Concussion – Don’t be a HEADCASE
With this year’s exhilarating Rugby World Cup now over and the start of the Premiership season now in motion, we’re continuing with the rugby theme this month.
In my last post, I briefly highlighted the importance of identifying and treating concussion appropriately, so this month I’m expanding on the topic, highlighting how to recognise and treat concussion in-line with the current guidelines being implemented by World Rugby and the Rugby Football Union (RFU).
What is concussion?

Concussion is a brain injury caused by a direct blow to the head or to other parts of the body resulting in impulsive forces to the brain. In turn, this causes a release of brain chemicals that temporarily change the way that the brain normally functions and as consequentially can lead to a wide range of symptoms or signs, which can effect:

  • Thinking and remembering
  • Mood and behaviour
  • Level of consciousness
  • A range of physical symptoms.

Signs and symptoms of concussion include:

  • Loss of consciousness
  • Seizure or convulsion
  • Amnesia
  • Headache
  • “Pressure in head”
  • Neck Pain
  • Nausea or vomiting
  • Dizziness
  • Blurred vision
  • Balance problems
  • Sensitivity to light
  • Sensitivity to noise
  • Feeling slowed down
  • Feeling like “in a fog“
  • “Don’t feel right”
  • Difficulty concentrating
  • Difficulty remembering
  • Fatigue or low energy
  • Confusion
  • Drowsiness
  • More emotional
  • Irritability
  • Sadness
  • Nervous or anxious

N.B. Loss of consciousness occurs in only 10% of concussions.

Why is it important to recognise concussion and treat it appropriately?

By continuing to play with concussion, there is an increased risk of:

  • Post-Concussion syndrome
  • Up to 3 times increased risk of further concussion or other injury due to impaired thinking/ reaction time/ balance.
  • Impaired personal and team performance
  • Potential long term neurodegenerative problems
  • Second Impact Syndrome or Death (rare)

How do you manage concussion?

Concussion is managed on a principle of 4 R’s:

Recognise – Identify a mechanism of injury that could result in a concussive event or the display of possible signs and symptoms from the player as described above.

Remove – On identifying a player who you suspect may have concussive symptoms, remove them from play immediately. IF IN DOUBT, SIT THEM OUT.

N.B. Once a player has been removed from the field of play, they MUST NOT return to play that day. They should also remain supervised and not be allowed to drive that day. Best practice advice is to see a medical practitioner as soon as possible on the day of injury, however in reality this is not always possible. Therefore common advice is to go home, remaining under supervision and go to hospital if symptoms worsen. Signs to look for that require immediate referral to a hospital include:

  • Drowsiness when normally awake or cannot be awoken
  • A headache that is getting worse
  • Weakness, numbness or decreases in coordination and balance
  • Repeated vomiting (twice or more) or prolonged nausea
  • Slurred speech, difficulty speaking or understanding
  • Increasing confusion, restlessness or agitation
  • Loss of consciousness
  • Convulsions
  • Clear fluid coming out of ears or nose
  • Deafness in one or both ears
  • Problems with eyesight

Recover – Quite simply, rest. Both mental and physical rest is paramount following concussion. It is reasonable for a student to miss up to a couple of days of academic studies (extended absence is uncommon) as the cognitive effort involved in studying can aggravate symptoms.

Return – Undergo a graduated return to play pathway under the guidance of a medical/ healthcare professional (HCP). It is important to note that this should not be undertaken until you have been cleared by an HCP or doctor and the mandatory minimum rest period has elapsed, or until all symptoms have cleared (whichever is longest).

What is a Graduated Return to Play (GRTP) Pathway?

As the name suggests, the GRTP is a rehabilitation pathway that consists of progressive stages of physical and cognitive exertion enabling the player to gradually and systematically return to play. The stages of this pathway are listed below:

The mandatory rest period currently advised for players on a non-enhanced GRTP pathway (this is where the GRTP is not supervised by a medical practitioner) is 14 days once all symptoms have cleared. While the remaining pathway progressions are the same for everyone, there are some differences in application of the pathway beyond this period:

Adults (anyone over 19 years of age) can progress each stage over 24hr intervals, whereas adolescents and children (anyone aged under 19) must complete the pathway over 48hr intervals.

In the event a player gets a return of their symptoms when undertaking a stage of the GRTP, they should consult with their medical practitioner and repeat the previous stage after a minimum 24/48hrs of symptom-free rest. They could then only progress once they complete that stage symptom-free. The pathway would look as follows:

In summary, concussion is a complex injury that if unidentified or poorly managed can have serious consequences for the injured player. Therefore it is important to follow the 4 R’s of concussion management and undertake a suitable GRTP to ensure a full recovery before returning to competitive, full contact rugby.

An example of a GTRP pathway and process:

Stage 1: REST

Rest for the mandatory minimum period or until symptoms have resolved completely (whichever is longest). It is recommended to seek medical/ HCP clearance to start Stage 2 of the GRTP.

