Rugby & Concussion: An update from Amsterdam Consensus
Dr Jamie Kearns

I am going to be giving an update on concussion in relation to the Amsterdam Consensus meeting in October of 2022.

This was a group of world-renowned experts both clinicians and researchers who came together to discuss the research that has been done in concussion over the last 4 to 5 years and try to collate the most up to date research in regards to both concussion identification, management and long-term outcomes. The publication of this research was released in July of 2023 in the British journal of Sports and Exercise Medicine.

It is important to know that the definition doesn’t exactly have to be a head impact, a force that can be transmitted to the head from a knock to the body or neck can also cause a concussive episode. It’s important that with regards to that that you are not waiting for it specifically to be a head impact and it’s also important to know that symptoms may be delayed on set while the majority of symptoms may be presented immediately they may also evolve over the next few days particularly over the next 72 hours after a head injury episode to be aware that not all players or individuals will present symptoms directly after the episode. To note no abnormality is seen on standard scans or imaging so things like CT Brains or MRI Brains would be normal after a concussion and these tools or devices are used to out rule any serious pathology, particularly something like a brain bleed or something of more serious concern but unfortunately the current technology won’t be able to diagnose a concussion from a scan or an imaging test that you have done.

The range of symptoms do not always involve loss of consciousness and I think that is important to be aware of as it can be less than 25 percent of concussions that actually contain a loss of consciousness so you shouldn’t be waiting for a loss of consciousness in order to be checked for a concussion. It’s really important that people do understand that you don’t have to be knocked out to have a concussion and that’s an important message to be aware of and I think the message has been acknowledged overtime and it’s good to see that people are much more aware of this. What happens is, there is a cascade of events that happen internally that we can’t specifically where the neurotransmitters in the brains energy systems are affected and that’s why the signs and symptoms can evolve overtime and lead to different presentation of symptoms and indeed at different time points.

In the context of Irish Rugby, I’m making this relevant to us in our presentation. The Irish study which has been taking part in Limerick since 2016 would look at the rates of injury across amateur rugby and schools senior cup. Within that, it has been noted that over every season concussion has been noted to be the highest injury in terms of prevalence and incidents and likewise in school’s rugby concussion would account for approximately 14% of all injuries within the AAL game its somewhere between 11% and 14% and slightly higher in the women’s game between 10% and 19% depending on the season. Certainly, this is a common injury and it is something we need to be aware of and well clued in on in terms of managing it and also be up to date with the research. The average length of time off from a concussion within the amateur game is approximately 27 days for men and about 51 days for women so certainly within the amateur game there seems to be a delayed return to play within the female game and whether that’s down to lack of access to medical care or even prolonged symptoms is something that needs to be investigated further but overall the research would suggest that there is a difference in return to play between males and females in sport in other settings. That might be a level of reflection on the amount of medical care that maybe people are getting in the female game and the delay in diagnosis is what might be causing this. In school boys the average level of duration off is about 30 days and again some of that is going to be mandated by the IRFU with regard to their mandatory stand down of 23 days for u18’s and 21 days for the over 18’s in the amateur game.

The key part in terms of education and to manage concussion really is about the recognition and with regard to that one of the newest tools that was developed within the consensus meetings was the Concussion Recognition Tool 6. This is a specific tool used for non-medical personnel for example, those attending a game whether it be a coach, parent or even a medically trained assistant at a game. Within this there is a framework of different things that are important to look at and one of the most important things is at the start point and it is the red flags or things that we look for which may suggest something more serious than a concussive episode or would warrant further immediate medical attention. Within that, you will see the middle section has a red flag section of things that would warrant the contact of the emergency services. On the following page, it has a breakdown of things that would help us to identify a concussion after the red flags have been ruled out. Within that, they would look for things such as visual clues or things that the injured individual might describe in terms of loss of consciousness, loss of balance or things like a brief seizure or unsteadiness. After that, it is then a question of what the individual may present with or the symptoms that they report. In this situation they might describe some physical symptoms, emotional symptoms or even changes in their cognition or thinking. Sometimes, people may present immediate symptoms of confusion or disorientation or potentially they may not be aware of their surroundings. Anyone presenting immediate symptoms particularly headache or dizziness on the pitch should be removed straight away as these are people who tend to have prolonged symptoms if it is not recognised. Finally, they give an advice section to give to someone with a suspected concussion if they are not being transferred to the emergency department for further onward referral. These should be medically assessed before any return to play, they shouldn’t be left alone in the first 3 hours as this is a time period where worsening of symptoms might warrant medical attention. They shouldn’t be on their own and again use recreational drugs that may confuse a situation as it may lead to altered cognition and presentation which would then loose the presentation of the individual if they were to have further, more serious underlying conditions. Again, they shouldn’t drive a motor vehicle until clear to do as there is a concern about a post injury seizure and obviously that could end in a serious road collision or accident if someone was to drive in that situation.

