Concussion in sport: are new guidelines a game changer for primary care?

SPORT-RELATED CONCUSSION AND PRIMARY CARE

The clear benefits to individual, population, and planetary health from participation in physical activity and sport must be balanced against supporting individuals following injury. Over recent years, sport-related concussion (SRC) and its potential sequelae have gained increasing interest and attention, and the current Rugby World Cup will hopefully illustrate the progress made in treating SRC more rigorously. Two recent publications: the consensus statement from the Concussion In Sport Group (CISG) at the 6th International Conference on Concussion in Sport, Amsterdam,¹ and UK Government landmark concussion guidance,² will help refine the understanding, diagnosis, and management of SRC.

SRC is common in high impact and collision sports,³ and is a condition many GPs will have seen. Over 1% of all emergency department attendances in England and Wales in 2016 were due to concussion, with many more potentially undiagnosed or coded incorrectly.⁴ SRCs account for a significant proportion (up to 60% in children and adolescents) of these cases,⁵ and the UK brain injury association, Headway, reports increasing rates of head injuries and acquired brain injuries over the past two decades.⁶ This may also reflect increased recognition and media coverage of the condition.

The landscape for SRC has been a tumultuous one. A 2021 UK House of Commons Select Committee report criticised awareness of the condition within the UK healthcare system as insufficient to adequately address long-term sequelae, and recommended a programme to better record and treat the condition.⁷ Long-term sequelae of concussion may include cognitive and neurological issues. Controversy regarding academic retractions from a lead SRC researcher has done little to dispel concerns over conflicts of interest and a lack of transparency.

RECOGNISING AND ADDRESSING SRC

Concussion is a traumatic brain injury caused by a direct blow to the head, neck, or body resulting in an impulsive force being transmitted to the brain. It can present with a wide range of signs and symptoms, and can affect a person’s thinking, concentration, memory, mood, and behaviour. It is important to note that a concussion can occur without direct head trauma and presentation of symptoms can also be delayed. Common signs and symptoms are outlined in the UK Government guidance, including ‘red flags’ that warrant urgent assessment in an emergency department. Anyone with a suspected concussion should be immediately removed from the field of play and assessed by an appropriate healthcare professional within 24 hours of the injury.² Those working in sport will be aware of specialist assessment tools pertaining to individual sports that aid clinicians when diagnosing concussion. These are often based on the ‘Sport Concussion Assessment Tool’ (SCAT6 is the most recent and follows the CISG consensus, see Box 1), which are most effective within 72 hours of injury and can look at changes from baseline (pre- season) scores. They assess symptoms and signs; cognitive screening across orientation, memory, and concentration; and coordination and balance. In practice, given the time pressures and the absence of baseline values, it is unlikely that these assessments can be adopted fully into routine primary care consultations.

Resource	QR code
If in doubt, sit them out. UK Concussion Guidelines for Non-Elite (Grassroots) Sports
Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022
Adult SCAT6 (aged ≥13 years) Sport Concussion Assessment Tool. For use as part of a clinical assessment in the first 72 hours of a concussion
Adult SCOAT6 (aged ≥13 years) Sport Concussion Office Assessment Tool. For use as part of a clinical assessment after the first 72 hours of a concussion
Child SAT6 (aged 8–12 years) Sport Concussion Assessment Tool. For use as part of a clinical assessment in the first 72 hours of a concussion
Child SCOAT6 (aged 8–12 Years) Sport Concussion Office Assessment Tool. For use as part of a clinical assessment after the first 72 hours of a concussion
Headway. Mild head injury and concussion

• SCAT = Sport Concussion Assessment Tool. SCOAT = Sport Concussion Office Assessment Tool.

Box 1.

Guidelines and resources

However, they can be useful as a symptom checklist and guide to approaching the assessment of someone with suspected concussion. Additionally, the accompanying Sport Concussion Office Assessment Tool (SCOAT6; Box 1) is designed for a more comprehensive assessment at a later time point (>72 hours) and includes orthostatic and cervical spine assessment; symptom exacerbation from vestibular-ocular motor screening; and screening for sleep quality and signs of depression or anxiety. This again might provide a useful guide for GPs seeing patients at a later time point with ongoing symptoms, and can help identify predominant features that might define subsequent focused management.

