Concussion

By Emmet Magee

Diagnosis, protocols, and a treatment shift away from dark room rest!

Firstly, let’s look at the definition of a concussion. Concussion has been defined as ‘’a traumatically induced transient disturbance of brain function occurring when external forces of different intensities provoke rapid acceleration–deceleration of the brain’’ (McCrory et al., 2017).

What are the signs and symptoms of a concussion?

The symptoms are usually subtle, such as dizziness and “seeing stars.” Some of the more frequent symptoms include headache, dizziness, nausea and imbalance. Loss of consciousness occurs in a minority of cases (Tator, 2013).

UPMC Sports Medicine Concussion Program

The University of Pittsburgh Medical Center (UPMC) have been at the forefront in bringing advancements to concussion management. They have developed the highly regarded UPMC Sports Medicine Concussion Program. Within Ireland, they have appointed clinical leads to provide specialist treatment for concussion patients. In addition, those clinical leads have since developed close links and have provided training for physiotherapists across Ireland to make specialist concussion treatment more accessible.

And we are delighted to provide this at MDC Physiotherapy!

Here is a nice infographic developed by UPMC, to outline the clinical profiles of concussion. With each clinical profile, there is a tailored treatment. As outlined below, these clinical profiles are known by carrying out special tests which are performed by the healthcare professional.

Return to play protocols

These are guidelines which project the recovery timelines from concussion onset to full return to play. As per the literature, this should only be a guideline and no two concussions are the same!

Below are some of the concussion return to play guidelines out there at present. The Gaelic Athletic Association (GAA) have developed a clear protocol on their website for both adult and children playing members.

GAA (Adults)

Rehabilitation stage	Functional exercise at stage	Objective of stage
1. No Activity (24-48 hours)	Physical and Cognitive Rest	Recovery
2. Light Activity (At least 1 day)	Walking, swimming, cycling, keeping intensity <70% max permitted heart rate	Increase HR
3. Sports Specific Exercise (At least 1 day)	Running drills	Add movement
4. No contact Training drills (At least 1 day)	Progress to more complex training drills – passing drills, progressive resistance training	Exercise, coordination and cognitive load
5. Full contact Practice (At least 1 day)	Following written medical clearance, participate in normal training activities	Restore confidence and assess functional skills by coaching staff
6. Return to Play (Minimum 7 days since diagnosis)	Normal game play	Return to competitive action

GAA (Children aged 5 – 18)

Rehabilitation stage	Functional exercise at stage	Objective of stage
1. No Activity (48 hours min)	Physical and Cognitive Rest	Recovery
2. Light Activity (At least 4 days)	Walking, swimming, cycling, keeping intensity <70% max permitted heart rate	Increase HR
3. Sports Specific Exercise (At least 4 days)	Running drills	Add Movement
4. No contact Training Drills (At least 4 days)	Progress to more complex training drills – passing drills, progressive resistance training	Exercise, coordination and cognitive load
5. Full contact practice (At least 1 day)	Following written medical clearance, participate in normal training activities	Restore confidence and assess functional skills by coaching staff
6. Return to Play (Minimum of 14 days since diagnosis)	Normal game play	Return to competitive action

IRFU guide to Concussion in amateur rugby

The IRFU in conjunction with SAFE rugby developed a Graduated Return to Play (GRTP) protocol which outlines clear and concise stages to be followed post-concussion in amateur rugby union.

Players under 20 years of age must take a minimum of 23 days to get through the GRTP.
Adult players must take a minimum of 21 days.

The full protocol can be found at: https://d19fc3vd0ojo3m.cloudfront.net/irfu/wp-content/uploads/2019/01/30172053/IRFU-Concussion-Brochure-2018.pdf

So, what are the key points that we now know about concussion?

Complete rest IS NOT the answer! Research supports that complete prolonged rest is associated with poorer outcomes and may delay an individual’s return to work, study or play (Silverberg and Otamendi, 2019).
‘Relative rest’ and a more active approach within concussion rehabilitation is advised.
No two concussions are the same! Each concussion requires a thorough clinical examination and an individualised management plan for a safe and quicker return to activities or play.
Concussion doesn’t just happen in athletes. It can affect the general population too!

If this is a topic that affects you and you would like a thorough assessment, why not contact us on 045 530007 to find out more.

References

McCrory P., Feddermann-Demont N., Dvořák J., Cassidy J.D., McIntosh A., Vos P.E., Echemendia R.J., Meeuwisse W., Tarnutzer A.A. What is the definition of sports-related concussion: A systematic review. Br. J. Sports Med. 2017;51:877–887. doi: 10.1136/bjsports-2016-097393.
Concussion | GAA does – Gaelic Athletic Association (no date). Available at: https://learning.gaa.ie/Concussion (Accessed: October 18, 2022).
Collins, M.W. et al. (2014) “A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion,” Knee Surgery, Sports Traumatology, Arthroscopy, 22(2), pp. 235–246. Available at: https://doi.org/10.1007/s00167-013-2791-6.
Collins MW, Kontos AP, Okonkwo DO, et al. Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015. Neurosurgery. 2016;79(6):912-929. doi:10.1227/NEU.0000000000001447.
Silverberg ND, Otamendi T. Advice to Rest for More Than 2 Days After Mild Traumatic Brain Injury Is Associated With Delayed Return to Productivity: A Case-Control Study. Frontiers in Neurology. 2019 ;10:362. DOI: 10.3389/fneur.2019.00362. PMID: 31037065; PMCID: PMC6476280.
Tator CH. Concussions and their consequences: current diagnosis, management and prevention. CMAJ. 2013 Aug 6;185(11):975-9. doi: 10.1503/cmaj.120039. Epub 2013 Jul 22. PMID: 23877672; PMCID: PMC3735746.