Concussion in Rugby

 

Concussion is still the most common injury within Rugby, with around 70% of concussions occurring during the tackle.

Following on from our first article about behind repetitive concussion being linked to  early onset dementia, we are now going to look at concussion itself, it’s symptoms, and how to manage concussion on the pitch, as well as persistent concussion post injury.

What is concussion?

Concussion is a type of traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.

It was originally thought that it was the brain hitting the skull causing it to ‘bruise’, which caused concussion symptoms. However, it’s actually a mechanical stretching / shearing of axons and deformation of the neural membrane which creates a chemical disturbance between Potassium(K+), Calcium(Ca++) and Sodium (Na+).

“Immediately after biomechanical injury to the brain, abrupt, indiscriminant release of neurotransmitters and unchecked ionic fluxes occur. The binding of excitatory transmitters, such as glutamate, to the N-methyl-D-aspartate (NMDA) receptor leads to further neuronal depolarization with efflux of potassium and influx of calcium. These ionic shifts lead to acute and subacute changes in cellular physiology.” (1)

It is this chemical change and imbalance that actually causes concussion symptoms.

Assessing head injuries on the pitch.

When a head injury occurs on pitch, the team medic will use a technique called SCAT5, starting with an immediate/on-field assessment which comprises of;

  • Taking note of any red flags  – (RED FLAGS: • Neck pain or tenderness • Double vision • Weakness or tingling/ burning in arms or legs • Severe or increasing headache • Seizure or convulsion • Loss of consciousness • Deteriorating conscious state • Vomiting • Increasingly restless, agitated or combative.)
  • Checking for observable signs of concussion
  • Memory assessment using Maddock’s questionnaire
  • Examining the level of consciousness using the Glasgow Comma Scale
  • Cervical spine assessment

If any of the above flag as positive, the player will be sent off and there will then be an off-field assessment which is preferably carried out in a clinical setting which involves:

  • Taking a comprehensive history of the players condition
  • Symptom evaluation
  • A cognitive screen, which is a measure of orientation and immediate memory.
  • A measure of concentration
  • A neurological screen
  • Delayed recall

 

What are the symptoms of concussion and how long do they last?

Post-concussion syndrome can last up to four weeks after injury. Persistent Concussion Syndrome can last several months after injury.

It is extremely important not to dismiss symptoms of concussion and to take rest and rehabilitation seriously when managing concussion symptoms.

Players should be given a form to complete after a TBI to assess how their concussion symptoms progress over the following weeks post injury.

Symptoms are scored between 0-6  (0 being no symptomatic – 6 being severe.) which includes anything from the below list:

  • Headache
  • Pressure in head
  • Neck Pain
  • Nausea or vomiting
  • Dizziness
  • Blurred vision
  • Balance problems
  • Sensitivity to light
  • Sensitivity to noise
  • Feeling slowed down
  • Brain fog
  • Don’t feel right
  • Difficulty concentrating
  • Difficulty remembering
  • Fatigue or low energy
  • Confusion, Drowsiness
  • More emotional
  • Irritability
  • Sadness
  • Nervous or Anxious
  • Trouble falling asleep

 

Players are also asked to score symptoms during physical / mental activity. If symptoms worsen, the activity should be scaled back.

Rest & Rehabilitation

Until recently, most doctors advised patients with a concussion to rest completely from mental and physical activities, until concussion symptoms disappeared.

Studies now show that complete rest lasting longer than 2 days can actually lead to worse outcomes. Moderate physical activity within the first week of a concussion, even on the first or second day, actually speeds recovery time and lessens the chances of developing post-concussion syndrome.

Aerobic exercise helps brain function by increasing blood flow to the brain, which gives the brain the oxygen it needs to function properly. It also causes the brain to produce chemicals that stimulate cell growth and improve neuroplasticity.

For example, the brain-derived neurotrophic factor (BDNF) is a protein that promotes the growth of neurons and increases synaptic plasticity, which improves communication between cells in the brain. Studies show that every time you exercise, your body produces this protein. Regular exercise increases its production and benefits even more. This post-exercise cognitive boost continues for hours after exercise and is an important factor in healing from brain trauma and in improving cognitive abilities.

In a recent Clinical Journal of Sport Medicine study on sports-related concussions, it found that of the 126 patients that participated in supervised exercise during the early, symptomatic stages of their concussion returned to their sport earlier (26.5 days) compared to those who didn’t (35.1 days).

Certified athletic trainers and physicians oversaw what they deemed appropriate exercise. They monitored each patient’s heart rate, perceived exertion and severity of symptoms at two-minute intervals, with intensity gradually increasing.

Athletes started at a low intensity with exercise that required little head and body movement, like a stationary bike. Other exercise modalities included an elliptical machine, dynamic rotational exercises like the use of medicine balls, agility drills and sport-specific exercises when tolerated.

Exercise was only increased when symptoms didn’t. If a patient reported symptoms, the intensity of the exercise was decreased or stopped altogether.

Managing persistent concussion syndrome.

There are a few things to look at when treating persistent concussion syndrome.

Depending on the symptoms, looking at the MSK system is usually a good place to start.

Neck strain is a common concurrent injury that contributes to symptoms like headaches, nausea, dizziness, trouble sleeping, and difficulty with cognitive processes. Treating the neck can often reduce these complaints effectively.

Vestibular therapy can also be effective for some of the symptoms. The vestibular system is part of the inner ear. It works with information it receives from the eyes, muscles and joints to help us maintain balance and spatial awareness.

If this system was damaged by a concussion or other head trauma, the brain can receive erroneous signals about the body’s position. As a result, you might experience dizziness, vertigo, nausea, head pressure, and headaches when you are moving. It can also cause excessive fatigue.

Nutrition can also help with PCS by reducing inflammation to the brain.

Your gut and brain are connected physically through millions of nerves, most importantly the vagus nerve. The gut and its microbes also control inflammation and make many different compounds that can affect brain health. Recent studies show that your brain affects your gut health and your gut may even affect your brain health. The communication system between your gut and brain is called the gut-brain axis. The gut-brain axis is a term for the communication network that connects your gut and brain.

So when it comes to nutrition, for people with PCS, it is advised that you eat an anti-inflammatory diet high in Omega 3 and protein.

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If you feel you are suffering from Persistent Concussion Syndrome, it is important you seek medical help from concussion specialists. Don’t try to managed symptoms with exercise before seeking specialist advice first.

 

Helpful links for players and parents.

SCAT 5

HEADCASE