This page has been designed to provide coaches with up to date information about concussion.
Please find below key information and resources to use when identifying and managing concussion.
Concussion is a type of brain injury, caused by a knock to the head or anywhere on the body where the force is transmitted to the head; it can also be caused by a fall. It commonly causes short-lived neurological impairment (impairs the functioning of the brain) and the symptoms may evolve over the hours or days following the injury. While all concussion should be assessed by a doctor, most will resolve without the need for specific treatment. Rest, followed by gradual return to activity is the main treatment.
All concussions are serious.
Recognising concussion can be difficult, but proper response and management can help prevent further injury or even death. Most people who sustain concussion do not lose consciousness. There are several possible symptoms and signs but they are not specific to concussion. The signs and symptoms can be subtle. Onlookers should suspect concussion when an injury results in a knock to the head or body that transmits a force to the head. A hard knock is not required, concussion can occur from relatively minor knocks. The Concussion in Sport Group developed this Pocket Concussion Recognition Tool to help those without medical training recognise concussion.
There may be obvious signs of concussion such as loss of consciousness, brief convulsions or difficulty balancing or walking, however the signs can be more subtle. Below is a list of symptoms or signs that may indicate concussion.
- Loss of consciousness
- No protective action in fall to ground directly observed or on video
- Impact seizure or tonic posturing
- Confusion, disorientation
- Memory impairment
- Balance disturbance
- Athlete reports significant, new or progressive concussion symptoms
- Dazed, blank/vacant stare or not their normal selves
- Behaviour change atypical of the athlete
Critical symptoms/signs – if an athlete displays these signs they may have a more serious injury. They should be immediately taken to the nearest emergency department
- Neck pain
- Increasing confusion or irritability
- Repeated vomiting
- Seizure or convulsion
- Weakness or tingling/burning in the arms or legs
- Deteriorating conscious state
- Severe or increasing headache
- Unusual behavioural change
- Double vision
In addition to the above listed symptoms of concussion, if an athlete has one or more of the following signs after a knock, tackle or fall, the athlete has signs of concussion and should be immediately removed from sport and reviewed by a medical practitioner.
- Loss of consciousness
- Seizure or jerky movements after a knock
- Dazed or looking blank/vacant
- Slow to get up, drowsy
- Unsteady on feet or balance problems
- Changed behaviour – may be more irritable, agitated, anxious or emotional than normal
When an athlete is suspected of having a concussion, first-aid principles still apply. A systematic first-aid approach to assessment of airway, breathing, circulation, disability and exposure applies in all situations. Neck injuries should be suspected if there is any loss of consciousness, neck pain or a mechanism that could lead to spinal injury. Neck stabilisation should be undertaken and a hard collar splint applied until a neck injury can be ruled out. If a hard collar splint is not available, the injured athlete should be kept still, not moving the head, until a medical assessment can be conducted or until an ambulance arrives.
When an athlete has a concussion or suspected concussion, it is helpful to note the following details at the time of the injury to assist the treating doctor:
- When: time of injury
- How: for example, cricket bat to the head or a blow to the head from opponent’s shoulder etc
- Where: where on the body, for example temple, shoulder or back of head
- What: what occurred next including symptoms such as loss of consciousness, convulsions, amnesia, vomiting or confusion
- Additional useful information: any further symptoms such as behavioural changes or loss of memory.
A medical practitioner should review any athlete with suspected concussion. In a situation where there is no access to a medical practitioner, the athlete must not be returned to sport on the same day. If there is any doubt about whether an athlete is concussed that athlete should not be allowed to return to sport that day.
An athlete with suspected concussion should be reassessed to look for developing symptoms and cleared by a medical practitioner before returning to sport. Due to the evolving nature of concussion, any athlete cleared to return to sport after being medically assessed for suspected concussion should be monitored closely for developing symptoms or signs.
“If in doubt, sit them out"
If there is any doubt about whether an athlete is concussed, that athlete should not be allowed to return to sport that day.
A medical practitioner should review any athlete with suspected concussion, and the athlete should be reassessed to look for developing symptoms and cleared by a medical practitioner before returning to sport. Due to the evolving nature of concussion, any athlete cleared to return to sport after being medically assessed for suspected concussion should be monitored closely for developing symptoms or signs.
The diagnosis of concussion should be made by a medical practitioner. They will take a clinical history and conduct an examination that takes into account mechanism of injury, symptoms and signs, cognitive functioning and neurological assessment including balance testing.
The internationally recommended Sport Concussion Assessment Tool (SCAT3) and Sport Concussion Assessment Tool for children ages 5 to 12 years (Child-SCAT3) cover these indicators. These should not be used in isolation but as part of the overall clinical assessment.
Any athlete with suspected or confirmed concussion should remain in the company of a responsible adult and not be allowed to drive. They should be advised to avoid alcohol and check medications with their doctor. Specifically, they should avoid aspirin, anti-inflammatories (such as ibuprofen, diclofenac, naproxen), sleeping tablets and sedating pain medications.
The athlete’s medical practitioner should provide head injury advice to the athlete with concussion and their carers.
Once the diagnosis of concussion has been made, immediate management is physical and cognitive rest. This allows the brain to ‘rest’ and helps recovery. In order to allow both physical and mental rest, time off school or work may be needed. Mental rest may include refraining from playing computer games, reading and watching television. See below information on ‘Return to learn’.
