Concussion is a type of brain injury. It is a complex injury that is challenging to evaluate and manage. The Concussion in Sport Group (CISG) international Consensus Statement defines concussion as ‘a traumatic brain injury, induced by biomechanical forces’. It generally results from a knock to the head, face or neck - but may be anywhere on the body which transmits force to the head. Concussion involves short-lived impairment of neurological function. Concussion is an evolving injury that may change over the first few hours or over a few days. In most adult cases, symptoms are resolved within 14 days of injury.

Diagnosing concussion can be difficult - but is critical to correctly managing and preventing further injury.

Diagnosis relies on the clinical assessment of symptoms and signs. There is no specific diagnostic test which confirms the presence or otherwise of concussion.

For Adults: Medical practitioners can use the Concussion in Sport Group Sport Concussion Assessment Tool 6 (SCAT6) as part of an overall clinical assessment to assess potential concussions.

For Children: The Child Sport Concussion Assessment Tool (Child-SCAT6) can be used to assess concussion in children aged 5 – 12 years.

People without medical training can use the Concussion Recognition Tool (CRT6), also developed by the Concussion in Sport Group.

Acute presentation

First-aid principles still apply for athletes suspected of having a concussion. Responders should systematically assess the airway, breathing, circulation, disability and exposure of the athlete in all situations.

Cervical spine injuries should be suspected if there is any loss of consciousness, neck pain or a mechanism that could lead to spinal injury. Until a cervical spine injury can be ruled out, undertake manual inline stabilisation and apply a hard collar.

In diagnosing concussion, medical practitioners should do a clinical history and examination that includes:

• mechanism of injury
• symptoms and signs
• cognitive functioning
• neurological assessment including balance testing
• a completed concussion assessment using the SCAT6 for adults or Child-SCAT6 for children aged 5 – 12 years

As part of the assessment medical practitioners may use:

• Computerised neurocognitive testing. Pre-season baseline neurocognitive testing is useful to compare against post-injury scores. Programs have reference ranges that can be applied in the absence of a baseline test.
• Medical imaging where there is suspicion of serious head or brain injury.

Currently, no serum biomarkers assist in the diagnosis of concussion. Blood tests and medical imaging is not indicated in the diagnosis or management of uncomplicated concussion.

Delayed presentation

Medical practitioners often have athletes present to the clinic during the week, having suffered a potential concussion over the previous weekend. This poses challenges. If there is any suspicion that a concussion occurred on the weekend, the medical practitioner should assume that a concussion did in fact occur. There is no test or series of tests which can conclude that a concussion did not occur.

Six key video review steps for the team clinician

Video technology is used by many professional sports to support identification of concussion, differentiate between mandatory and discretionary concussion signs and, in some instances, assist with return to sport decisions. The 2017 Berlin Concussion in Sport Group Consensus Statement identifies six steps for video-review focused on concussion identification.

Six key video-review steps for the team clinician

1. Look for the suspected head impact event
2. Look for the immediate response of the injured athlete (0-2 s). Does the athlete fall to the ground? If the athlete falls, is there loss of head and neck control? Does the athlete protect himself/herself when falling? If the athlete remains upright, is he/she steady on his/her feet?
3. Look for the subsequent response (2-5 s). If the athlete falls, does he/she move spontaneously? Is there evidence of purposeful voluntary movement (ie, placing the ball or completing a tackle)? Is there evidence of a concussive convulsion or tonic posturing? How does the athlete respond to the attending medical staff (this phase may extend for substantially longer than 5 s, particularly if in-line cervical immobilisation is required)? If the athlete remains standing, the distinction between the subsequent and late responses may be unclear.
4. Watch for the athlete’s late response when returning to his/her feet (if the athlete has fallen). Is the athlete unsteady when attempting to get to his/her feet and return to sport? Does the athlete need help from others to stand up? Are the athlete’s movements fluid and coordinated? Does the athlete fall to the ground?
5. Watch the athlete’s behaviour on return to sport. Are his/her actions appropriate or not? Does he/she move immediately to the correct position on the field of play?
6. Observe the responses of other athletes and match officials.

