Concussion- can I play in my match?

Sarah is a 14-yr old girl brought in after colliding heads during football training. She seemed ok the morning after, but on attempting lessons it became clear she was struggling to concentrate and complaining of a grumbling headache. 

Concussion is the topic of a recent editorial in the BJGP, highlighting the potential consequences of under-recognition and inadequate advice following injury. So, what are the key pointers for us in primary care?

Firstly, concussion is a brain injury, and as such needs to be taken seriously. It’s been a really hot topic in both professional and amateur sport for a good few years with increasing recognition that not acting appropriately on concussions (especially repeat concussions), can impede recovery and put people at risk of more serious brain disease down the line. 

Diagnosis

Concussion is a clinical diagnosis, with symptoms often apparent immediately after head injury, but sometimes emerging 24-48hrs later. We should suspect it with any of the following symptoms post head injury (NICE NG232): 

• Sensory and motor: headache, visual disturbance, photophobia, hyperacusis, dizziness, nausea, drowsiness, fatigue, reduced balance, excess sleep or insomnia
• Cognitive: ‘brain fog’, disorientation, poor concentration, slowed response
• Emotional: emotional lability/ irritability, depression, anxiety 

Assessment tools? The SCAT6  can be used up to 7 days post injury as a diagnostic aid for adults and children aged over 13yrs (Child SCAT6 for children aged 8-12). However, this cannot be performed correctly in less than 10-15 minutes and is therefore too lengthy for a standard primary care consult. Side note-for any parents/ sports fans out there, it’s worth being aware of the CRT6 score, an immediate pitch side assessment tool that includes a clear summary of red flags and symptoms alongside 5 quick questions to help identify potential concussion, with prompts to sit the player out and get further medical assessment. 

Imaging?

Whilst imaging is not indicated for diagnosis of concussion, we do need to check that Sarah does not have any red flag symptoms or risk factors indicating the need for a scan to rule out alternative pathology, such as intracranial bleed. These include loss of consciousness, post-traumatic seizure, amnesia, neurological deficit, reduced GCS, abnormal drowsiness, recurrent vomiting, bleeding/ clotting disorder, signs of skull fracture and/or dangerous mechanism of injury (NICE NG232). The BJGP editorial also highlights unusual behaviour change, increasing confusion/ irritability, severe or increasing headache, severe neck pain, history of brain surgery, and current drug of alcohol intoxication as red flags for consideration of further assessment.

Thankfully Sarah does not have any of these.

What next?

We can reassure Sarah that symptoms of concussion typically resolve within 2-4 weeks, and signpost her to the excellent ‘If in doubt, sit them out’, UK Concussion Guidelines for Non- Elite (Grassroots) Sport for information to support her recovery as well as the red flags for urgent medical assessment. It contains a schedule for graduated return to activity, moving from 24-48hrs of rest to a phased introduction of activity at a pace guided by symptoms. Importantly, non-essential screen time should be avoided for at least 48 hours.  Return to education/ work is prioritised ahead of return to sporting activities, and there should be no return to competition before 21 days from injury. 

When to seek review?

The concussion guidelines recommend patients seek GP review if they still have symptoms at 28 days post injury (roughly 10-20% patients BJGP). Review is also advised if symptoms are not improving by 14 days or are worsening.

 NICE guidance advises we ‘consider referring people who have persisting problems to a clinician trained in assessing and managing the consequences of traumatic brain injury’. However, as the BMJ editorial highlights, there is significant variation in what is available. They advocate for widespread roll out of community concussion clinics to support patients and clinicians in managing this common problem.

So, what about Sarah? She is deeply miffed to be told that she can’t play her upcoming match and restricted access to screens including her phone serves a further blow; but the deal is slightly sweetened by the idea of a day off, phasing back into schoolwork gradually!