An educational commentary on concussion in sports

Concussion in contact sport is a common occurrence, especially in rugby union (rugby) where it accounts for approximately one quarter of all time-loss injuries in a match (1, 2). There is always strong debate over concussion in rugby, particularly youth rugby. Concussion occurs most commonly in the tackle, with higher risks associated with high accelerations of the players, head to head contacts, and poor tackling techniques (2). In one particular case from 2017, a prominent top level international rugby player was seen on the television replays of a test match to have sustained a head injury after a tackle. The player showed initial signs of concussion, yet carried on playing, and subsequently took two more aggressive knocks to the head within a minute of the first injury. The player finished the game without undergoing a concussion test, also playing the test match the following week. This sort of medical decision making should alarm any concerned rugby supporter. In other past heated rugby debates, in the United Kingdom particularly, a study was brought forward a case for the banning of the tackle in youth rugby due to the high risk for sustaining a head injury. This was responded to by scientists working for the World Rugby union, where they challenged the claims based on the current literature regarding concussion in youth rugby. 

Concussion presents with adverse physical, cognitive and emotional functions, especially in the first week after the injury (3). If there is an increased severity of symptoms, it is likely that the recovery will be longer (3). When deciding if a player can return to play after concussion, it is recommended by the literature to have a no return on the same day policy, as well as a guided symptom free progressive return to play protocol (3). Research generally shows that a physiological recovery time of around 10-30 days occurs, although clinical recovery usually occurs sooner than that (4).

The conundrum clinicians seem to be facing is when to safely allow a player to return to play. In the case of the high level international rugby player, the clinical reasoning to allow the player to play the whole game after the injury, and not sit out the game 7 days later, needs to be scrutinised. According to reports, the player went through medical assessment after the game and there was no concern over his symptoms and cognitive/physical state. Current best practice is to allow return to play based on these clinical symptoms, although research has shown that neurobiological recovery might extend beyond the recovery of these clinical symptoms (3). Research has not yet linked any subclinical metabolic markers to full recovery from concussion (4). Are players damaging themselves or putting themselves at increased risk by playing with subclinical symptoms of concussion? There is poor long term prospective evidence for the consequences of early return to play following concussion, although some literature suggests that repeat injury (second impact syndrome), prolonged symptoms, increased risk of musculoskeletal injury, more severe physiological dysfunction, or increased risk for neurodegenerative disease may result (3).

A scientific standpoint for healthcare professionals

Research has suggested that the current best practice for return to play is a graduated progression of increasing physical and cognitive demands, whilst remaining symptom free (4). Currently there are safety protocols being implemented in the game to reduce the occurrence of concussion, such as law changes to the tackle area (2). Modifications to change the accelerations of players into a contact situation, and further law changes regarding the legal execution of a tackle are other potential solutions (2). Removing the tackle form the game completely may be a scientifically supported notion, however one must consider that the identity of the game may be lost with this initiative and should be carefully considered in the future (2). Rugby currently gives youth players a particular health benefit from engaging in regular physical activity at a young age, and removing the identity of the game may result in a loss of interest from youth players (1). There is not concrete research available to try to change the current safety protocols for reducing the risk of concussion, or for correctly identifying and treating the condition (2). As sideline bystanders, it may not seem like the right decisions are being made, but currently evidence based safety protocols are in place and equip the medical staff to make the correct decisions in allowing the players to return to play. As evidence based practitioners in the field of sports, it is important that clinicians stand firm on their belief in the scientific method of clinical reasoning, as in this case, as it forms the basis for good care of all athletes.

Future recommendations

The future recommendations based on research and individual case reports such as this is that there needs to be long term prospective research to identify specific relationships between clinical and subclinical physiological recovery from concussion (4). An integration of concussion management into current best practice for return to play protocols is essential to ensure the health and safety of players participating in rugby (4). Education and behaviour modification in players, coaches, and referees has already shown to be a viable option for future risk modification strategies (2).

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