MANAGING SRC

Once SRC has been recognised or diagnosed, a short period (24–48 hours) of relative rest is advised, where only light- intensity physical activity that does not, or only minimally, exacerbates symptoms is undertaken, and there is no increased risk of contact, collision, or falling. Reducing smartphone, screen, and computer use, as well as cognitive load, such as work and school, for at least the first 48 hours can help recovery. In the first 24 hours they should not consume alcohol, be left alone, or drive a motor vehicle. Individuals should seek urgent medical assessment if any red flags are present and are advised to seek medical advice from their GP if symptoms persist beyond 28 days, which may include onward referral. Signposting people to appropriate resources can help educate them on what to expect and the recovery process. Subsequently, a logical graduated return to school/work and then sport can be started, where progression through stages is dependent on minimal and transient (the CSIG advise <1 hour) exacerbation of symptoms. These include increasing tolerance for physical activity and cognitive activities, such as reading, before returning to study, work, and then sport. UK Government advice is that individuals should not return to competitive sport before day 21 following a concussion, and only providing they have been symptom-free at rest for 14 days and during non-competitive training. The CISG suggest similar graduated stepwise strategies for return to learn and return to sport.^1,2 The majority of individuals will recover within 28 days but in those who do not, CISG recommend a comprehensive review including cognitive, vestibular, oculomotor, autonomic, and mental health assessments.¹ Sport and exercise medicine physicians and neurologists with an interest in concussion would be well placed to review a patient with prolonged symptoms.

WHAT NEXT FOR SRC?

The limited availability of NHS specialist services in the UK for supporting those with complex or persistent symptoms presents a barrier to joined-up care. This gap could potentially be bridged by those with expertise in this area, such as sport and exercise medicine specialists and GPs with Extended Roles working as part of a wider multidisciplinary team, including neurologists, vestibular rehabilitation specialists, and neuropsychologists.

One understandable concern with regards SRC is the risk of Chronic Traumatic Encephalopathy (CTE): a neurodegenerative condition potentially associated with repeated head impact. This has evolved to a postmortem neuropathology referred to as Chronic Traumatic Encephalopathy Neuropathologic Change (CTE-NC) and the recently defined clinical entity of Traumatic Encephalopathy Syndrome (TES).⁸ Although the former appears more common in brain bank pathological samples of former professional athletes exposed to repetitive head impacts than in those of the general population, the CISG highlight that there are no cohort studies to examine causation, and the prevalence of both diagnoses in former athletes is unknown. They suggest that it is reasonable to consider a potential association of the extensive exposure to repetitive head impacts experienced by some professional athletes with the neuropathology of CTE- NC.¹ It is notable that the CISG voted the potential long-term effects of SRC as the highest priority for future research.

A further consideration is the understanding of SRC in different populations. The consensus statement highlights the difficulties in assessing concussion in para-athletes and children. For the former, who appear to have a higher risk of SRC, the unique and varying presentation and pathophysiology of concussion, and the lack of validated assessment tools present barriers to progress.¹ Assessment tools for 8–12- year- old children, the Child SCAT6 along with the Child SCOAT6, have been published (Box 1) and provide a framework for recovery, but there is scope to build on the limited evidence in these groups. There is also limited information in the consensus statement regarding concussion in females, despite the emerging evidence that female athletes may be more susceptible to SRC and have worse outcomes than males.⁹ Finally, there is potential for a better understanding and recognition of SRC through emerging technologies, including developments such as Inertial Measurement Units (IMUs) in mouthguards,¹⁰ and salivary micro- RNA samples.¹¹ All in all, SRC — bridging pitchside, primary, and secondary care — is being taken more seriously than ever.

Early identification and management of SRC by GPs will help to safeguard an individual’s immediate and long- term health, as well as support a return to sporting activities. GPs should be comfortable in at least recognising and managing straightforward concussions, and know when and where to refer more complex cases. This in turn depends on local commissioners putting in place appropriate care pathways for people with SRC so that both patients and clinicians are adequately supported in managing this potentially serious condition (Box 2).