Any athlete with suspected concussion should be REMOVED FROM SPORT, medically assessed and monitored for deterioration No athlete diagnosed with concussion should be returned to play on the day of injury.

Minimum criteria for diagnosing concussion are:

1. A thorough assessment looking at loss of consciousness, symptoms, cognition, neurobehavioural symptoms, and balance – with any abnormality being a potential sign of concussion.
2. A concussion assessment using the SCAT6 for adults or Child-SCAT6 for children aged 5 – 12 years. Note: the diagnostic utility of the SCAT decreases 3-5 days post-concussion.

Any athlete with suspected or confirmed concussion should:

• remain in the company of a responsible adult
• not be allowed to drive
• be advised to avoid alcohol
• have their medications reviewed.

Specifically, concussed athletes should avoid:

• aspirin
• anti-inflammatories (such as ibuprofen, diclofenac or naproxen),
• sleeping tablets
• sedating pain medications.

If the athlete is diagnosed with concussion, immediate management is physical and cognitive rest. This may include time off school or work, and relative rest from cognitive activity. Having rested for 24 – 48 hours after sustaining a concussion, the athlete can begin light intensity physical activity - as long as the activity doesn’t cause significant and sustained deterioration in symptoms.

Children and adolescents

Sport-related concussions are common in children and adolescents aged 18 years or younger. For this age group, a more conservative approach to diagnosis and management is recommended This is because this age group:

• has a slower rate of recovery from concussion
• has unique physical, cognitive and emotional differences
• is more vulnerable to concussion, due to factors including decreased myelination, poor cervical musculature, and (possibly) increased head to neck ratio
• the role of cerebral blood flow alterations in the pathophysiology of concussion may be more significant

The Graded Return to Sport Framework requires those aged 18 or under to be symptom free for 14 days prior to medical clearance to return to contact or high-risk activity. To be clear, that is not 14 days from the time of concussion. It is 14 days from when the athlete becomes symptom-free. This recommendation allows for the individual case variability in symptom duration. It ensures that the most vulnerable individuals have demonstrated a clear capacity to perform all normal activities of daily living, including non-contact exercise, without symptoms, before they return to the field of play.

Return to learn

‘Return to learn’ is about the athlete’s gradual return to their usual program at school or work.

A graded return to learn and return to sport should occur concurrently. Activities that do no exacerbate symptoms should be introduced first and may be related to either their return to school or sport.

Physiotherapists can use the Return to Learn Care Plan to communicate to teachers the requirements for a concussed child or adolescent.

Return to sport

‘Return to sport’ is about the athlete’s gradual return to full sporting activity and a physiotherapist is well placed to guide this process.

Having rested for 24 – 48 hours after sustaining a concussion, the patient can begin light intensity physical activity - as long as the activity doesn’t cause significant and sustained deterioration in symptoms.

Physiotherapists can use these Graded Return to Sport Frameworks to inform their Return to sport patient programs.

• Graded Return to Sport Framework for Community & Youth
• Graded Return to Sport Framework in the Advanced Care Setting

Predictors of clinical recovery can assist the Clinical Management Team in managing the concussed athlete. These predictors are associated with prolonged recovery:

• high severity of acute and subacute concussive symptoms
• a high number of concussive symptoms
• prolonged loss of consciousness (longer than one minute)
• post-concussive seizure
• previous history of concussion
• age of the athlete
• female sex
• history of depression, anxiety or migraine.

A physiotherapist is well-placed, whether as a primary care practitioner in community sport, or as the consistent point of athlete contact in high-performance environments to observe evolving concussion symptoms.

In uncomplicated cases the physiotherapist’s role may involve oversight and guidance through the graded return to sport framework (GRTSF).

