Persistent symptoms

Many people will experience symptoms after a concussion beyond 4 weeks. These are ‘persistent symptoms’ that will require help from health professionals. Up to 25% of people still experience symptoms at 3 months(Polinder et al. 2018), and with those who attend hospital after concussion, nearly 12% of children and 31% of adults experience symptoms beyond 3 months, with more than 50% still report some symptoms at 12 months(Machamer et al. 2022).

We estimate that 36,000 people in Australia

90,000 people in the UK

And 470,000 people in the US will experience persistent symptoms each year!

Academic Performance in schools.

1 in 5 children will suffer a concussion by the age of 10.

• A history of concussion in the past 12 months was significantly associated with a higher risk of poor academic standing during the same period.
• Young people hospitalized with concussion had 30% higher risk of not reaching the national minimum standards for numeracy, 40% higher risk for reading.
• In years 3-9, hospitalisation with concussion leads to 64% higher risk of not completing year 11 and 75% not completing year 12.(Lystad et al. 2022)
• Concussion leads to an increased risk of mental health issues with to a 2-fold higher risk of suicide. (Fralick et al. 2019; Ledoux et al. 2022)
• Children who have previously suffered a concussion are four times more likely to sustain another concussion (Fitzgerald et al. 2022)
• Concussion results in a 65% increase in lower limb injury for up to one-year post-concussion (Avedesian, Covassin, and Dufek 2020)
• There is increasing interest in the role in concussion recovery and sporting performance too.

What about employment?

• Concussion is associated with reduced income. For those who attend emergency, 17% were still not working at 12months, however this improved if support is provided within the first 3 months (Gaudette et al. 2022)

Avedesian, Jason M., Tracey Covassin, and Janet S. Dufek. 2020. “The Influence of Sport-Related Concussion on Lower Extremity Injury Risk: A Review of Current Return-to-Play Practices and Clinical Implications.” International Journal of Exercise Science 13 (3): 873–89.

Daneshvar, Daniel H., Evan S. Nair, Zachary H. Baucom, Abigail Rasch, Bobak Abdolmohammadi, Madeline Uretsky, Nicole Saltiel, et al. 2023. “Leveraging Football Accelerometer Data to Quantify Associations between Repetitive Head Impacts and Chronic Traumatic Encephalopathy in Males.” Nature Communications 14 (1): 3470.

Fitzgerald, Melinda, Jennie Ponsford, Natasha A. Lannin, Terence J. O’Brien, Peter Cameron, D. James Cooper, Nick Rushworth, and Belinda Gabbe. 2022. “AUS-TBI: The Australian Health Informatics Approach to Predict Outcomes and Monitor Intervention Efficacy after Moderate-to-Severe Traumatic Brain Injury.” Neurotrauma Reports 3 (1): 217–23.

Fralick, Michael, Eric Sy, Adiba Hassan, Matthew J. Burke, Elizabeth Mostofsky, and Todd Karsies. 2019. “Association of Concussion With the Risk of Suicide: A Systematic Review and Meta-Analysis.” JAMA Neurology 76 (2): 144–51.

Gaudette, Étienne, Seth A. Seabury, Nancy Temkin, Jason Barber, Anthony M. DiGiorgio, Amy J. Markowitz, Geoffrey T. Manley, and TRACK-TBI Investigators. 2022. “Employment and Economic Outcomes of Participants with Mild Traumatic Brain Injury in the TRACK-TBI Study.” JAMA Network Open 5 (6): e2219444.

Ledoux, Andrée-Anne, Richard J. Webster, Anna E. Clarke, Deshayne B. Fell, Braden D. Knight, William Gardner, Paula Cloutier, Clare Gray, Meltem Tuna, and Roger Zemek. 2022. “Risk of Mental Health Problems in Children and Youths Following Concussion.” JAMA Network Open 5 (3): e221235.

Lystad, R., A. McMaugh, G. Herkes, G. Browne, T. Badgery-Parker, C. Cameron, and R. Mitchell. 2022. “The Impact of Concussion on School Performance in Australian Children: A Population-Based Matched Cohort Study.” Journal of Science and Medicine in Sport / Sports Medicine Australia 25 (November): S36–37.

