Cricket has become the latest of major sports in which concussion is receiving keen attention. The understanding of concussion and its management have changed to the extent that even the hallowed rules of cricket have been modified to suit.
The International Cricket Council in July 2019 announced new rules that allow ‘like for like’ substitution of concussed players for men and women’s international and first-class cricket.
Since that announcement, test cricket has seen two such replacements. Australia’s Steve Smith and the West Indies’ Daren Bravo were both replaced one day after they presented with symptoms of concussion.
In both cases, there was a visible head injury after which the player appeared unaffected. Yet, by the next day, they had to be replaced.
Diagnosing a concussion is challenging, given that the signs and symptoms can be very subtle. Often, it presents with dizziness, wooziness, haziness in front of the eyes, or slight lethargy, or inability to make quick decisions. The player may not feel this till the next day.
The actual injury is not something that shows up on an MRI or CT scan like a fracture would on an x-ray. It doesn’t have clear tell-tale signs that medical personnel can use to confirm the diagnosis.
Something as subtle as a change in persona could be the only sign. And what’s more, it may not become evident until 24-48 hours later, so it requires close monitoring of anyone who gets a hit on the head.
Given the difficulties with diagnosis and return to play decisions, guidelines have been developed to improve the standard of decision making in this area.
The consensus statement put forward by the Concussion in Sport Group in 2016 at the Fifth Annual Conference on Concussion in Berlin is one of the main guidance documents that exist today.
The document emphasises the importance of baseline assessments so that subtle changes can be matched against the athlete’s personal “normal.”
This is done by administering the Sport Concussion Assessment Test (SCAT5) (available at https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf) at the start of the season, and many times after the injury until the results match the baseline. This should be done by qualified medical personnel.
The SCAT5 is used to assess athletes 12 years and older whilst the child SCAT5 assesses children ages 5-11.
In reality, there are many situations where no medical personnel is present (school and community competitions) and in these cases, trainers, coaches and physical education teachers, with appropriate training, can use the Concussion Recognition Tool (CRT5) to identify possible concussion and seek medical attention for the athlete.
Most sporting activities are fast-paced and the restricted field of view of the medical team imposes limitations on side-line observation which adversely impact the diagnostic process.
In October, the Sport Concussion Group released their consensus statement regarding signs that one should look for on video review of a match to determine whether a concussion occurred. These include lying motionless for more than two seconds, unsteadiness (motor incoordination), stiffness of any limb (tonic posturing), floppiness, or a blank, vacant look.
So, a concussion has been detected. What next? Management of the player follows a six-stage graduated return to play strategy, beginning with 24 to 48 hours of physical and cognitive rest, followed by activities of daily living, light exercise, sport-specific exercise, non-contact training drills, full practice and return to competition.
Each stage has at least 24 hours between it, but longer if the previous stage is not cleared. The SCAT5 test is performed periodically in tandem with clinical examination and other investigations if needed.
To date, this has shown to lead to the least long-term effects and allows the quickest return to sport. Yet, it requires a minimum of six days (and sometimes up to many weeks). If symptoms are still present after ten to 14 days for adults or one month for children, they should be seen by a concussion specialist.
Children require special consideration and a graduated return to school protocol is recommended. Recovery begins with short periods of daily activity at home that do not aggravate symptoms followed by schoolwork being done at home, part-time return to school and full-time return.
No child should return to playing sport without full, symptom-free return to school. Schools must be accommodating and be prepared to provide the support to help the child ‘catch up’.
Playing sport is an essential part of child development and the relevant ministries must work with the schools to ensure that sport-related concussion policies are in place. Teachers, coaches, students and parents must receive concussion education.
Happily, more and more sports today treat concussion injuries with the seriousness it deserves and are making safer decisions.