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Finding a levelheaded approach to concussions ~ Dr. Chris Bradshaw

This post is the first part of a two-part series on concussions and sports medicine.

Concussion has for many years been a contentious issue in sports medicine circles, and its management, both acutely and long-term, has been the topic of much debate. I am not an expert on head injuries and concussion. I write from the perspective of a physician involved in a contact team sport, in which concussion and its long-term effects are causing a great deal of debate, discussion, and maybe a little hysteria. I am aware that the management of concussion has not always been ideal, but I am keen to manage the players under my care to the very best standards possible.

Historically, in contact sports in particularly, there was a mandatory holiday given to those diagnosed with concussion. In some football codes this time off playing was a week; in other sports such as boxing, the holiday granted was a month. Whilst there was not a lot of science behind these rules, the time off was considered conservative enough to allow for full recovery in the majority of cases.

In the 1990’s, research out of Australia based around some basic neuropsychological testing, started to challenge these paradigms. The rationale was to use simple tests of cognitive function to assess whether or not a participant was recovered enough from their concussive episode to return to play.

The first of these tests was a digit symbol substitution test (DSST), and participants did the tests preseason as a baseline test, and once concussion was suspected the test could be run again. If the player came within a percentage of his pre-participation screen, he could return to the field of play. This allowed for participants in some sports being deemed fit to return to play later in the game in which they were concussed.

Al Alburquerque #62 of the Detroit Tigers after being struck in the head by a ball during batting practice before the game against the Baltimore Orioles at Oriole Park at Camden Yards on August 12, 2011 in Baltimore, Maryland. Alburquerque received a concussion and was hospitalized overnight for observation. Photo by Keith Allison. Used with permission. All rights reserved. Source: flickr

Al Alburquerque #62 of the Detroit Tigers after being struck in the head by a ball during batting practice before the game against the Baltimore Orioles at Oriole Park at Camden Yards on August 12, 2011 in Baltimore, Maryland. Alburquerque received a concussion and was hospitalized overnight for observation.
Photo by Keith Allison. Used with permission. All rights reserved. Source: flickr

More recently computerized tests have replaced the DSST, but anecdotally there was always the feeling amongst clinicians that they weren’t sensitive enough, that they somehow missed subtle decrements in cognitive function.

There was also the knowledge that some players deliberately did badly on their preseason test, to lessen the chance of them being ruled out during the season! As a result of this a test to be used pitch side to assess for concussion, the SCAT test, was developed and went one step closer to taking some of the guesswork out of the assessment of acute concussion.

At the end of 2011 the Australian Football League and their medical officers decided on a ruling that any player diagnosed with concussion had to sit out the rest of the game and could not return to field again, even if they seemingly had recovered cognitive function. That diagnosis was based on the SCAT test and other game day assessments.

After a conference in Zurich in November 2012 dedicated to concussion, further elements to help diagnose concussion are being mooted and recommended. These include the use of video analysis to screen for post traumatic “staggers” and brief seizures –again with the thought if a concussion is diagnosed then the player cannot return to the field of play on that given day.

These changes will likely be challenging, but they will clarify the acute treatment of concussive episodes and will diminish the risk of a concussed player being allowed to continue to play. They will possibly force some of the football codes to address rules for specific substitutions for concussed players. In some forms of rugby, for example, there already is in place a “head bin” which allows time for a player with potential concussion to be adequately assessed. All of these innovations have one thing in mind -a player’s welfare and safety.

Chris Bradshaw is a Sport and Exercise Physician with the Olympic Park Sports Medicine Centre based in Geelong. Since 2006, he has been the head medical officer for the Geelong Football Club. Bradshaw has also experience with the Premier League with Fulham from 2003-2005, and was the Australian Track and Field Doctor from 1997 to 2000, culminating in the Sydney Olympics. He was also with Richmond Football Club from 1992 to 2003. 

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