Early recognition and management of concussion ‘critical’

Morgan Liotta

11/03/2021 4:51:00 PM

High-profile injuries and emerging research is helping to chart appropriate assessment and management of concussion and its long-term impacts.

Graphic of person's head
Research is revealing greater long-term impacts linked to concussion.

Repeat head injury, concussion and diagnosis of chronic traumatic encephalopathy (CTE) particularly in professional sports players, has recently generated a greater focus on the long-term effects on the brain.
Diagnosis of CTE is met with some uncertainty, given it can only be diagnosed post-mortem.
But formal investigations into the suicides of Australian Football League (AFL) players come following links between head injury and subsequent long-term mental health issues, with some players pre-empting a donation of their brain for CTE research after they die.
Many AFL players have been forced to retire following repeated bouts of concussion, a narrative mirrored in the American National Football League (NFL), where extensive research into traumatic head injury has been carried out.
A 2017 study found that 87% out of a sample of 202 former NFL players received a post-mortem diagnosis of CTE.
‘We still don’t know why some people’s symptoms persist for many months, sometimes even years. But we suspect psychology may play a role,’ La Trobe University School of Allied Health Associate Professor Alan Pearce previously said.
‘We understand how to diagnose and treat concussion in the short term, but we are yet to uncover how to best assist people with persistent post-concussion symptoms to return to leading productive lives.’
Meanwhile, more and more women are taking up contact sports such as AFLW and studies are now suggesting that women are more likely to sustain a sports-related concussion, and have more severe, long-lasting symptoms.
Yet, research into concussion has also only started to gain traction within the past two decades, and even then most clinical trials have predominantly focused on men over women.
Two more recent US studies have also helped reveal more information around concussion
The Journal of Neurotrauma found that it is linked to many health risks – both short- and long-term – including depression, diabetes, hypertension and other neurological disorders such as stroke.
The second study, published in The Journal of Head Trauma Rehabilitation examined self-paced physical and cognitive activity of a small cohort of young people aged 11–17 years during the first week after sustaining a concussion.
It found that alone, activity neither sped nor delayed recovery, indicating that children and young people with concussion ‘may have some flexibility to determine their own activity levels during recovery’.
‘This study is the first to objectively measure self-paced cognitive activity during the first week post-injury,’ the authors wrote.
‘While increased physical and cognitive activity may help reduce post-concussion symptoms, reduced symptoms may also lead to increased physical and cognitive activity levels, highlighting the need for further research to better understand this bi-directional relationship.’ 
To help GPs and emergency medicine doctors effectively assess and manage concussion, the Australasian College of Sport and Exercise Physicians (ACEP) is hosting a free webinar, approved for Continuing Professional Development (CPD) points by the RACGP, Australian College of Rural and Remote Medicine and Australasian College for Emergency Medicine.
The panel of presenters consists of sports doctors and Fellows of ACEP.
Among the presenters is Dr Martin Raftery, Chief Medical Officer at World Rugby 2011­–20 and Medical Director of FPES Australia.
He told newsGP that the management and prevention of head injuries is ‘extremely important’ for GPs to have on their radar.
‘We hear about concussion and the effects of concussion in elite sportspeople, but concussion in community sport will be the type of sport-related concussion GPs are most likely to deal with,’ he said.
‘However, it should be noted that research confirms that only 20% of head injuries presenting to accident and emergency departments are related to sport – meaning head injuries are a societal problem.
‘It is critical that we manage concussion in and out of sport appropriately, as the first step in reducing any potential long-term issues.

‘The presence of CTE is hotly debated in the media as well as in the scientific community, and irrespective of this debate, early recognition and management of concussion is critical if we are to prevent long-term problems associated with head injuries.’
The webinar will cover best approaches to assessing concussion in the general practice and hospital setting.
‘The key areas covered include an outline of the symptoms and signs associated with a concussion, a structured approach to assessing concussion, [as well as] how to deliver management advice to the concussed patient,’ Dr Raftery said.
‘We expect that GPs will learn how to [better] recognise and manage concussion, and also become confident in managing a return to sport and return to learn.’
The webinar covers concussion in people of all ages and makes specific reference to return-to-sport timelines in children and adults.
A case study of a 17-year-old will walk participants through the process from immediate presentation, same-day and follow-up care, and what doctors might advise the patient to do. Prior to which, each of these stages is covered in more detail – with the case study an application of these learnings. 
Pre-learning for the webinar also links to both the adult and child Sport Concussion Assessment Tool, fifth edition (SCAT-5).
The SCAT-5 is recognised as the standardised tool in for assessing sports players aged 13 years and over. For children, the Child SCAT-5 is recommended, as well as the recently developed first national head injury guidelines for children.
With more athletes sustaining head injury and long-lasting related issues, Dr Raftery said the webinar is timely.
‘The goal of this webinar is to provide a practical approach to the recognition and management of concussion for GPs,’ he said.
‘The GP is on the frontline when it comes to head injuries, and improving their knowledge in this area will improve outcomes from head injuries for all patients in every walk of life.’
Webinar dates run from 16 March to 1 July 2021, with rotating presenters. Registration is available online.
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