In more complex cases, with prolonged symptoms and recovery, the physiotherapist can play a crucial role including further clinical review of cases that do not progress as expected through the Graded Return to Sport (GRTS), or management of Vestibular and Occulomotor (VOM) dysfunction in initial/ early assessment post-concussion.

Appropriate management, including cervical and VOM rehabilitation supports more complete recovery. The Interdisciplinary care flow chart for athletes with concussion helps guide health practitioners through an appropriate system for managing athletes with concussion.

It is recommended that a return to all aspects of life approach is used when rehabilitating an athlete post-concussion. This ensures that the five domains i.e., physical, cognitive, emotional, fatigue and sleep are targeted appropriately.

The updated graded return to sport framework (GRTSF) below assists practitioners to guide athletes through the recovery process and return to sport. A collaborative multidisciplinary approach to concussion management with shared decision making is encouraged.

Concussion is an evolving injury and symptoms can change over time in one or more domains. All affected domains may not be evident during the early stages of the graded return.

Reintroduction of daily activities is appropriate if the activities do not severely exacerbate symptoms following the initial 24-48 hour period of rest. After the initial period of relative rest, graded return to school and/or work is advised.

Mild exacerbation of symptoms may occur during progression through the GRTSF. This is acceptable as long as the exacerbations are temporary, that is, the symptoms return to baseline before the next exercise session. Moderate or severe exacerbation of symptoms or symptoms that persist until the next scheduled bout of activity (considered prolonged symptoms) require further review by the Clinical Management Team (CMT).

The GRTSF requires those aged 18 or under to be symptom free for 14 days prior to medical clearance to return to contact or high-risk activity. To be clear, that is 14 days from when the athlete becomes symptom-free. This recommendation allows for the individual case variability in symptom duration. It ensures that the most vulnerable individuals have demonstrated a clear capacity to perform all normal activities of daily living, including non-contact exercise, without symptoms, before they return to the field of play.

The Clinical guidelines for further review post-concussion outlines evidence-based assessment tools that can be used by the CMT to guide athlete management and rehabilitation. No single assessment tool exists for the diagnosis of concussion nor for the identification of symptom domains affected. Thus, clinical judgement of the CMT is vital in the rehabilitation and return to sport process.

Physiotherapists can use these GRTSF to inform their Return to sport patient programs.

• Graded Return to Sport Framework for Community & Youth
• Graded Return to Sport Framework in the Advanced Care Setting

In addition to the SCAT6 , there are evidence-based tools and questionnaires that can assist the Clinical Management Team (CMT) (e.g., physiotherapists or medical practitioners) to identify impairments.

Questionnaires such as PCSQ, PSQ and MPCS assist in identifying symptom domains that may be affected following the concussion including physical, cognitive, emotional, fatigue and sleep.

Tools   such as the BESS (the modified-BESS is a component of the SCAT5), Near Point of Convergence (NPC) and VOMS can be used to identify VOM impairments. The following video demonstrates the VOMS assessment and can be useful to guide physiotherapists assessing athletes post-concussion

None of these tools can or should replace clinical judgement when reviewing a concussed athlete. They may however help guide the CMT in the rehabilitation of athletes’ post-concussion.

Correct identification of clinical impairments post-concussion can help guide specific rehabilitation. The following infographic, can be a useful tool to guide the clinical review process.

Technologies such as eye tracking devices, neurocognitive tablet applications (i.e., Apps), and other sensory organisation testing devices may have a role in VOM assessment. Access to such tools may vary and currently there is limited evidence for clinical utility in athletic populations. Ongoing research in this area is required to better understand the value of these tools in the diagnosis and management of concussion.

There is a potential link between mental illness and concussion, although the relationship is not clear. Athletes with a history of mental illness require a more cautious approach. A conservative Return to Sport strategy is recommended.

There are a number of organisations with information on mental illness and 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 supports Australians to protect their mental health through education and awareness.