Concussion And Return To Sport: Is The SCAT-3 Enough?

Concussion is a hot topic in sporting circles at the moment. It has gained a lot of media attention recently, and there has been a HUGE amount of research published on the topic in the last 5 years. In Australia, all of the major professional sporting codes have implemented strict concussion rules whereby a player who has signs and symptoms of a concussion, is not allowed to return to the field of play. The concussed player must then also complete a graduated 7-10 day return to sport (RTS) plan and pass the SCAT-3 concussion test prior to being cleared to RTS.

What I especially love about this hard-line stance, and the amount of research and media attention concussion gets at the professional level, is that grassroots football is also taking notice and implementing widespread change – (see article).

These changes to protect the player and enhance player welfare is a positive step in the right direction for the long term mental health and cognitive health outcomes of the athlete. But what about the protection of the recently concussed player from subsequent musculoskeletal injury?

Should we be doing more than the SCAT-3 to determine the readiness of a player to RTS?

From the outside looking in, the player may appear fine and they may kill the SCAT-3 test. They may have no concussive symptoms such as fogginess or exercise induced headaches. They might be able to recall what day and year it is. They might be able to recall a list of words and recite the months of the year backwards. They might be able to stand on one leg with their eyes closed for 30seconds. They might even be able to recall a sequence of 5 numbers backwards too.

But what about the effect of concussion on the subtlety's of their performance; their reaction time, their decision-making ability, their cognitive attention and their dynamic postural control? These things are also affected after a concussion, but how are they tested? I'm sure these things get screened during the 7-10 day graduates RTS protocol. But maybe they are not, as recent research consistently shows that athletes who have sustained a concussion have a higher risk of sustaining a subsequent injury within the 3-12 months upon RTS. And before I go on, I’m not talking about another concussion, I’m talking about an injury to any part of the body!

• In a cohort of elite European soccer players, it was found that players who sustained a concussion were 50% more likely to sustain a subsequent injury in the next 12 months. They were also 70% more likely to sustain an acute sudden onset injury (eg. ankle sprain), rather than a gradual onset injury (adductor longus tendinopathy) (reference).

• In a cohort of NCAA Division 1 athletes, those that sustained a concussion were 2.5x more likely to sustain a subsequent, acute, non-contact lower limb musculoskeletal injury within 3 months of being cleared to RTS (reference).

• In another study of college athletes, those athletes who sustained a concussion were 2x more likely to sustain a lower limb, musculoskeletal injury in the 6-12 months after being cleared to RTS (reference).

• Lastly, in a cohort of professional rugby union players, those that sustained a concussion were 60% more likely to sustain a subsequent injury in the same playing season. Furthermore, the median time to sustain a subsequent injury was 53 days vs 114 days for non-concussed players (reference).

So it seems from the above literature that not only do we need to protect the players brain and minimise the risk of future concussions, we also need to be doing more to prevent subsequent musculoskeletal injury in concussed players.

And it makes sense that they do get injured at higher rates compared to non-concussed players. Think about it for a second...

A recently concussed player has been cleared to RTS, but their dynamic lower limb control is still impaired compared to prior to their concussion. As a result, they may land from a jump with impaired balance and sprain their ankle.

Another player may have had a heavier head-knock and has had to take 2 weeks off training due to ongoing symptoms of their concussion. So for 2 weeks they trained only at 20% of their usual training loads. All of a sudden at the 2 week mark, they feel normal again, pass the graduated 7-10 day protocol and the SCAT-3, but tear a hamstring in the second game back because their acute to chronic workload ratio is out of the “sweet spot”.

I understand that it’s a very tough area to manage, and each concussed player will have different RTS plans based on many factors. For example, a RTS plan will be very different for a player who has an upcoming grand final vs coming back for an early-season, regular-season match. Also I'm sure age, and previous numbers of concussions will weigh into the decision-making process too.

I don’t actually have any solutions to minimise the risk of subsequent musculoskeletal injury to the concussed athlete, but I do have some questions and would love to open up a discussion with experts in the field:

• Do we need to perform more RTS tests prior to being cleared?

• Should we be performing speed, agility or balance tests routinely with our concussed players, and compare the results to pre-season tests? If so, should be also be testing them again in a fatigued state?

• Does the player need to conduct more conditioning sessions to get them back in the “sweet spot” in regards to acute to chronic workload ratio, particularly if they have had a prolonged absence from training or sport?

• Does the player need to come back through lower grades of sport to get a dose of a slower, less intense game-play?

• Are computer-based neuro-cognitive tests such as CogState Sport or ImPACT routinely conducted and compared to pre-season scores? If not, should they be part of a complete RTS decision-making process?

As I said, I don't necessarily have any answers to these questions but I would love to hear some insight from sport doctors and sports physios who are currently working in the area, and how they manage a player's RTS program and if they consider subsequent injury to the rest of the body. If so, how do they go about reducing the risk of subsequent injury?

I hope you all have enjoyed this blog and I hope that I have provided some insight to the fact that subsequent musculoskeletal injury is a real issue with players who have been recently been concussed. As you are all aware, I am passionate about injury prevention, so please feel free to share this one widely to get a discussion started about how we can try and best manage concussed players and reduce their risk of future sports injury.

For further reading and information regarding concussion, see - http://sma.org.au/resources-advice/concussion/

Cheers! Have a great day!