Concussion: A comprehensive look at one of the most severe/concerning sports injuries

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Concussion: A comprehensive look at one of the most severe/concerning sports injuries

SRi thanks Dr Akbar de Medici of the Institute for Sport, Exercise and Health for compiling this report.

Player concussions continue to be the most concerning and predominant medical condition in World Sports.

Injury surveillance systems bring to light the severity of the problem; 189 concussions occurred in the English Professional Rugby Union 2014/2015 season, whilst for NFL, an alarming 281 concussions were suffered during the 2017 season.

It comes as no surprise that concussion is the most reported injury in these particular sports, and the rate of injury is growing year on year.

However, these increasing statistics are also due to players, coaches and officials becoming more knowledgeable as to what the indicators of a concussion are.

Additionally, media coverage has added to this awareness, as has a greater specification of the signs and symptoms of concussions, which has aided healthcare professionals in making their diagnosis.

This article aims to cover the key issues apropos to concussion, and intends to provide the decision makers in professional sports club with the most up to date, and vital information needed to ensure concussion is treated effectively and safely.

What is a concussion and how is it recognised?

Concussion is a mild traumatic brain injury caused by a direct blow to the head or an indirect/transmitted force such as a hit to the body. This causes a temporary brain dysfunction that can manifest as a number of signs or symptoms, with the most common ones being headaches, dizziness, memory disturbance or balance problems. Contrary to popular belief, loss of consciousness is rare in concussion and occurs in less than 10% of cases.

Symptoms of concussion typically appear quickly but onset can be delayed, in some cases, for up to 2 days. In such cases medics may rely on the individual, their team mates or associates to report any concerns.

If there is any suspicion of a player being concussed, a safety first “If in doubt sit them out” approach is adopted, and the player is withdrawn from sports till they can be assessed by an experienced medical professional.

To date there is no objective test, or imaging technique that can confirm concussion, however, a consensus has been reached by various major world sports governing bodies as to the tell tale signs and symptoms that constitute a concussion.

A common difficulty in trying to prevent concussion is how to tackle the variety of means that can cause it in the first place, whether it’s a direct below to the back of the head, or a glancing blow to the temple. A popular misconception is that a helmet will protect a player from concussion, however, evidence to date proves this theory incorrect.

Another impediment is the fact that individuals have a varied threshold of developing concussion. That’s to say, a given force vector may cause concussion in one player, but not another.

It is possible that individual’s differences are the reason studies using force measuring devices have been unsuccessful in diagnosing or predicting concussion.

Some research has suggested that neck strengthening could be beneficial in helping players better attenuate heavy blows. Nevertheless, from our experience, it is more often the unexpected/blindsided hits that cause concussion, which are evidently hard to be prepared for.

Studies have also proven that women and children are far more susceptible to head injuries, and to develop symptoms of concussion secondary to contact sport. As such, specific rules to protect this subgroup of athletes are often established.

Legislation is the predominant strategy to date that has resulted in improved player safety in numerous sports. Fundamental rule changes such as penalising dangerous play in Rugby Union and NFL, and not rewarding high risk behaviour (for example, reducing the points awarded for a direct kick to the head in Taekwondo), have led to reduced high risk incidents.

Although the NFL’s latest figures illustrate an increase in the number of concussions reported in the 2017 regular season, the numbers occurring in competitive matches overall reduced. However, interestingly, the number of concussions during pre-season increased. This could perhaps be put down to the fact that competitive matches are better policed.

What are the concerns around concussion?

For the player

An individual’s decision making skills and reaction times may be impaired, so a player increases their risk of sustaining another injury when they play with a concussion.

We have also found from our own experience, which is backed by supporting evidence, that playing with a concussion can also prolong symptoms, and result in an athlete’s delayed return to their sport.

The greatest concern though is the possibility that a second impact before a player is able to completely recover from a concussion can be fatal.

For the team

A concussed player may become a liability to their team, as they put themselves and others at risk of injury, and therefore may also compromise the team’s success through underperforming.

For everyone

A key concern for all who play sports with a high incidence of head injury, from the grass roots to professional levels, is the possibility of developing the neurodegenerative condition Chronic Traumatic Encephalopathy (CTE).

CTE is an early form of onset dementia, which can only be diagnosed post-mortem, which has been identified in the brains of some retired National Football League (NFL), Ice Hockey, Rugby and Football (Soccer) players.

Management and return to sports

Initial management of a concussed player begins with recognition of concussion, and the immediate removal of the player from the field. Once removed, the player cannot return to sports that day in the interest of their own health.

The player then undergoes a graduated return to play protocol, which involves a progressive exercise program to introduce them back to sports in a step-wise fashion. The individual will then move on to a period of relative rest (usually 14 days in a standard care pathway), during which symptoms must resolve, after which they are to partake in four stages of incremental training based activity.

