Concussion
What is Concussion ?
A concussion is a type of mild-Tramautic Brain Injury (mTBI) following high force head impact. This is the most common type of brain injury and can often result in a short term, transient disturbance to cognition, neurology and physical function .
People who have concussion may experience:
headache
nausea or vomiting
dizziness
problems with balance
problems with attention
confusion
sensitivity to noise and light
brief convulsions
temporary memory loss
drowsiness
blurred vision
being more emotional, anxious or sad
The HeadCheck app, developed by Murdoch Children’s Research Institute, is a useful tool to recognise the signs of concussion in children and adolescents.
Concussion injuries occur in response to any one, or a combination, of the following mechanisms:
A) Direct “bruising” to areas of the brain that strike the walls of the skull as it moves or “bounces” within it.
B) Tearing, shearing and stretch injuries to nerves and small blood vessels. This usually affects deeper areas of the brain and regions close to the brain stem.
C) A change in the brain’s chemical balance (which has a toxic effect on brain tissue). This is thought to have the largest impact on brain injury and delayed recovery. Inappropriate or excessive stimulus for the bran can continually cause these toxic neurochemical imbalances, causing chronic damage to the brain.
Current research divides concussion into the following 7 categories of injuries:
Cognitive – difficulty with memory, speech, complex thought, multi-tasking
Oculomotor – issues with eye movement control
Affect/Emotional – responding inappropriately to emotional triggers
Cervical Spine – pain or movement issues of the neck
Headache – localised or general, constant or intermittent
Cardiovascular – heart rate & blood pressure control and coordination
Vestibular – problems with reactions to changes in head motion and position
How common is Concussion ?
In sport, concussion is a very common head injury - most often encountered in contact sports, such as Australian rules football, rugby league and rugby union. People can also be concussed in anything with a risk of falls, such as horse riding, cycling and skiing. Brain Injury Australia estimates that every year in Australia more than 3,000 people are hospitalised with concussion while playing sport.
Hospitalisation rates for concussion across different sports have been examined in Australia, and when adjustments were made for increasing participation rates, the sports with the highest concussion rates are motor sports (181.8/100,000), equestrian (130.3/100,000), Australian Football (80.3/100,000), all codes of rugby (49.9/100,000), and roller sports (44.8/100,000)
Outside of sport - falls are the leading cause of adult non-sports related concussions, followed by motor vehicle accidents and violence.
In these settings, non-sports concussion still require meticulous assessment and management plan to return to daily activities gradually and safely - however, the goals may shift from Return to Sport/Play timelines, to Return to Work or Return to Study focus.
Concussion Complications
Most people who have concussion will recover without any direct treatment within 2 weeks, but sometimes complications can occur which can extend this process.
It is important that people with concussion rest and that their recovery is monitored regularly by their doctor or physiotherapist.
It is crucial that in any head injury/head impact scenario, the following signs should be a warning to immediately seek medical attention or call an ambulance:
new onset neck pain or tenderness
double vision
tingling or weakness in the arms or legs
a severe headache
a seizure
loss of consciousness
vomiting
unusual agitation or restlessness
Early Diagnosis and Screening
There are a number of signs that should point to suspecting a concussion in sport. When concussion is suspected, a through assessment needs to be performed.
On-field signs of concussion:
• Loss of consciousness
• Lying motionless, slow to get up
• Seizure
• Confusion, disorientation
• Memory impairment
• Balance disturbance
• Nausea or vomiting
• Headache or ‘pressure in the head’
• Visual or hearing disturbance
• Dazed, blank/vacant stare
• Behaviour or emotional changes, ‘not themselves’
Once an athlete has been removed from the field , they should have an assessment performed by a qualified medical practitioner or physiotherapist. Before this point, parents/coaches/other athletes may be able to assist with detecting certain subtle signs of concussion:
• Pale
• Difficulty concentrating
• Fatigue
• Sensitivity to light/noise
• Confusion, disorientation
• Memory impairment
• Nausea
• Headache or ‘pressure in the head’
• Feeling slowed or ‘not right’
• Dazed, blank/vacant stare
• Behaviour or emotional changes, not themselves
X-Rays
Though uncommon, some people may have serious structural injuries to their cervical spine (neck) with a concussion. Those with significant neck pain, substantial loss of range of motion, or specific neurological signs would benefit from an X-ray to rule out serious pathology and direct immediate management more accurately.
MRI or CT Scans
The majority of MRIs and CT scans are negative for those with concussion syndrome (6). In uncommon cases where head scans do show changes in structure related to a brain injury, this information doesn’t usually help in determining the treatment needed. While MRI isn’t established as an effective screening tool for concussion, these scans are useful in ruling out of sinister pathology such as bleeding within the brain or skull.