‘Return to learn’ is the phrase used to describe the process of building back into usual program at school or work.
Once the diagnosis of concussion has been made, immediate management is physical and cognitive rest. This may include time off school or work and relative rest from cognitive activity. Having rested for 2-3 days after sustaining a concussion, the patient can return to learn. Returning to school or study should occur before returning to training or physical activity in school-aged athletes. Increasing the ‘load’ on the brain when concussed (by thinking or concentrating for long periods) can bring on or worsen symptoms of concussion. Gradually increasing the load on the brain without provoking symptoms is recommended. School programs may need to be modified to include more regular breaks, rests and increased time to complete tasks. Exams during that period may need to be postponed. The guidelines surrounding management of concussion from the Concussion in Sport Group Consensus Statement include prioritising return to school and learning before commencing return to physical activity.
A concussed child must not return to sport until they have successfully resumed normal school activities without aggravating their symptoms.
‘Return to sport’ is the phrase used to describe the gradual process of returning to full sporting activity.
Having rested for 2-3 days after sustaining a concussion, the patient can commence a return to moderate intensity physical activity, as long as such activity does not cause a significant and sustained deterioration in symptoms. The majority of concussive symptoms should resolve in 7-10 days. Once symptoms have resolved the patient can begin a staged return to physical activity. The activity phase should proceed as outlined below with at least 24 hours spent at each level. The activity should only be upgraded if there has been no recurrence of symptoms during that time. If there is a recurrence of symptoms, there should be a ‘step down’ to the previous level for a minimum of 24 hours after symptoms have resolved. The steps in the activity phase are:
- begin with light aerobic activity (at an intensity that can easily be maintained whilst having a conversation) until symptom-free
- basic sport-specific drills which are non-contact and with no head impact
- more complex sport-specific drills without contact, may add resistance training
- full contact practice following medical review
- normal competitive sporting activity.
Children and adolescents may be more susceptible to concussion and take longer to recover. A more conservative approach to concussion management should be taken with those aged 18 years or younger. Return to learn should take priority over return to sport. School programs may need to be modified to include more regular breaks, rests and increased time to complete tasks. The graduated return to sport protocol should be extended such that the child does not return to contact/collision activities less than 14 days after the resolution of all symptoms.
There is a potential link between mental illness and concussion, although the relationship is not clear. Any athlete with a history of mental illness should discuss this with a doctor. A more cautious assessment and a more conservative approach to return to sport is recommended in these individuals.
There are a number of organisations with information on mental illness and information on where to go for help:
Lifeline provides a 24 hour, 365 days per year crisis support and suicide prevention service. It is free and provides immediate support for those in need.
Headspace is a national youth mental health support service providing mental health assistance to those aged 12–25.
Beyond Blue is an organisation aimed at improving community mental health education and awareness through several programs.
There has been recent concern about potential long-term consequences of concussion. While the link between concussion and long-term illness is uncertain, taking a conservative approach to concussion management is important.
Chronic traumatic encephalopathy (CTE) is a type of degenerative neurological disease that may be associated with a history of previous concussions. There is currently no reliable evidence clearly linking sport-related concussion with CTE. Further research is required to better understand the condition and its association with concussion. The evidence purporting to show a link between sport-related concussion and CTE consists of case reports, case series and retrospective analyses. Due to the nature of the studies, and the reliance on retired athletes volunteering for an autopsy diagnosis, there is significant selection bias in many of the reported cases. The studies to date have not adequately controlled for the potential contribution of confounding variables such as alcohol abuse, drug abuse, genetic predisposition and psychiatric illness.
The AIS and the AMA support the call for properly constructed prospective studies which control for confounding variables, looking into the long-term health implications of concussion.
Helmets will not stop concussion from occurring.
Evidence suggests that helmets, mouth guards or other protective devices offer little if any benefit in the prevention of concussion. These devices are important, however, for the prevention of other types of traumatic head injuries such as skull fracture and subdural hematoma (bleeding around the brain).
Sporting organisations need to continually review their policies for best practice concussion diagnosis and management.
High-risk sports such as professional collision sports need to ensure that medical personnel are appropriately trained in the detection and management of concussion.
Sporting organisations in Australia have responded to the increased concern regarding concussion. The four major football codes have introduced rule changes in recent years to ensure more thorough clinical assessment of the athlete with suspected concussion and to enforce guidelines around management of the concussed athlete.
Given the increasing awareness of sport-related concussion and the associated community concern, many sporting organisations have developed their own guidelines for the management of the condition. These guidelines are constantly evolving through ongoing review. There is a high degree of congruency and alignment across the various sporting codes, supported by the latest scientific evidence on concussion diagnosis and management.
The following sports have concussion policies available on their websites:
Under-reporting of concussion by athletes still appears to be a problem. Education to improve the knowledge and understanding of the condition is required to address this problem, as legislation alone has been shown to be ineffective.
Athletes themselves need to have a good understanding of concussion in order to appreciate the importance of reporting symptoms and complying with rest and return to sport advice. Parents and coaches must also be able to recognise the symptoms and signs of concussion in order to detect concussions at the community sport level where there is no medical supervision present.