The number one thing that can be done for a person in this certain situation is to remove them from play and this should be common across all sports games. The saying is “IF IN DOUBT SIT THEM OUT”. The reason for this obviously is to prevent any further episode so people who continue to play with symptoms of a concussion will go onto develop a much more severe concussion if they were to develop a second episode which will lead to much more prolonged symptoms. Certainly, by removing them from a second injury you would reduce the severity of a concussive episode or indeed shorten the duration of symptoms post that injury. A serious thing to look out for is something called 2^nd impact syndrome. This is where someone received a second injury or a 2^nd concussive episode or head injury that there can be rarely an episode of significant brain swelling which can be serious and lead to seizures and also in some places can be fatal. This is obviously a very important thing to recognise and prevent from happening.

With regards to those who have been diagnosed with a suspected concussion particularly within an amateur setting where there hasn’t been a medical input it is definitely been shown that the earlier someone receives medical attention after a concussive episode that it shortens the duration of that episode. Within the medical setting, whether that be with their primary care physician or sports physician or someone who specialises in concussion that the player should be re-evaluated. Once it’s past 72 hours they have a device called the SCOAT 6 which is the Sports Concussion Office Assessment Tool. There is also a child-based version of this for those 12 and under. This is a multi-modal assessment which involves a symptom checklist, neuro-cognitive testing, some balance assessment, assessment of  vestibular function, autonomics neuro-system assessment and also a neurological and vital assessment to out rule any other serious pathology’s that need to be treated prior to managing the concussive episode. It does incorporate screening for underlying issues such as anxiety and depression and these are not mandatory but maybe optional if the person was to present with prolonged symptoms that maybe are being complicated by the development of maybe some anxiety symptoms or some depressive symptoms that can commonly occur after a concussion but also if present prior to a concussion it can lead to more prolonged symptoms. As I said this is best used within 72 hours to 30 days post injury and can be used within the setting of a primary carer. It takes a bit of time to do but it can give us a very good direction towards whether or not treatment needs to be directed in terms of rehabilitation this can help guide that.

With regards to the rehabilitation of concussive episodes I think its important to be aware that most episodes are self-limiting and that will resolve spontaneously on their own. It is important to be aware though that 30% of people will experience Post Concussive Symptoms (PPCS) or what are now called persisting symptoms and there is a slightly higher rate in those under the age of 18 as they will tend to take a little bit longer to resolve from symptoms. Prolonged rest is no longer recommended and I think this is an important message to us in terms of a return to activity after a concussive episode and it has been shown that those that were prescribed prolonged rest actually take longer to recover and that a self-limited and self-directed return to activities of daily living within the first 24-48 hours is actually important. Allowing people to do normal low-level activity in terms of walking and activities of daily living but maybe reducing screen time for the first 48 hours has been shown to reduce the persistence of symptoms. After that 48-hour period I think it is important then to encourage a return to exercise in a very graduated and personalised way. Within that, its worthwhile aiming for a low level of activity with up to (if its not prescribed) 50% of what we would consider the maximal heart rate that produces symptoms. If that is something that you’re not prescribed by a physician or a physiotherapist then aiming for about 50% of your heart rate in terms of a low-level 15-20 minutes on a bike is a helpful starting point. This will then be progressed on as symptoms are tolerated and you can then progress on to a running based activity over the following 24-48 hours. We’re happy that as long as there is only a mild exacerbation of symptoms then it is ok to progress on. Within a mild exacerbation that would really be graded as something where it’s approximately a 1 to 2 out of 10 in severity. As long as the symptoms are not increasing above 1 or 2 out of 10 and are resolving quite quickly then we are happy for people to progress on in their rehabilitation to allow them to return to activity as this has been shown to be the best treatment in terms of reducing the prolonged nature of symptoms after a concussive episode.

