The Latest Research on Concussion in Sport: Understanding and Managing Concussions

No two concussions are the same, and no two recoveries are the same. However, our approach to concussions has evolved with the latest research. In 2022, the international scientific and clinical community gathered in Amsterdam to create the 6th international consensus statement on concussion in sport. This statement, published in the British Journal of Sport Medicine, provides the most up-to-date strategies for preventing and managing concussions in sport.

A wide number and variety of studies were conducted, reviewed and integrated into one document and published, detailing the definitions, policy changes, research progress and treatment updates. Let's start with the basic definitions.

Understanding Persisting Post-Concussive Symptoms (PPCS):

Up to 30% of children and adults with sport-related concussions experience persisting post-concussive symptoms (PPCS). First, the consensus helped to create a definition of what PPCS is, so that we know what we're up against.
The diagnosis of PPCS relies on symptom reports, preferably using standardized and validated symptom rating scales, as developed by the consensus and clinical experience.
Currently, research does not support the use of other specific tools or measures for clinical diagnosis of PPCS, such as biomarkers or imaging, but this is being studied!
Symptoms lasting 2 weeks or longer for adults and 4 weeks or longer for children after a sport-related concussion are typically deemed PPCS.
Luckily, the latest research does show methods and policy changes that have been shown to decrease the longevity of symptoms.

Early Phase Management:

Step 1: Remove the individual from play. Seek emergency medical attention with any red flags.
Step 2: Allow for relative rest for 24-48 hours.
Step 3: Introduce supervised light aerobic exercise to facilitate recovery, ensuring it does not exacerbate symptoms for more than 1 hour or increase symptoms by two or more points on a 0-10 scale.

Role of Physiotherapy in Concussion Management:

Any athlete with a suspected concussion should be removed from play and medically assessed, with no return to play on the day of injury. This is one of the few absolutes from the consensus.
Physical activity and prescribed aerobic exercise treatment are beneficial early in recovery after SRC. Again, it must be graded exercise. This is really where the clinical decision making process of a physiotherapist comes in to play. We’ll be able to help our patients understand how to recognize the signs of overload to facilitate a faster recovery. Cervicovestibular rehabilitation programs are recommended for adolescents and adults with symptoms of dizziness, neck pain, and/or headaches.
Vestibular rehabilitation may benefit adolescents with dizziness lasting more than 5 days. We’ll use tools like frenzel goggles to evaluate a nystagmus (twitching of the eye) that would indicate a vestibular dysfunction and what we will do to correct it.
Active rehabilitation and collaborative care may be beneficial for adolescents with persisting symptoms of all types.

Multimodal Clinical Assessment and Differential Diagnosis:

A multidisciplinary team is recommended to assess individuals with persisting symptoms, considering the types, patterns, and severity of symptoms, as well as associated conditions and contributing factors.
The professional standards of a variety of disciplines as well as the careful evaluation of various other factors might examine if a cognitive function is due to a pre-existing condition. For example, if the patient has autism or other neurological conditions, certain tests will need to be adapted. Equally, in the specific clinical or sporting context of multiple sports, a team of clinicians will be able to correlate their approach to the needs of that specific sport. Safely reintroducing a dancer to their activity is going to look different than a hockey player, for example.
Important diagnostic considerations that a multi-disciplinary team can address include mental health issues, learning difficulties, visual and ocular-motor problems, headaches and migraines, sleep disturbance, and pain.

Updated Tools for Healthcare Professionals (HCPs):

The consensus released a new and updated SCAT6 as a tool for HCPs to use within the first 72 hours of suspected concussion. It is now updated to include more red flags, indicating the need for an ambulance and emergency medical intervention.
The Sport Concussion Office Assessment Tool (SCOAT6) assists HCPs in clinical determination and management assistance three days post-injury, for in-clinic evaluations.
The Concussion Recognition Tool 6 (CRT6) is a tool for teachers, coaches, and parents to facilitate awareness and understanding of concussion.
Protective Measures and Strategies:
While the evidence is still developing, the consensus identified some key areas where the research can develop with a focused approach. Mouthguards were found to be associated with a 28% lower rate of sport-related concussions specifically in ice hockey.
Policy changes in leagues has also been a hot topic in the news but is demonstrating a measured effect as well. Disallowing bodychecking in child and adolescent ice hockey reduces the concussion rate by 58% without unintended consequences for later skill development.
A coordinated approach between HCPs and coaches can mean that further policy development and knowing why implementation is important has the capacity to really help prevent concussions in youth activities and very much to assist in reducing the longevity of symptoms.
Strategies limiting contact practice in American football lead to a 64% lower practice-related concussion rate.
Neuromuscular training warm-up programs in rugby are associated with a 32%-60% lower concussion rate.
While the consensus showed encouraging data on these fronts, it was also exciting to see that current concussion management strategies may also reduce recurrent concussion rates. A lot of this is the education that we can provide on the importance of multi-modal diagnosis, graded recovery and appropriate rest following any head injury.
Recovery Factors and Management:
Symptom burden post-injury predicts a longer recovery after sport-related concussions. Here’s a heavy one, but it seems to make anecdotal sense! The stronger the symptoms, the longer the recovery tends to be. Physiotherapy is a recommended intervention for anyone who has sustained a concussion. In one instance, a study looked at those who employed a physiotherapy program early in the acute phase (day 3-5) another after 30 days and the final cohort who did no rehabilitation. This study demonstrated that even those who started a physiotherapy program (that included vestibular and oculomotor rehabilitation) later in their recovery, were still able to shorten their recovery time over the cohorts who did no physiotherapy at all.
Rest and Exercise After Concussion:
Strict rest until symptom resolution is not effective. The guidance used to recommend isolation in a dark room. Well, we all went through COVID and we know how that felt. The same is true for a concussion recovery. Although light sensitivity is a common trigger, complete isolation and immobility is not advised and can bring on different issues instead.
Instead, light-intensity physical activity during the first 48 hours after concussion can help facilitate recovery.
Prescribed subsymptom threshold aerobic exercise treatment, based on individual heart rate thresholds, can be started within 2-14 days of concussion and reduces the incidence of persisting symptoms.
The other really effective trick to consider is that screen time reduction during the initial 48 hours after injury can aid in recovery. Really, anything that flares symptoms in the first 48 hours should be avoided, for sure.

Conclusion:
With the latest international consensus statement, we have gained valuable insights into understanding and managing concussions in sports. By following evidence-based guidelines and using updated tools, we can prioritize the health and well-being of athletes while promoting safe participation in sports.

Remember, if you suspect a concussion, always seek medical assessment and adhere to appropriate management protocols to ensure a safe and effective recovery.

This article draws from the 6th International Conference on Concussion in Sport held in Amsterdam on 27–30 October 2022. Dr. Kathryn Schneider, PT, PhD, was a co-author and maintains a clinical practice at our Evidence Sport and Spine North location. Read the full consensus statment here.