Stage 2: LIGHT AEROBIC EXERCISE

Complete a 20-minute steady-state session on a static bike at up to 70% effort of predicted maximum heart rate. This is calculated as follows: (220 – player’s age) x 0.7.

e.g. A 20 year old would work to a maximum heart rate 140 beats per minute 220- 21 = 200, 200x 0.7 = 140. Therefore a 20 year old should exert no more effort than required to raise their heart rate up to 140bpm (monitored using a heart rate sensor).

Stage 3: SPORT SPECIFIC EXERCISE

Providing the player remains symptom free for 24/48 hours following completion of stage 2, progress and complete the following running session with 2 mins rest between sets:

Warm up with a lap around the pitch and any stretches, activation exercises you may normally do as part of a warm up.

Set 1

Run from the 22m line to the far try line (approx. 80m). Walk from the try line to the nearest 22m line as your recovery period. Repeat x 5.

i.e. Run from the blue cone to the far red cone. Walk back to the nearest blue cone and repeat.

Set 2

Facing the direction you are going to run, perform a lateral shuffle from the touchline to the 5m line. Run from the 22m line to the far try line (approx. 80m).  Walk from the try line to the touchline on the 22m line as your recovery period.  Repeat x 3 in each direction (therefore performing a left and right shuffle).

i.e. Lateral shuffle from the yellow cone to the blue cone, then run from the blue cone to the far red cone.  Walk back to the nearest yellow cone and repeat.

Set 3

Sprint 10m and decelerate in an arc over the next 10m.  Repeat x 3 in each direction.

i.e. Sprint from the blue cone to the pink cone, changing direction to finish at the other pink cone.

Set 4 – the same as Set 1.

Run from the 22m line to the far try line (approx. 80m). Walk from the try line to the nearest 22m line as your recovery period. Repeat x 5.

i.e. Run from the blue cone to the far red cone. Walk back to the nearest blue cone and repeat.

Total session volume, excluding warm up approx. 1.5km. Work up to 85% effort of predicted maximal heart rate.

Stage 4: NON-CONTACT TRAINING DRILLS

Providing the player remains symptom free for 24/48 hours following completion of stage 3, progress and complete the following skills and weights sessions:

Skills session:

Warm up with a lap around the pitch and any stretches, activation exercises you may normally do as part of a warm up. 2mins rest between drills.

Drill 1: Simple box runs

Run around a box grid 3 times in each direction.

Drill 2: Linear 25m sprint, catch and pass x 5 each side (requires 2 more individuals to pass and catch).

Sprinting over 25m, receive a pass from one side and pass off to the other side whilst on the move. Repeat 5 times in each direction.

Drill 3: 10 x 10m box runs – carry pass and catch each cone x 3 each side.

Carrying a ball, perform drill 1. However on this occasion at each cone pass the ball to someone standing in the middle of the grid and catch it back whilst working your way around the grid. Keep this as fluid and dynamic as possible (i.e. Not stopping and starting at each cone)

Drill 4: 10 x 10m box evasive running drill with ball carry x 5 (Requires one other person to act as defender and is strictly a non-contact drill)

Within the boundaries of the same 10 x 10m grid the box runs have been performed, this drill requires the rehabilitating player to carry the ball to one of the corners (random allocation – selected by either the player or defender) with the defender blocking the pathway. The idea here is that the defender lets the player pass, however makes it harder to do by getting in the way. Repeat x 5

Overall session volume approx. 1km. High intensity session, no heart rate monitoring guidance necessary at this stage.

Weights session:

N.B. Exercises are dependent on equipment availability. Perform exercises with a weight you are familiar with and is appropriate for the number of reps and sets.

Warm up as appropriate.

Bench press 10 x 3

Bench pull 10 x 3

Shoulder press 10 x 3

Lat pull downs 10 x 3

Squats 10 x 3

Lunges 10 x 3 each side

Upon completion of this stage, the player must be reviewed by a doctor and cleared to return to contact training.

Stage 5: CONTACT PRACTICE

Providing the player remains symptom free for 24/48 hours following completion of stage 4 and has been medically cleared to progress to stage 5, complete the following contact session:

Tackle a (pillar) bag x 5 e/s

Carry a ball into tackle pad x 5 e/s (moderate intensity)

Carry a ball into tackle pad x 5 e/s (high intensity)

Controlled tackling drill x 5 e/s

Controlled being tackled x 5 e/s

Stage 6: RETURN TO FULL CONTACT RUGBY MATCHES

Upon completion of contact practice, providing the player remains symptom-free for the 24/48hr period thereafter, they are considered fit to return to play full-contact rugby (Stage 6).

References:

England Rugby (2015) Concussion- Headcase. [http://www.englandrugby.com/my-rugby/players/player-health/concussion-headcase/]

World Rugby (2015) Player Welfare: Concussion. [http://playerwelfare.worldrugby.org/concussion]

Paul is a top rugby physiotherapist who splits his time between professional rugby at Wasps RFC and at Complete Physio. You can find him at our Angel clinic (www.complete-physio.co.uk/clinics/angel). To make an appointment, call 020 7482 3875 or email paul@complete-physio.co.uk.