Clinical Review
Forum
‘Better to miss one game
than the whole season’
Concussion can often be difficult to diagnose on the sidelines and
is an injury that needs highlighting, writes Sean Moffatt
Concussion is a common injury sustained by those who
participate in contact sports. Recent research carried out
in the US indicates that 300,000 concussion injuries occur every year among the athletic population.1 Concussion
can often be difficult to diagnose on the sidelines, and
issues regarding management, follow-up and return to play
can prove problematic in the absence of guidelines.
A US study of primary care physicians dealing with concussion indicated that almost 70% routinely used published guidelines in managing patients with concussion.1
Recent research carried out in Ireland suggested that between 20-30% of Irish GPs were involved in sports medicine and as team doctors in various sports. Of those who
participated in the study, 27% had a postgraduate qualification in sports and exercise medicine.2
Recently, the GAA Medical, Scientific and Player Welfare
Committee identified concussion in sports as an injury that
needed highlighting. After reviewing the available literature and international guidelines, the Position Stand on
the Management of Concussion in Gaelic Games was published in December 2007.3
Defining concussion
Sports concussion is defined as “a complex pathophysiological process affecting the brain, induced by traumatic
biomechanical forces”.4
Several common features incorporating clinical, pathological and biomechanical injury constructs that may be
used in defining the nature of a concussive head injury
include:4
• Concussion may be caused by a direct blow to the head,
face, neck, or elsewhere on the body with an “impulsive”
force transmitted to the head
• Concussion typically results in the rapid onset of shortlived impairment of neurological function that resolves
spontaneously
• Concussion may result in neuropathological changes, but
the acute clinical symptoms largely reflect a functional
disturbance rather than structural injury
• Concussion results in a graded set of clinical syndromes
that may or may not involve loss of consciousness.
Resolution of the clinical and cognitive symptoms typically follows a sequential course
• Concussion is typically associated with grossly abnormal
structural neuro-imaging studies.
Mechanism of injury
When a player suffers a concussion injury, the brain suddenly shifts, shakes or rotates inside the skull and can
Table 1
Concussion signs and
symptoms
Symptoms
• Nausea
• Dizziness
• Confusion/amnesia
(memory difficulties)
• Fatigue
• Light-headedness
• Headaches
• Irritability
• Disorientation
• Seeing bright lights or
stars
• Feeling of being stunned
• Depression and sleep
disturbance
Signs
• Loss of consciousness
•P
oor co-ordination or
balance
•P
oor concentration and
attention span
• Slurred speech
• Vacant stare/glassy-eyed
•S
low to answer questions or follow direction
• Inappropriate playing
behaviour
•D
ecreased playing ability
• Fitting/convulsion
• Personality change
•D
isplaying inappropriate
emotions
Concussion should be suspected in the presence of ANY ONE
or more of either symptoms, signs or memory difficulties
knock against the skull’s bony surface. In the minutes to
days following a concussion, brain cells remain in a vulnerable state. Brain function is temporarily impaired and
the athlete is at risk of further injury if not removed from
play.
Symptoms and signs of concussion
Following concussion, players may experience many different kinds of symptoms (see Table 1). Contrary to popular belief, most concussion injuries occur without loss of
consciousness (Loss of consciousness [LOC] is not necessary for the diagnosis of concussion, but if it occurs it
requires immediate medical intervention).
Some symptoms develop immediately while others may
appear gradually. Other symptoms may be subtle and go
unnoticed by the athlete, coach or medical personnel.
Management
If a concussion injury is suspected the following steps
should be taken:
• The player should not return to play in the current game
or training without medical assessment
• The player should be medically assessed as soon as
possible
• The player should not be left alone, and regular observation for deterioration is essential over the next 24-48
hours after a concussion injury
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Clinical Review
• Players should not drive after a concussion injury
• Inform the player’s parents/guardians about the concussion injury
• Enquire regarding previous concussion injury
from player, coach or parent
• Deterioration in the player’s condition
(such as increasing headache, drowsiness, confusion, repeated vomiting, unsteadiness, limb weakness or seizures)
warrants immediate medical attention
and admission to hospital for assessment
and imaging if required
• Return to play must follow a medically supervised stepwise approach
• A player should never return to play while symptomatic
“When in doubt, sit them out!”
