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Concussion in Football

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Introduction

In the high-energy and physically demanding sport of football, concussions are an ever-present concern that can impact both amateur and professional players. At ‘The Football Physio‘, we are dedicated to advancing player safety and health through education and effective management strategies. This blog explores the critical aspects of concussion in football—covering its symptoms, assessment, treatment, and the Football Association’s recommended return-to-play protocols. By understanding and addressing concussions, we aim to enhance the protection and well-being of football players at all levels.

What is a Concussion?

A concussion is a type of traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head. It can also occur from a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce or twist within the skull, leading to structural and chemical changes in the brain and, in some cases, damaging brain cells. It is important to note, that other injuries may occur alongside a concussion such as a skull or facial bone fracture, or a more significant brain injury such as a subdural hematoma.

Symptoms of Concussion

Concussion symptoms can vary widely among individuals and may appear immediately or develop over hours or days. Common symptoms include:

  • Physical Symptoms: Headache, dizziness, nausea, vomiting, blurred vision, sensitivity to light and noise, and balance problems.
  • Cognitive Symptoms: Confusion, feeling foggy, difficulty concentrating, memory loss (amnesia) related to the injury, and slowed reaction times.
  • Emotional Symptoms: Irritability, sadness, increased emotionality, and nervousness.
  • Sleep Disturbances: Trouble falling asleep or sleeping more than usual.

Assessment of Concussion

Effective assessment of a concussion involves a combination of on-field evaluation and follow-up medical examinations:

On-Field Evaluation

Initial assessment on the pitch is crucial for identifying potential concussions and ensuring the player’s immediate safety. The Concussion Recognition Tool 6 (CRT6) is widely used for this purpose. The CRT6 helps identify suspected concussions and provides guidance on the steps to follow if a concussion is suspected. It focuses on recognizing visible signs and symptoms of concussion, and it includes a quick cognitive assessment.

Key components of the CRT5 include:

  • Observable Signs: Look for any visible signs of concussion such as loss of consciousness, lying motionless on the ground, balance disturbances, or disorientation.
  • Symptoms Check: Ask the player about symptoms like headache, dizziness, nausea, blurred vision, or sensitivity to light and noise.
  • Memory Assessment with Maddox Questions: Evaluate orientation using the Maddox Questions integrated into the CRT5:
    • What venue are we at?
    • Which half is it now?
    • Who scored last in this game?
    • What team did you play last week/game?
    • Did your team win the last game?

Incorrect responses to any of these questions indicate a possible concussion, necessitating the player’s immediate removal from play for further evaluation.

In addition to the CRT6, other tools like the Sport Concussion Assessment Tool (SCAT6) can be used for a more comprehensive on-field assessment. SCAT6 provides a structured approach to assessing symptoms, balance, and cognitive functions on the field, supplementing the initial evaluation provided by CRT6.

Medical Examination

A comprehensive medical examination is crucial for accurately diagnosing and managing concussions as well as any other associated injuries. This includes:

  • Head and Facial Injury Assessment:
    • Skull Fractures: Checking for signs such as swelling, bruising (especially behind the ears or around the eyes), and cerebrospinal fluid (CSF) leakage from the nose or ears.
    • Facial Fractures: Evaluating for asymmetry, visible deformities, or misalignment in the facial bones, as well as assessing for tenderness or abnormal movement.
    • Soft Tissue Damage: Inspecting for lacerations, bruises, or hematomas on the scalp or face.
    • Eye Injuries: Checking for signs of trauma such as periorbital ecchymosis (raccoon eyes), subconjunctival hemorrhage, or changes in pupil size and reactivity.
  • Neurological Assessments: Evaluation of cranial nerve function, motor coordination, and reflexes to determine any disruptions caused by the concussion.
  • Cognitive Testing: Assessments of memory, concentration, and problem-solving abilities to gauge the impact on cognitive functions.
  • Symptom Evaluation: Monitoring and documenting symptom progression or resolution over time to guide treatment decisions.
  • Neuroimaging: Reserved for severe symptoms or when structural brain injury is suspected, using CT or MRI scans to identify any brain abnormalities.

