Overview of Concussion

What is concussion?

Concussion is a traumatic brain injury following direct contact or sudden acceleration and deceleration of the brain inside the skull. In non-medical terms this is best explained as uncontrolled movement and collision of the brain inside the hard-non-elastic skull bones. Concussion could therefore be best described as the ‘shaken brain’-syndrome (where a syndrome is a set of medical signs and symptoms, which are correlated with each other). The short-term signs and symptoms of a concussion can be disturbances in physical ability, cognitive function, emotional stability and/or sleep. The severity of these symptoms differ broadly and therefore a concussion is not always obvious from the signs and symptoms. Concussion is a ‘hidden’ injury without obvious signs such as limping or bleeding. This can make the diagnosis difficult and requires proper and thorough examination.

Why is a special concussion programme necessary?

Because concussion is a “hidden injury” with few visible signs such as limping or bleeding, it can easily be missed. Awareness among the public, players, sport officials and, of course, healthcare providers is essential to recognize the condition. Early recognition and appropriate treatment is necessary to reduce recovery time and prevent complications. Playing with concussion also leads to poor performance and increased risk of other injuries. International sports bodies such as the International Football Federation (FIFA) have emphasized the importance of correct concussion management and have implemented far reaching measures in this regard, such as rule changes.

Sport governing bodies over the world are increasingly adopting policies to address the previously unknown risks of Sports Related Concussion. Internationally, the most effective way to deal with the sudden changes in medical management of concussion, is a unified approach by organized sport.

The main trigger for the heightened attention to was the highly-publicized lawsuit won by former professional American Football players, who sustained concussion in their careers, against the National Football League (NFL). The NFL was found guilty of neglect by not making players aware of the risks, underdiagnosing and mistreating of concussions. A financial settlement of around a billion USD has been reached, and more is to come.

What are the risks?

A concussion can have far-reaching medical and performance consequences. A possible short term complication is the development of a post-concussion syndrome, a condition with a long recovery time, sometimes even more than a year. Another even more severe risk is the second-impact syndrome, which can occur when a concussion is not addressed well and a repeat blow to the head happens, while the brain is still vulnerable. This condition can be lethal or result in severe disability. Long term chronic brain dysfunction, such as early degeneration of the brain, or chronic traumatic encephalopathy (CTE) has recently been linked to concussion. From a sports perspective, participating with concussion can lead to poor performance and increased risk of any injury.

Can Concussion and the complications be prevented?

Full prevention of concussions is not possible, especially in sports where contact is part of the nature of the game. However, adjustments of rules or other preventative measures can certainly assist in lowering the incidence and the complication rate. Accurate recognition of a (possible) concussion followed by proper management can reduce the chances of some serious complications such as post-concussion syndrome and CTE.

Full prevention of the potentially lethal second-impact syndrome is possible by instant removal of players with suspected concussion from the field of play.

Who carries the responsibility in case of concussion in sport?

An athlete who sustained a concussion will in most cases not be capable to recognize a concussion and make decisions on management.

In most professional sports a properly trained healthcare provider is available to provide medical coverage during training and games. Principally recognition of a concussion in that environment should not be a problem, especially if the health care provider is allowed time for a proper assessment. Ignoring or overruling medical decisions and advice by coaching staff unfortunately still happens and can be dangerous in cases of suspected concussion.

In amateur and youth leagues, proper medical coverage is limited. Unawareness of the symptoms and possible consequences of concussion among players, coaches and parents, especially in young athletes, is a realistic health threat.

What is the best approach?

internationally adopted medical protocol has been developed. It has been shown that adherence to the medical protocol have significant positive results on having the athlete available for competition at the earliest possible time and in preventing severe complications.

International Federations like FIFA and World Rugby, among others, have adopted concussion policies, aiming to raise awareness, improve recognition of concussion symptoms and signs, early management and path to return to play. To this end, FIFA will even implement a new rule, providing 3 minutes for on-field assessment for a possible concussion during the 2018 FIFA Football World Cup in Russia.

Raising public awareness, education of role players in sport such as coaches and referees, healthcare providers from field side emergency care professionals to general practitioners, emergency physicians, sports physicians, and other specialties, is currently seen as the best practice.