashgrove@physioworks.com.au
- Sandgate – 32691122 – sandgate@physioworks.com.au