The Sideline Concussion Assessment Tool is the most commonly administered test for sports related concussion. However this is a screening test rather than a true diagnostic test and it’s designed to be used for sports injuries and immediately following a concussion. This tools’ usefulness as a concussion test decreases the longer after initial injury is it administered - with research suggesting a loss of effectiveness in as little as 3 days .
The SCAT-5 includes a modification to the broadly used Maddocks questions (modified version below):
At what venue are we today?
Which half is it now?
Who scored last in this match?
What did you play last week?
Did your team win the last game?
There is also a modified version of the SCAT-5 for children aged 5-12 years which involves age-appropriate questions and parent/carer input.
Without any of these assessment tools available or accessible, the adage should hold true - “ if in doubt, sit them out ”.
Concussion Management
Acute & Short-Term Rehab
In the acute setting any head injury requires standard First Aid management.
In the sporting context, concussion will almost always rule out the player from the game or training session following immediate screening for the need for further remedial attention/paramedics (usually Sports Trainer/Athletic Trainers carry out these assessments, otherwise sideline Physiotherapists and Sports Doctors can assist with more complex/severe cases).
Recovery of concussion related Brain injury will occur through 2 main mechanisms:
Healing of the damaged nerve cells (this tends to happen in the early phases of recovery)
Undamaged neurones compensating for the damaged areas (usually occurring in the later phases) – i.e. neuroplasticity
In order to achieve this, the brain needs to be provided with the optimal environment for healing - which will differ between individuals depending on their symptoms and environmental needs.
Different types of stimulus can affect someone following concussion differently (e.g., sounds, lights, visual focus, mental focus etc) which is why it is important to have all symptomatic areas assessed and treated as early as possible to avoid ongoing problems.
Long Term Management
Following concussion, there is up to 3 x the risk for another concussion. There is also research showing that in people with Alzheimers/Parkinsons Disease, 20-30% have a history of at least 1 concussion, compared with only 8-10% of people without Alzheimers/Parkinsons Disease.
Because of this - it is important that care is taken in the rehabilitation process to reduce risks for additional concussion, as well as progressive neurological deficits.
Usually Physiotherapy & Exercise Physiology can guide people on appropriate activity modifications and restrictions (such as contact sports, school, work etc) in order to ensure they have the safest return to physical activity and function. This may involve graded/progressive rehabilitation exercises to build tolerance to more strenuous tasks including school, work, studying and sport-specific demands.
In elite rugby, most concussions occur to the tackler (due to high acceleration and body postures with the upper body/head inclined forward). In these athletes, a structured return to tackling /contact with ongoing risk assessment should be implemented. This could involve modifications to technique to reduce risk or changing the position on the field that is played to reduce exposure to high velocity contact.
There is also a role for targeted exercise programs that strengthen the neck and trunk muscles in sport-specific or vulnerable positions. Depending on the individual demands of the person (as well as their individual anatomy /injury history) - different exercises will be required improve weak links and reduce risk for concussion/head injury.
Rehabilitation and Return to Sport
Experienced physiotherapists can assess and treat patients who require help in this area. This includes targeted manual therapy techniques to improve freedom of movement and reduce pain, as well as physical therapy exercises to improve core strength, stability, and functional movement patterns. Physiotherapy and therapeutic exercise are also effective for reducing Post Concussion syndrome symptoms such as vertigo/dizziness, balance disturbance, cardiovascular/blood pressure symptoms, mental health etc.
81% of new concussion patients have some variety of vestibular dysfunction/inner-ear related dizziness, which is why this area of rehabilitation is so crucial in the recovery process.
Studies show that vestibular rehabilitation combined with physiotherapy treatment directed at the neck, significantly reduces post-concussion recovery time
In particular, contact Sport requires an additional degree of caution given the nature of the activities and the associated risk.
This also requires a specialised return to sport program that incorporates graded exposure to impact, and targets any weak links that could otherwise increase risk for injury.
Concussion Clinic
We offer a Concussion Clinic for athletes of all backgrounds as well as the general population who may have suffered from head injury. This covers all aspects of head injury and concussion including dizziness, neck/back pain, visual disturbances, headaches and any other functional deficits.
While there is no cookie cutter approach to managing concussion - our concussion clinic will usually incorporate the following components:
Comprehensive Medical & Injury History
Neurological Exam
Oculomotor Vision Tests
Vestibular Tests/
Orthopaedic / Physical Exam
We utilise high quality evidence-based rehabilitation techniques to assist athletes and general populations gain relief from their symptoms and return to their previous level of performance.
With combined Physiotherapy, Exercise Physiology and Sport’s Science expertise - our comprehensive assessment process and precise treatment strategies are designed to guide people back to doing what they love.