In 2022, the 6th International Conference on Concussion in Sport was held to prepare an updated evidence-informed consensus statement for the management of sport concussion1. Below is a summary of the panel’s definition of sport-related concussion and their updated recommendations (11 R’s).
Definition:
Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain. Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged. No abnormality is seen on standard structural neuroimaging studies…
RECOGNIZE: Concussion (mTBI) is diagnosed based on mechanism of injury, clinical signs, and acute symptoms. Symptoms include feeling confused, dazed, disoriented, headache, nausea, dizziness, balance problems, vision problems, sensitivity to light, and/or sensitivity to noise, foggy, slow, and irritable.2
REDUCE: Prevent concussion by encouraging policy/rule changes in contact sports, and using mouthguards in ice hockey (which reduced concussion rate by 28%). Neuromuscular training warm-up programs helped decrease concussion rates in rugby, and may be helpful in other sports.
REMOVE: If concussion is suspected, remove from play immediately. Use a screening tool such as the SCAT (in the first 72 hours) and the SCOAT6 (after 72 hours). Do not return to training that day if there are signs of: actual or suspected loss of consciousness, seizure, tonic posturing, ataxia, poor balance, confusion, behavioural changes and amnesia.
REFER: Refer to clinicians with knowledge and skills in concussion management. This multidisciplinary team may include: sports medicine physicians, athletic trainers/therapists, physiotherapists, occupational therapists, sports chiropractors, neurologists, neurosurgeons, neuropsychologists, ophthalmologists, optometrists, physiatrists, psychologists and psychiatrists.
RE-EVALUATE: Office visit of a concussion-informed healthcare practitioner. Examination items may include:
- Word recall and Digit Backwards tests
- Measurement of systolic and diastolic blood pressure as well as heart rate taken in two positions:
- Supine position, rest for 2 min and take measurements.
- Follow with the standing position, measure again after 1 min.
- Evaluation of cervical spine range of motion, muscle spasm and palpation for segmental or midline tenderness.
- A neurological examination includes the assessment of cranial and spinal nerves, motor function, sensation and deep tendon reflexes.
- Timed tandem gait as a single task and a more complex dual task with the addition of a cognitive task (such as serial 7’s, months backwards or word recall backwards).
- The modified Vestibular-Ocular Motor Screen (VOMS).
- Delayed word recall a minimum of 5 min after completion of the immediate word recall test.
REST and exercise: Strict rest until resolution of symptoms is NOT recommended. Instead, Relative Rest (reduced screen time, continue activities of daily living) is recommended immediately and for up to 2 days after the injury. Begin light physical activity (walking or stationary cycling) in the first 2 days. Healthcare providers can prescribe subsymptom threshold aerobic exercise progression. Avoid the risk of reinjury (fall) until cleared for higher-risk activities.
REHABILITATE: If dizziness, neck pain and/or headaches persist for more than 10 days, cervicovestibular rehabilitation is recommended. Rehabilitation can include physical therapy for the neck, vestibular, oculomotor, and balance systems, and subsymptom threshold exercise progression.
RECOVER: Consider the following three components to determine recovery:
- Assessment of symptom reports (including symptom resolution at rest, with cognitive activities and following physical exertion).
- Other outcomes relevant to ongoing symptoms (response to physical exertion, post-traumatic headaches, standing balance, dynamic balance, vestibulo-ocular reflex (VOR) function, oculomotor (OM) function, symptom reproduction with VOR and OM testing (eg, VOMS), cognition, dual tasking).
- Measures of return to activity such as RTL and RTS (see below).
RETURN-TO-LEARN: Initially, adjustments are recommended including modified schedule, limited screen time, extra time to complete assignments, and delaying tests. Progressively return to activities, while making sure symptoms are not increased more than 2 points on a 0–10 point scale and for less than an hour. Student-athletes should complete full RTL before unrestricted RTS.
RETURN-TO-SPORT: 6 steps to RTS using symptoms, cognitive function, and examination findings as guide for progression. Medical determination of readiness to return to at-risk activities should occur prior to returning to any activities at risk of contact, collision or fall. (Physical therapists are qualified in Colorado to determine readiness for return-to-play.)3
- Early Activity
- Aerobic Exercise (Light progressing to Moderate)
- Individual sport-specific exercise
- High-intensity Non-contact activity
- Practice and Full contact
- Competition
RECONSIDER/RESIDUAL EFFECTS: Further studies are needed regarding possible association between sports participation and potential long-term cognitive effects.
To learn more about concussion rehabilitation, click here.
If you are experiencing post-concussion symptoms including headache, neck pain, dizziness, imbalance, or difficulty returning to sport, you may benefit from individualized physical therapy in Boulder, CO with Dr. Sarah Burkhardt.
or email sarah@seatosummitpt.com with any questions!
References
(Photo Credit: Laura Burkhardt)
- Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam. October 2022. British Journal of Sports Medicine 2023;57:695-711. ↩︎
- Silverberg, ND, Iverson, GL, Cogan, A, et al. The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation. Volume 104. Issue 8. 2023. Pages 1343-1355. ↩︎
- http://leg.colorado.gov/sites/default/files/2019a_1208_signed.pdf?utm_medium=email&,utm_source=govdelivery ↩︎