After a week serving the Bulls U18 Craven Week squad, I thought it would be a good idea to continue from my last blog post on concussion. This time, a short reflection on my thoughts and some guidelines for concussion.
Firstly, what a privilege it was to serve an incredible Bulls U18 side. They boys really did something special this year at the tournament, and despite losing in the final to WP, we all felt we were victorious in achieving our team goals we had set. During the week, we had two cases of suspected head injuries. The first was in game 1 against Border, where upon doing screening after the game for injuries, one of our players reported symptoms of headache and drowsiness. The player mentioned there was a moment in the game where he took a big contact, but nothing that was noticeable to any of the medical staff, match officials, or coaches, and he didn’t have any on-field symptoms. A SCAT-5 assessment was done as per suspected concussion guidelines, and a repeat assessment done 3 days later where his score had improved with no signs or symptoms noted. Technically, according to IRB guidelines, the player should have had a mandatory two week off for physical and cognitive rest because of a ‘suspected concussion’. However, concussion remains a clinical diagnosis, and clinical judgement is essential. A consensus statement on concussion was published in 2018, and in it the ‘stunned athlete’ is discussed. This is where they player falls into the category of signs and symptoms for concussion, only they are temporary. This transient injury may not be a full-blown concussion, but there is no definite way to confirm this. In our case, there was no real concern of a severe on-field or post-game concussion, despite a few minor symptoms. We made the diagnosis that it was a transient, temporary head injury rather than a concussion. It is so important to be conservative in our approach to managing concussion and consider the full picture when making clinical reasoning calls. Therefore, we put the player on three full days physical and cognitive recovery, and he played the last game with no issues.
The second case was during the game in match 2 against WPxv, where a player made a game-changing tackle, but this also left him with on-field signs of head injury (discussed below). We followed the principles of recognise and remove, and sent the player for a head injury assessment at the medical tent. They ruled him out for the remainder of the tournament, according to the predetermined tournament protocols. The player had no symptoms post game or the day after, but I do believe that this was a good decision to rule him out, as we know that symptoms of concussion may disappear straight after the incident, but the head injury is still there.
Why am I writing this blog? Simply because it is a very difficult situation for players, medical staff, coaches, and tournament organisers. Concussion is becoming a big talking point in contact sports such as rugby, and especially in youth rugby. From a medical perspective, someone must be held responsible for player safety, and generally the medical staff of any team assumes that responsibility. The first rule of sports first aid is “do no further harm!” Making difficult calls regarding serious injuries such as removing from play for suspected head injury will not always be celebrated by the players and coaches, but if it is in the best interest of the player than it must be done. A coach may desire his strongest players to always be on the field, resulting in pressure to look-past injuries such concussion. A player may not fully understand the situation that signs and symptoms may disappear after the game. This can be extremely frustrating for them as they may feel they have recovered enough to play. In our situation this past week, the coaches were fully on board for removing the player from the field as they had seen the signs and symptoms first-hand after the tackle. The coaches had a sit-down with the player and discussed the situation that he cannot play the final game, making the whole process a lot easier to manage. I think it is best to have full co-operation like this between coaches, players, and medical staff to ensure safety of the players.
So how do we recognise and diagnose concussion. The most important thing to remember is that concussion is a functional injury that effects the way the brain works, and not necessarily a structural injury. Functional impairments occur through processing and dealing with information. The IRB has standardised guidance protocols for recognising on-field suspected head injuries, as well as off-field clinical signs and symptoms. These are as follows:
So what do we do if we suspect a player has a concussion? Firstly, remember to do no harm, despite any pressure from outside sources such as coaches and parents etc. The SCAT-5 is a useful tool for assessing concussion in players, but should not be used as a stand alone tool for decision making. It covers signs, symptoms, cognitive screening (orientation, memory, concentration, delayed recall), and neurological (balance) assessments. The IRB guidelines for managing concussion are as follows:
- Remove from pitch
- Do not leave alone
- Do not allow to drive a motor vehicle
- Do not consume alcohol
- Same day medical review
- 24-hours complete physical and cognitive rest (rest the body, rest the brain)
- Graduated return to play protocol
The graduated return to play protocol is a 6-stage guideline of how to progressively return a player to training and matches after sustaining a head injury.