Within that return and rehabilitation, this is a simple guide that would guide the staged graduated progressions. Within it you can see the first few days so step 1 is a symptom-limited activity that don’t exacerbate symptoms and then generally progressing onto that light exercise of up to 50/55% of a max heart rate. That can simply be calculated by a simple formula which is 220 minus age. Within that, that might be a stationary bike and that’s usually quite beneficial as it prevents any head movement and then progressing onto similar maybe moderate activity and then increasing heart rate running based activity. The first light blue section is safe to progress on without the need of medical clearance and this is really designed to help to return to activity which is both helpful but also good for progression back to incorporation in training and sport. The second darker blue section can be used after somebody has been cleared to return to maybe a training-based activity. The upper section would be one were there is a low risk of any further injury and there is no risk of any head impact at that stage. Whereas, once you progress into that lower section that is when you are at risk of a subsequent head injury starts to increase and that’s why we delay that bit until medical clearance.

Important for students and even those returning to work is this return to learn process and again this is individualised and the majority of people will have returned to full learning at approximately 10 days. However, it is important to be aware that up to 40% of individuals may have some academic dysfunction or disability when it comes back to learning in terms of struggling in the school room or struggling in the classroom in the first couple of days after a concussive episode and by not recognising that it can lead to prolonged symptoms again. Again, these are really the people who would struggle in this situation and those with the greater initial symptom burden so those who present with maybe very severe symptoms on day 2 to 3 after a concussive episode they are the ones who maybe are more likely to benefit from a personalised approach to their return to learn where maybe there are some modifications around the length of time that person goes back to school or maybe reducing the amount of homework in the first 24-48 hours will help with the return to activity and the return to normal learning.

With regards to the return to sport, the average time to symptom free is approximately 14 days and the return to sport is approximately 19 days for most athletes. Again, this does intend to vary between males and females but there is a slightly longer duration for those under 18 up to 16 days versus 15 days for those over 18. Factors that would increase that time tend to be that delayed removal from a game like someone who suffers an injury within a game and then plays on with persistent symptoms. As mentioned earlier, delayed access to a healthcare professional can also be associated with the delay in the return to play and also initial higher symptom burden and severity of symptoms at the time of presentation has consistently been shown to predict how long someone will take to return to play.

With regards to onward referral those who are struggling with persistent symptoms those who are experiencing recurrent episodes of concussion and those who are being affected with a complicated mood disorder like anxiety symptoms or a low mood even complications with sleep or reluctance to engage in activity and those with parental concern or the athlete themselves is concerned should really be referred onto a specialist who look after individuals with concussive episodes and would understand the management going forward.

One of the new areas that they have looked at within the consensus statement is the ability to reduce the number of concussive episodes. There is increasing evidence for the use of mouth guards and this would’ve come from Ice Hockey within Canada but certainly some of the previous studies in rugby would suggest while non-statistically significant that the use of mouth guards has shown to be beneficial in reducing the number of concussive episodes. Other ways we can look at that in terms of policy change and obviously the IRFU have brought in the reduction in tackle height which has been shown both in France and abroad that has reduced the overall incidence of concussion. The reduction of contact within practice sessions has been known to reduce the episode of concussion within the NFL and has been taken across to rugby where the level of contact has been reduced in training to prevent the number of concussive episodes in training and that is evident in the statistics in both the Irish study which shows that the number of concussive episodes within training is actually very low and the majority of concussive episodes seems to happen within the match setting.

Another thing that has been shown to reduce a number of concussive episodes is a neuromuscular training warm up which was shown in England to reduce concussive episodes and all injuries and this is something that can be co-ordinated through the strength and conditioning coaches prior to a training session. What is also important is the early identification of a concussive episode to reduce any recurrent episodes as early identification management reduces the severity of the subsequent episode and how long that person would take to return to play. Again, early identification, recognising and removing that individual is probably key to preventing further episodes.

Finally, a question we get asked is when should someone consider not playing contact sport anymore? This isn’t specific to rugby but it can be across all sports. I think while there is no specific set guidelines and no specific evidence to guide this in terms of factors we would look at people who maybe have had prolonged symptoms or persisting symptoms after a concussive episode. Obviously, if you have neurological abnormalities on a physical examination then them people should not be cleared to return to rugby until they are fully assessed. Any deficits on neuropsychological testing, despite time away from contact sports again would suggest a need for re-assessment. It should really be a multi-disciplinary approach where the person is seen by a number of specialists who work in concussive management who would be able to guide the decision around returning to contact sport or avoiding contact sport. One of the things we look at is concussions that are evident after maybe a lower impact like a transmitted force in concussion that we maybe previously wouldn’t have. Anything that has structural abnormalities again would be warranted further neurosurgical or neurological review and these are all things that need to be taken into consideration. It should obviously be balanced by the benefit of participation in activity and physical activity which are all shown to reduce the incidents of both mood and neurological disorders as well as the benefit of team-based sport for reducing the likelihood of anxiety and depression and isolation that can occur when these are removed.