The player is only able to advance to the next stage if they show no symptoms at risk or during physical activity. If any symptoms do occur, the player must rest for a minimum of 24 hours (or 48 hours if they are under 19 years), and then return to the previous stage before attempting to progress.

Complex/delayed recovery

80-90% of acute concussions have uncomplicated recoveries, which are generally resolved in seven to ten days.

These types of simple concussions can be managed by primary care physicians, or team medics who have experience in caring for concussed patients.

There is also the possibility that for some individuals, they may suffer from prolonged systems that can last for several weeks to months, which can significantly affect their quality of life.

It is difficult to predict who may be at risk of having a protracted recovery, but the following factors may increase this risk:

      • multiple previous concussions
      • increasingly less force required to cause a concussion
      • history of migraine, epilepsy, meningitis/encephalitis
      • history of anxiety, depression or sleep disorder
      • presence of a learning disorder such as dyslexia or attention deficit hyperactivity disorder.

Some common complaints of individuals experiencing delayed recovery include headaches with or without physical activity, difficulty in concentrating, struggles with focusing in busy environments, and generally feeling below average.

These complaints are generally grouped under the label of “post-concussion syndrome”, but can actually be the result of a disturbance of one of a number of systems inside the head. For example, a disturbance of the vestibular or balance system can result in a constant feeling of unsteadiness.

For this reason, it is strongly recommended that complex concussion cases are handled by an experienced multidisciplinary team who will work to identify the predominant underlying condition, and will actively manage it.

The Institute of Sports, Exercise and Health (ISEH), in collaboration with the National Hospital for Neurology and Neurosurgery, has established a Complex Concussion Clinic to address this need.

Established in 2015, the Complex Concussion Clinic has since seen over 250 professional and amateur athletes, diagnosed with “post-concussive syndrome.” The clinic is also the only centre officially recognised by the Football Association (FA) and Rugby Football Union (RFU).

Working closely with both the FA and RFU, the Complex Concussion Clinic ensures the needs of the organisation and the player involved are maintained, as well as independently governs the medical needs of the player.

What is in store for the Future?

The biomarkers of brain injury are currently being researched in blood, saliva and urine, to aid in discerning the diagnosis of concussion. The aim of the research is to determine an easy objective test that can give a result quickly and accurately.

Additionally, novel imaging studies are being carried out on current and retired players, to analyse the features of acute concussion, and possible long term sequelae of playing contact sports.

Recently, there have been increasing concerns regarding the potential long-term ramifications that may result from repeated hits to the head, such as heading a ball, which are not severe enough to cause a concussion. Whilst the severity of these types of injuries are not as high as concussion, they can lead to players developing neurological impairments, be it temporary or permanent, such as the aforementioned neurodegenerative condition CTE.

Enough of this shared anxiety has resulted in one sport national governing body to ban heading in youth games. However, this decision is not ubiquitous, and most other national and international governing bodies are still awaiting the results of further research before taking a final stance on the matter.


Concussion is now undoubtedly one of the most important medical issues in professional sport. Its importance in regard to protecting the health and safety of players is paramount, however, from a financial perspective, it has also proved to be a huge burden for many organisations. For example, in 2014, the NFL suffered a significant financial penalty due to the injury. NFL initially settled on $675 million in compensation for players with neurological symptoms, an additional $10 million towards education and medical research, and a further $75 million for testing.

Whilst the sports industry has recognised the issue, medical science still lags behind. At present, there is no definitive test to diagnose concussion, or a foolproof formula for optimal recovery, nor an understanding of the exact long-term outcome for those who’ve suffered from concussion.

Therefore, it is imperative we acknowledge the evidence that does exist, and ensure professional clubs are urged to keep in line with the key recommendations put forward by medical professionals, to protect the players.

Governing bodies, such as the RFU and FA, are working closely with organisations like the International Olympic Committee and the Institute of Sport Exercise & Health, to ensure the management of concussion is handled to the upmost standards. These governing bodies ensure good clinical standards are maintained, collect data from their players to analyse, disseminate information and regularly update rules/regulations to prevent unnecessary player harm. Evidently, other sports are being urged to act in a similar manner.

To summarise, the rapidly evolving environment concerning concussion means every individual involved in the welfare of professional athletes need to ensure they remain knowledgeable, and their mechanisms in place remain up to date, about all recent changes. A particular focus on education, strong links with specialist units and supporting efforts of their governing bodies are important factors to remaining au courant with concussion.

The negative effects of concussion, as discussed, can have very serious, long-term effects to athletes exposed, which is why it is imperative this medical injury is correctly, and expertly, managed across all sports.

Alistair Milner is the Global Performance Lead and a Partner of SRi. Contact him directly at