Concussion and sport

Helmy`s paper {1} on concussion and sport raises a very important issue in Sports Medicine: the safe return to sport following a traumatic brain injury. The article high-lights the many"tools" available to assist in the diagnosis and assessment of sports concussion, incorporating both physical and cognitive assessment. These fail to incorporate the first principles of medical assessment, namely history and examination followed by appropriate test.

The history of the injury is probably the most critical element in assessing a case of concussion. The history of a head injury leading to concussion will often be observed by a pitch side doctor, who may have witnessed the trauma. The intensity and pattern of impact is a key element in deciding on the severity of the injury. To go directly to the examination and test element of the assessment certainly dilutes the ability to make a competent evaluation of a concussed player. The over reliance on an assessment tool can also dumb down the doctor patient consultation, and may leave a player vulnerable to being returned to play on the basis of a test, which may be administered by a non medic, and often carries more weight in the heat of a competitive football match, than the clinical experience of a pitch side medical practitioner`s opinion.

As a former rugby team doctor a helpful rule of thumb which was employed, was to withdraw a player from play if he was still symptomatic by the time the doctor arrived to the pitch site of head injury. This is on average 18 seconds, and is nearly always more than 10 seconds. The rationale being that this is the time frame for a boxing match to be terminated following a "knock out".

The sight of an Australian rugby player during a 2013 Lions test, and recently a Premiership goal keeper returning to play, despite clear evidence that a traumatic brain injury had taken place, underscores the point. They may well have passed the "test" ,that allowed them to return to play, but clearly had sustained a brain injury, and their return to play appeared to be fool hardy.Once a concussion has taken place, the brain becomes more vulnerable to a second concussion which is potentially catastrophic. Hence the need for caution and consideration when returning a player back to the field of play.

When returning an individual to sport after a concussion further care must be taken. Medical investigations, such as Brain MRI and Neurophysiology investigations will fail to identify all brain injuries, and may only become positive late in the process. The clinical history of symptoms often gives the greatest information, as the neurological examination is usually normal. Similarly cognitive testings are non specific, and can be "foxed" by a player who wishes to return to play, by posting a poor score in preseason testing{2}. Return to play should therefore be given careful and due consideration, with a bias on the clinical picture. Over reliance on a test does not serve the injured well. It does however give a sense of security to a sports team, who wish to get "their man, back on the pitch".

This raises the question, of the role of the team physician. Is his responsibility to the injured player, or to the success of the team?

Over 15 years ago, the doctor attending a rugby match looked after both teams, and made independent decisions regarding the welfare of the players. Modern medicine has greatly improved player care , with the availability of immediate high standard medicine to elite athletes and field sports players. However the practitioners can be compromised when making independent medical decisions when it comes to professional player withdrawal from play, when the management wishes to see player continuing, even when less than 100% fit and well.Has the day dawned when an independent doctor needs to be present at professional matches to decide if an individual is fit to continue on the pitch. An independent doctor can also ensure that the sports recommendations for concussion are enforced and followed, and not "flouted", as Helmy`s paper confirms is often the case in elite sport{1}.

This problem of unrecognized concussion has been highlighted in a recent publication relating to American Football which describes how the National Football League failed to deal with the clear scientific evidence relating to NFL concussions and brain injury.The NFL ultimately settled a costly law suit brought by thousands of former American Football players, who suffered long term morbidity from brain injuries which occurred during their football careers{3}. Further research has suggested a higher than expected incidence of chronic traumatic encephalopathy in pathology specimens of the brains of ex NFL players[4].

Sports Medicine First Aid has been thought to generations of doctors using the neumonic P.R.I.C.E.S., where P stands for "protect the player from doing further harm." The current vista of clearly injured players returning to the field, flies in the face of this old medical axiom. If team doctors are compromised in making clinical decisions, then an independent means of assessing the concussed must be sought, both at the time of injury, and when the player wishes to return to play. Failing to deal with the matter of concussion in a clear fashion, and not allowing experienced clinical medical input will only serve to increase the risk of serious injury for our field athletes, and may ultimately lead to significant long term morbidity for a large population of sports people, as has been the American experience.

1. Helmy A, Agarwal M, Hutchinson P J . Concussion and Sport.BMJ 2013, 347;f5748

2. Jackman B,Blue Blood- The Bernard Jackman Autobiography.ISBN 0-9563598-2-5.Irish Sports Publishing 2010

3. Fainaru-wada M,Fainaru S. League of denial.The NFL, Concussion, and the Battle for Truth . Crown Archetype. October 2013

4. Mc Kee A C, Cantu RC, Nowinski CJ Hedley -Whyte ET, Gavett BE, Budson AE et al
Chronic traumatic enchephalopathy in athletes:progressive tauopathy after repetitive head injury.J Neuropathol Exp Neurol 2009; 68: 709-35