A bumpy ride

Grant-Cross.

The outcomes of on-field collisions in recent Australian football matches have brightened the spotlight on how concussion should be identified and managed. Sport-related concussion affects athletes and participants at all levels of sport, from the part-time recreational athlete to the full-time professional. Increasing concerns about the incidence and possible health ramifications have reinforced the need to diagnose and manage concussion safely and appropriately.

Every year in Australia more than 3,000 people are hospitalised after being concussed playing sport, and it is estimated an additional 9,000 players are concussed but do not seek medical attention. Brain Injury Australia estimates as many as 30,000 players won’t report their concussion to teammates, coaches or family because they fear being removed from play. A cultural shift is required as this often invisible injury is ignored.

Doctors are at the forefront of managing concussion, in clinics and hospitals and on the sideline when assessing injuries. Obvious issues for treating doctors include understanding the current best practice to manage these injuries, the time it takes to treat these injuries effectively and managing pressure from athletes, parents, clubs and players to permit the player to return to sport.

Legal cases relating to high-profile athletes’ concussion injuries have increased awareness of concussion and the potential links with chronic traumatic encephalopathy (CTE) and other serious outcomes. This has led to extensive discussion around diagnosing and treating the injury, the rehabilitation process and return to sport decisions. Different sporting organisations have their own concussion policies and varying levels of medical support on the sideline. The lack of consistency can lead to confusion and ultimately affect the injured athlete.

With children and adolescents, a conservative, individualised approach to diagnosis and management is recommended due to a slower rate of recovery. It can be difficult to navigate between the player/patient, parent, and education provider, with the medical practitioner playing an important role here. A ‘return to play’ or ‘return to learn’ letter can be used by doctors.

Some players and coaches may not be aware of the dangers related to concussion and therefore push to minimise the injured player’s time away from the game. The ’if in doubt sit out’ message requires more support, and the use of high-profile ambassadors will add value to changing attitudes and practices. Increased education will help doctors and other sideline medical support (sports trainers, first aid and first responders) manage the pressures of those around them.

Dr Marc Cesana and Dr Karthik Badrinath – both part of the medical team supporting the Adelaide Football Club –say the role of the doctor in managing concussion must be to protect the player.

‘In the AFL, athletes have more exposure to concussion education and therefore have increased awareness of concussion and support the diagnosis and any precaution around treating concussion,’ Dr Cesana says.

‘AFL coaches and support staff are also educated about concussion management and are always supportive of medical advice.

‘Community and amateur sport may not have a medical team supporting their club. Many clubs and teams do have accredited first aid or sports trainers or volunteers on the sideline who are critical in recognising concussion injuries and referring to a doctor who understands concussion management.’

Dr Badrinath says 95% of concussion

Source: https://www.sportaus.gov.au/__data/assets/pdf_file/0005/683501/February_2019_-_ symptoms are resolved in between 10 and 14 days, especially with appropriate recognition and management. But a small number of concussion injuries require more complex management and referral to doctors with relevant expertise.

The challenge, Dr Badrinath says, is that there is no test that can diagnose concussion with 100% certainty. Tools such as the SCAT 5 assess symptoms, but honest, comprehensive reporting by the athlete is central to the diagnosis.

They say issues can arise when players, sports officials and parents do not understand or recognise concussion symptoms beyond the headaches and dizziness that commonly are associated with the condition.

‘The best management is recognising the potential for a concussion injury and removing the player from the game immediately, without returning to play until they have received appropriate assessment.

‘If concussion symptoms are not recognised and acted on there is the risk of short, medium or long-term consequences.’

Dr Cesana says some of the technology and practices employed by the AFL may be adapted for use at the local level.

• Medical staff are attentive and watch the incidence in real time.

• Medical staff watch the replay vision on the sideline with the technology available.

• Look out for certain signs, loss of consciousness, staggering, inability to retain their balance and with any of these areas identified the person is presumed concussed and cannot return to play.

• Any possible concussion is assessed, including using a SCAT5 test, in a quiet place away from the sideline.

• The replay vision is often reviewed again in the rooms.

• Doctors discuss the vision and review the baseline concussion testing to identify whether the player appears concussed.

• The player does not drive home and has someone stay and observe them overnight.

• The next day, the club doctor reviews the player, who is advised to rest for between 24-48 hours.

• Players are monitored daily by the club doctor.

Return to play protocol is split into three phases – REST, RECOVERY and RETURN TO FULL ACTVITY.

• A normal SCAT 5 is required to move from the rest phase into the recovery phase.

• A further normal SCAT 5 is required to move out of the recovery phase and into the return to full activity phase.

• Contact training cannot start before a Cognigram test is undertaken to compare post-concussion performance to their pre-season baseline.

• A player can only return to the game when all phases are completed with no recurrence of symptoms and the test results return to baseline.

• Other information can be obtained from family or housemates that live with the player.

• A player will be cleared to play only when the doctor is happy with all stages of protocol and a detailed discussion has taken place with the player. Short, medium and long-term risks must be discussed with the player.

• An individualised approach is needed as symptoms can differ between people and according to age and gender. The Community Concussion program is soon to be rolled out across South Australia. The aim is that by 2026, sporting codes will have adopted concussion protocols to ensure clubs and their officials, parents, players and sports trainers have a clear role in understanding and identifying the impact of concussion, acting appropriately to minimise further risk, and seeking medical assistance to reduce long-term impacts. Concussion policies and procedures will be automatically adopted, and actioned without hesitation with medical and sporting organisations agreeing to a consistent approach.

There is much work to do in this space and we are all aware of the ongoing concerns in relation to identifying concussion, the management and framework, referral and rehabilitation back to school, work and sport.

For more information about sportrelated concussion visit:

Australian Sports Commission Guidelines

• Concussion in Sport – Position Statement

• Sport-Related Concussion Treatment Pathway

• 5th International Conference on Concussion in Sports consensus statement

The latest guidelines on sports-related concussion will be released in mid-2023, following the 6th International Consensus Conference on Concussion in Sport (ICCCS) held in the Netherlands in October 2022. These guidelines from the world’s concussion experts will be used to develop updated concussion guidelines for sport in Australia and around the world.

The SA Sports Medicine Association (SASMA) has received funding from the Office for Recreation, Sport and Racing to deliver a concussion education program over the next three years. A Concussion Steering Committee has been established to guide the development of the program. A focussed effort is required to align Australia’s sporting and medical organisations’ policies and procedures, based on the ICCCS latest report, and create a consistent approach to managing concussion.

Adelaide Football Club Doctor Marc Cesana, says that updated concussion education could increase doctors’ knowledge and confidence in diagnosing and managing concussion injuries, recognising it is potentially not commonly seen in general practice.

It is proposed that practical support will be offered to general practice to help identify the injury using the current SCAT 5 tool and the latest international guidelines and guide concussion management and rehabilitation protocols. GPs interested in attending the concussion management workshops should contact SA Sports Medicine Association.