Sport and brain injury: Building the connection

The link between repeated concussions and permanent brain injury has been gaining traction in Australia over the past few years.
 
AFL players have retired prematurely due to concerns over the potential long-term effects, while a class action lawsuit has also been threatened.
 
Australian sports players are now pledging to donate their brains to research, and former rugby league players have been diagnosed with chronic traumatic encephalopathy (CTE) – a degenerative brain disease found in some people with a history of repetitive brain trauma.
 
CTE is commonly linked with American football players, with a JAMA study revealing a high prevalence of the condition among deceased players. Now that CTE is being identified in Australian sports players, the condition is receiving more attention.
 
Dr Gill Cowen, sports doctor and Chair of the RACGP Specific Interests Sport and Exercise Medicine network, is involved in the Concussion REcovery STudy (CREST) at Curtin University and Perron Institute.
 
The study aims to predict outcomes following mild traumatic brain injury, and is seeking participation from patients who have been involved in an incident likely to lead to a traumatic brain injury, with accompanying neurological signs and symptoms that can be attributed to that injury.
 
Dr Cowen believes that ongoing research is necessary to better understand the prevalence of CTE and its association with head trauma in sport.
 
‘Essentially, further research is needed to control for confounding variables and improve our understanding of CTE and any links to concussion,’ she told newsGP.
 
‘What is ideally needed is a national concussion registry where all mild traumatic brain injuries are recorded and the patients then followed longitudinally until time of death when a post-mortem examination can be made.
 
‘This will enable the identification of confounding factors such as alcohol use, drug use and other neurological and psychiatric diagnoses.’
 
GPs are part of that monitoring process, according to Dr Cowen, starting with the initial assessment to confirm diagnosis.
 
‘Concussion is a clinical diagnosis and should be made by a doctor – the GP is in the ideal position to make this diagnosis, often already having knowledge of the patient’s past medical history, and pre-concussion personality and behaviour,’ she said.
 
For assessment of sports-related concussions, Dr Cowen suggests taking a history from the player, a witness to the event (if possible), as well as looking for pre-existing factors which may suggest the patient is likely to be slow to recover, such as previous concussions, anxiety, depression, learning difficulties and migraines.
 
‘The GP [can] then assesses the patient’s symptoms from time of injury and current symptoms, before excluding focal neurology, assessing memory, cervical spine and balance, ideally with the help of a SCAT–5 [Sport Concussion Assessment Tool – 5th edition],’ Dr Cowen explained.
 
‘This assessment then allows serial follow up of the patient to monitor their improvement with cognitive and physical rest, followed by a graded and paced return to normal activity. It also allows for identification of an alternative diagnosis to concussion.’
 
Dr Gill Cowen believes that further research into CTE is needed to better understand the link with sports-related head injuries.

Dr Cowen also recommends an assessment by a neurologist with a specific interest in concussive head injuries in cases where patients do not recover within expected time frames, and GPs can refer these patients for neuropsychological assessment or vestibulo-ocular physiotherapy, depending upon where their deficits lie.
 
‘Approximately 90% of adults will recover within an expected 10–14 day period. The majority of children and adolescents recover by four weeks,’ she said.
 
For patients who are slow to improve outside the expected time frames, Dr Cowen has found they often demonstrate cognitive difficulties, vestibular and/or ocular dysfunction, headache-migraine symptoms, anxiety-mood disorders and fatigue.
 
‘It has been demonstrated that autonomic dysfunction, and vertibulo-occular and cervicogenic dysfunction are also seen in these patients,’ she said.
 
Some of the short-term effects of concussion or other brain injury can range from dizziness, headaches, nausea and vomiting, fogginess, neck pain, confusion, memory impairment, poor sleep, increased emotions, poor balance and unsteadiness.
 
Adverse long-term effects are now becoming more discernible, and Dr Cowen cites current literature that more research is needed to better understand these effects on cognitive impairment and mental health issues.

There are preventive measures that sports players can take following a head injury under guidance from their doctor, to help avoid some of these long-term adverse effects.
 
‘Current best practice involves an initial period of both cognitive and physical rest followed by a graded paced return to learning, activity, then sport,’ Dr Cowen said.
 
‘Initially, screen time should be avoided, and cognitive rest is crucial. Return to work or studies should be gradual with initial short periods of cognitive activity interspersed with rest time. These periods are increased over subsequent days providing symptoms do not return or worsen.
 
‘After an initial period of rest from physical activity it is recommended that gentle activity is recommenced, increased in increments every few days, providing symptoms are not exacerbated.’
 
Dr Cowen also advises her patients not return to sport until they are cleared as asymptomatic in full non-contact training, and after they have returned to normal cognitive and physical activities of daily living.
 
She is hopeful that best practice guidelines will continue to evolve in the area of CTE prevention and the link to sports-related head injury, and offers some advice in the meantime.

‘The best advice we can give our patients regarding potential concussive episodes and queries regarding return to play is, “If in doubt, sit them out” until full assessment is carried out by a doctor,’ she said.

concussion CTE head injury mental health sports medicine