Classification
For management purposes, concussion can be divided
into simple and complex concussion.4
Simple concussion
In simple concussion, a player suffers an injury that progressively resolves without complication over seven to 10
days. The management of simple concussion is complete
rest until symptoms and signs resolve fully. This is followed by a stepwise medically supervised return to play.
Complex concussion
Complex concussion includes cases where players suffer:
• Persistent symptoms (including recurrence of symptoms
with return to exercise)
• Prolonged loss of consciousness
• Concussion associated with specific neurologic signs or
symptoms
• Persistent
cognitive
impairment
(eg.
memory
difficulties)
• Recurrent concussion injuries (eg. second concussion in
same season).
This group of players requires additional assessment and
evaluation by doctors with specific expertise in the management of concussive injury, such as sports and exercise
medicine specialists, neurologists or neurosurgeons.
Return to play
Players, parents and coaches frequently consult the team
doctor or their GP for advice on when they can return to
play. Expert opinion suggests:3, 4
•A
concussed player should be removed from play and
should not return to play in the current game or training
session
•A
concussed player may attempt to minimise their injury
or refuse to come off, putting themselves at risk of further injury – players judgement may be impaired!
•P
ost-concussion symptoms may increase with exercise;
therefore return to play should be gradual and only begin
when the athlete’s symptoms have fully resolved after a
period of complete rest
•T
he return-to-play process is gradual and begins after
medical personnel have given the player clearance to return to activity. If any symptom/sign returns during this
process, the player must be re-evaluated by a doctor. It is
important to remember that symptoms may return later
that day or the next, not necessarily while exercising.
An example of the step-wise approach is:
•R
est until all symptoms and signs have cleared (physical
and mental rest)
• Light aerobic exercise (eg. exercise bike)
• Sport-specific training (soloing with ball)
• Non-contact training drills
• Full contact training after medical clearance
• Return to competition (game play) following
medical clearance.
There should be at least a period of 24 hours
for each stage, and the player should return to
stage one if symptoms recur. Weight training
should only be added in the later stages. Medical
clearance is required before the athlete returns to play.
Coping with symptoms and recovery
The best medical management for concussion is rest
(mental and physical). Players who suffer concussion injuries often feel tired, and may experience difficulties at
work or school with concentration and carrying out tasks.
Players may encounter mood difficulties and feel depressed, anxious or irritable with family or team-mates.
Other subtle symptoms can include balance difficulties
and sensitivity to noise and light. Avoidance of loud noises
and wearing sunglasses are often helpful. It is important to
enquire regarding these symptoms when dealing with players who have sustained a concussion injury.
Recovery from concussion should not be rushed, nor
should pressure be applied to athletes to resume playing
until recovery is complete, as risk of re-injury is high and
may lead to recurrent concussion, which can cause longterm damage.
The advice “better to miss one game than the whole season” often helps in getting the player to comply with rest
and gradual recovery.
Pre-season and concussion history
Doctors involved in team sports or individual sports ideally should enquire regarding previous concussion injury as
part of pre-season evaluation.
Professional team sports and some senior inter-county
GAA teams are using pre-season baseline neuro-psychological assessment tools as a baseline for comparison if
their players sustain a concussion injury, and to assist in
deciding when recovery is complete and the player is fit to
return to play.
In summary, GPs will frequently be called upon to assess
patients and players who are suspected of having a concussion injury and advice on return to play issues.
The SCAT sports concussion assessment tools (available at
www.medicalwelfare.gaa.ie under ‘Position statement on
concussion’) are helpful in treating and rehabilitating
patients back to full recovery and safe return to sports.
Sean Moffatt is in practice in Ballina, Co Mayo and has a
special interest in sports and exercise medicine
References
1. Pleacher MD, Dexter WW, Heinz WM. Concussion management by primary care providers. Commentary. Br J Sports Med, Jan 2006: 40
2. O’Keeffe N. Sports medicine – are GPs really on the ball? Forum 2007;
24(12): 10-11
3. GAA Medical, Scientific and Player Welfare Committee. Position Stand
on Concussion in Gaelic Games. December 2007 www.gaa.ie
4. McCrory P et al. Summary and agreement statement of the 2nd
International Conference on Concussion in Sport, Prague 2004. Br J Sports
Med. 2005; 39: 196-204
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