Machamer, Joan, Nancy Temkin, Sureyya Dikmen, Lindsay D. Nelson, Jason Barber, Phillip Hwang, Kim Boase, et al. 2022. “Symptom Frequency and Persistence in the First Year after Traumatic Brain Injury: A TRACK-TBI Study.” Journal of Neurotrauma 39 (5–6): 358–70.

Polinder, Suzanne, Maryse C. Cnossen, Ruben G. L. Real, Amra Covic, Anastasia Gorbunova, Daphne C. Voormolen, Christina L. Master, Juanita A. Haagsma, Ramon Diaz-Arrastia, and Nicole von Steinbuechel. 2018. “A Multidimensional Approach to Post-Concussion Symptoms in Mild Traumatic Brain Injury.” Frontiers in Neurology 9 (December): 1113.

So, what to look out for?

If we think of what the autonomic nervous system controls these are the things that can go out of kilter. And whilst the following symptoms may be triggered from other systems, it is worth considering

Cardiovascular: Changes and fluctuations in blood pressure or heart rate

Gastrointestinal: Nause, vomiting, bowel disturbances, loss of appetite

Sleep: Insomnia, excessive sleep, ineffective, non-restorative, sleep

Thermoregulation: Changes in body temperature and sweat response

Eyes: Unequal pupil size (anisocoria), sensitivity to light

How to Treat?

I have already touched on some of the possible interventions that could be considered on the road to recovery.

Sometimes the symptoms can be obvious, sometimes subtle but consideration of the autonomic system has a role to play in a multisystemic approach to assessment. As for the treatment here are three things to consider:

Medical – Potentially medication can be used to influence blood pressure and heart rate.

Physical – Graded exercise that respects the current heart rate threshold and any symptom provocation is generally accepted as an appropriate intervention.

Lifestyle – There is often a focus on structuring the loads (physical, mental and emotional) that a patient is placed under. Fatigue management is important and so is recovery optimization.

10^th May 2024 – Novak Djokovic is accidently struck on the head whilst signing autographs when a metal water bottle falls out of a spectator’s bag.

Djokovic reports “That has really impacted me a lot. After that I got medical care, been through half an hour, an hour of nausea, dizziness and blood,” Djokovic said. “I managed to sleep OK. I had headaches. The next day, or yesterday, was pretty fine, so I thought it’s OK. Maybe it is OK, maybe it’s not.”

12^th May 2024 – Djokovic is unexpectantly knocked out of the Italian Open 6-2, 6-3 by 29^th seed Alejandro Tabilo.

Djokovic reported after the game “Today under high stress, it was quite bad – not in terms of pain, but in terms of this balance. Just no coordination. Completely different player from what it was two nights ago.”

24^th May 2024 – Djokovic is knocked out of the Geneva Open by world no. 44 Thomas Machac, beating the world no.1 6-4, 0-6, 6-1.

4^th June 2024 – Djokovic withdraws at the Quarter-Final stage of Roland Garos following victory over  Francisco Cerundolo due to a meniscal injury in his knee.

Djokovic reported that he had felt the knee before the tournament, but a slip in the second set exacerbated the issue.

6^th June 2024 – Djokovic announces on his social media that he has had surgery on his knee having sustained a meniscus tear during his last match.

How common is concussion in football?

While the most frequent injuries in football involve the lower limbs, concussions and other head injuries, though less common, remain a significant concern. Head and neck injuries are rank as the 5th most common type of injury, making up about 5% of all football injuries. Specifically, concussions occur at a rate of approximately 0.5 per 1000 match hours, with an even lower incidence during training sessions.

How do head injuries occur?

Head injuries often happen during aerial challenges. Collisions involving head-to-head contact, elbow-to-head, knee-to-head, foot-to-head, and head-to-ground impacts are the primary culprits.

Are some positions more likely to sustain a concussion?

Yes, defenders are most prone to concussions (33%), followed by midfielders (30%), forwards (24%), and goalkeepers (13%). These injuries are most common in the final and initial 30 minutes of a match, particularly in midfield areas where collisions and aerial duels are frequent.

Is there a difference between the male and female game?