Treatment Options

Managing a concussion primarily involves rest and a gradual reintroduction to activities. Key aspects include:

  • Rest: Initial rest from physical and cognitive activities (such as reading, screen time, and schoolwork) to allow the brain to recover.
  • Gradual Return to Activities: Follow a step-by-step approach, known as Graduated Return to Play (GRTP), which includes light aerobic exercise, sport-specific exercises, non-contact training drills, and full-contact practice.
  • Symptom Management: Medications may be used to treat specific symptoms like headaches or sleep disturbances. However, most concussion symptoms resolve with time and proper management.
  • Monitoring: Continuous monitoring by healthcare professionals to track recovery progress and prevent premature return to activities.

Return to Play Protocols

Returning to play after a concussion involves a carefully monitored process to ensure the player has fully recovered. The Graduated Return to Play (GRTP) protocol, as outlined by the Football Association, typically includes six stages:

  1. Symptom-Limited Activity:
    • Goal: Recovery
    • Activity: Daily activities that do not provoke symptoms.
    • Considerations: Avoid physical exertion, heavy mental tasks, and any activity that worsens symptoms.
  2. Light Aerobic Exercise:
    • Goal: Increase heart rate
    • Activity: Light activities like walking or stationary cycling, keeping intensity below 70% maximum predicted heart rate.
    • Considerations: No resistance training or sport-specific activities.
  3. Sport-Specific Exercise:
    • Goal: Add movement
    • Activity: Running drills in football, without any head impact activities.
    • Considerations: Avoid activities that involve potential for head impact or vigorous body contact.
  4. Non-Contact Training Drills:
    • Goal: Exercise, coordination, and cognitive load
    • Activity: More complex training drills, such as passing and ball handling. May start progressive resistance training.
    • Considerations: No head contact; introduction to higher intensity and technical drills.
  5. Full-Contact Practice:
    • Goal: Restore confidence and assess functional skills by coaching staff
    • Activity: Full-contact practice and normal training activities.
    • Considerations: Monitor closely for any recurrence of symptoms. Requires medical clearance before proceeding.
  6. Return to Play:
    • Goal: Full return to competition
    • Activity: Normal game play and full participation in competitive activities.
    • Considerations: Player should be symptom-free and have completed the prior stages without recurrence of symptoms.

After the initial 48 hour rest period, ach stage should last at least 24 hours. If symptoms reappear, the player should drop back to the previous stage and attempt to progress again after a minimum of 24 hours. This protocol helps ensure athletes do not return to play prematurely, thereby reducing the risk of further injury and aligning with the best practices advocated by the Football Association.

The length of the return to play protocol is different for children and adults, a enhanced return to play protocol is also available for players in a professonal environment which requires more in depth assessment and monitoring. Further information on the FA return to play protocols can be found here.

ImPACT Concussion Assessment Tool: Many professional teams use the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) tool to assist in concussion management. This computerised tool evaluates cognitive functions such as attention span, working memory, and reaction time, providing a comprehensive view of the athlete’s cognitive state post-injury.

Conclusion

Concussions in football demand immediate attention and careful management to safeguard players’ health and future well-being. By understanding the causes, recognising symptoms, implementing thorough assessment and treatment protocols, and following strict return-to-play guidelines, we can reduce the risks associated with concussions.

Further Reading

FA 2023 – Guidelines for Managing Concussion

SCAT-6 – Sport Concussion Assessment Tool 6 (SCAT6)

Disclaimer

The information provided in this article is for educational purposes only and should not substitute professional medical advice. Always consult with a qualified healthcare professional for diagnosis, treatment, and personalised recommendations based on your specific condition. Some affiliate links may also be used in this article, these are from products we have specifically selected to display based on our own experience.

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