In conclusion, it’s important to re-emphasise that early recognition reduces the severity of concussive episodes. Avoid strict rest as this will only prolong symptoms and the earlier someone can return to activity then the shorter the duration of symptoms will be regardless if they return to play. Using exercise in a prescribed way and a progressive manner is also beneficial as treatment for a concussion. Early referral is warranted and will reduce on going symptoms if the person is not responding to the usual care.

POTS, I assume she means Postural Orthostatic Tachycardia Syndrome which is a sympathetic overdrive and it happens after head injuries, it can also happen after other injuries but in essence this is a disturbance of the autonomic nervous system and this is a recognised occurrence in concussive episodes.

I think it was actually under recognised but is now on the standard concussion assessment tool, particularly the office-based tool. This is a recognised complication that can occur but if it has been managed well and symptoms have been resolved then that’s a really positive outcome because a lot of times this is under recognised. It’s a positive outcome because it has been recognised and managed well.

In relation to the second concussion, I think it depends where you talk to people but I suppose the biggest risk of having a complicated concussion is having a previous concussion. Generally, what you find is the biggest risk or things I ask people to look out for is either a concussion is taking a long time to resolve or one that happening with less and less impact. Let’s say someone is having a recurring concussion and it’s only from a blow to the body or their holding a tackle bag and they get a concussion versus a significant trauma. There is some groups who will say that once you have been rehabilitated fully and symptoms have settled from a concussion and everything is clear there is no increased risk of concussion. Again, that is possibly debateable because I think there is always some risk but you have to balance that out versus the desire to continue playing a sport, the social inclusion and the benefit from a physical point of view. All of those things are positive effects of playing rugby and playing sport. I suppose, it’s a balance, there is always some elements of risk but it is just balancing out what the benefit is and then making an informed decision that way.

I think this is where the new concussion guidelines give a lot more direction and give people more control about what they can and can’t do and what they should and shouldn’t do and probably the key bit is the early introduction of exercise after 24-48 hours below a level that brings on your symptoms so actually getting out.

Firstly, not staying in a dark room for 24-48 hours would be the previous advice so obviously reducing screen time in the first 1 or 2 days will reduce symptoms and the severity of symptoms but after that resuming activity is tolerated, getting out meeting people, simple exercise in the form of walking and then a symptom limited return to activity maybe on a bike and building it up to a level by going through steps as in the return to play criteria.

What has also been shown to reduce the risk of a worse concussion or prolonged symptoms is an early interaction with a qualified professional, the people who see a physician early do better. They don’t tend to have prolonged symptoms and get guided towards the right rehabilitation for those people that need it early.

UPMC have a concussion network established around Ireland at the minute, so there are available clinicians in lots of the country now covering a large part. From Dublin across to the South, Southwest, Midwest and North as well.There is certainly good access if you go onto the UPMC website and look at the concussion network.

There is an availability of clinicians there who have access to neurocognitive testing, neuropsychological testing, online impact testing and then also specialist physiotherapy and vestibular rehabilitation so there is a good network there if people want to look on that as a guideline for maybe players that need assistance with complicated concussion.

Without seeing the person or knowing the situation, I think the ability to weight bear after 3-4 days and get the swelling down is usually the key bit. Once a player in our care in the rugby club, as you can imagine we would look at maybe some loaded exercises in terms of their ability to do a calf raise or do a weighted calf raise and then we have a guide in terms of our return to run which will involve a number of hopping exercises before introducing some straight line running and changes in direction. Once that is clear in the person then we would be happy to re-introduce them back into training.

I think the important bit with the common ankle sprain is that a lot of people will suffer from on going symptoms and recurring ankle sprains. They are the ones that can cause problems long term, I think whatever about the initial injury it’s the recurrent injury that we have to watch out for as we can cause serious damage to the ankle joint if they are not managed properly. They would be the ones where if you are getting someone with recurring ankle sprains it would be worth linking them with a physiotherapist or a sports medicine doctor just to get a proper assessment in that situation.

In relation to the second part of the question I think it’s really just important to be able to walk and weight bear pain free, being able to hop both forwardly and laterally you want them to be clear and then introduce some straight line running and change of direction. If they are all clear then I think there is no issue. Again, once someone has suffered an ankle sprain we would normally strap their ankle for a period of time afterwards because of their risk to injury.