Indeed, studies show that head and neck injuries occur more frequently in female players compared to their male counterparts (17% vs. 14%).

What are the impacts of concussion on football players?

Growing concerns have emerged following studies indicating that former professional footballers are 3.5 times more likely to die from neurodegenerative diseases than the general population. Conditions like dementia, Parkinson’s, motor neuron disease, and Chronic Traumatic Encephalopathy (CTE) are linked to repeated head impacts.

One of the lesser-reported impacts of a concussion is that athletes are reported to have a 2.5 times greater risk of sustaining a subsequent musculoskeletal injury following an initial concussion.

What about concussion substitutes?

The International Football Association Board (IFAB) approved the trial of permanent concussion substitutes in 2021. This measure was implemented in the Premier League and Women’s Super League, with FIFA initially trialling it in international competitions such as the FIFA Club World Cup™.

What else are authorities doing to protect players?

Authorities are continuously working to safeguard players. In 2021, new heading guidelines were introduced by The FA, Premier League, EFL, the PFA and the LMA, recommending that a maximum of 10 higher-force headers are carried out in any training week. In May 2024, the FA have begun phasing out deliberate heading in matches for all grassroots youth football from U7 to U11.

How can Your Brain Health help?

Your Brain Health is dedicated to promoting effective concussion management strategies within the football community. Through education, such as the online Level 1 course “Concussion – Are You Ready?”, players, coaches, and officials can learn to protect themselves and others, ensuring the long-term health and safety of everyone involved in the sport.

Together, by staying informed and proactive, we can ensure that football continues to be a source of joy, unity, and safety for all. Enjoy the matches, support your teams, and let’s keep our players safe on the road to glory at Euro 2024!

How common is concussion in cricket?

Concussions in cricket are less frequent than injuries to the hamstring, lumbar spine, and trunk. However, they still occur. Data indicates an annual concussion incidence of 0.9 per 100 players, or 2.3 males and 2.0 females per 1000 days in the elite game.

In England, during the 2023 domestic season, there were 17 reported concussions, each resulting in an average of 10 days lost per concussion.

How do head impacts occur in cricket?

The primary cause of head impacts in cricket is batters being struck by the ball from fast bowlers, accounting for 67% of such incidents. Other causes include close fielders being hit by the ball, collisions with other players or the boundary fence, the head striking the ground, and wicketkeepers being hit by the bat!

Is there a difference in Men’s and Women’s cricket?

Yes, there is a difference. In elite cricket, concussion rates are 0.4 per 1000 player hours for men and 0.5 for women. Interestingly, 53% of head impacts in women’s matches result in concussions, compared to 32% in men’s matches.

What is the impact of concussion in cricket?

Post-concussion, symptoms like balance issues, impaired concentration, and vision problems can affect performance relating to cricket. Repeated head impacts and concussions are linked to chronic traumatic encephalopathy (CTE), though there are no known cases in cricketers so far.

In 2021, Derbyshire wicketkeeper Harvey Hossein retired from cricket following a series of concussions.

What are the concussion protocols in cricket?

In 2019, the International Cricket Council (ICC) mandated concussion protocols, requiring players to pass a series of assessments before continuing play.

What about concussion substitutes?

Since August 2019, the ICC has allowed concussion substitutes in Test matches. If a player is diagnosed with a concussion, they can be replaced by another player who can fully participate.

Marnus Labuschagne became the first concussion substitute in the history of international cricket, replacing Steve Smith during the Lord’s test of the 2019 Ashes series. He went on to score 59 in the fourth innings to help Australia salvage a draw.

What are the helmet regulations?

Modern cricket helmets are designed to offer enhanced protection but cannot eliminate concussion risk entirely. Helmets must comply with the British Standard BS7928:2013, a mandate from the ICC to improve player safety. The introduction of neck guards has also been developed which have now been mandated by both Cricket Australia and the ECB.

What are the guidelines at an amateur club or school?

While elite teams have trained medical staff to manage head impacts, concussions also occur at the community level. In Australia, 28% of cricket-related hospital admissions were as a result head injuries.

Research indicates that players often lack awareness about guidelines, testing, and helmet regulations, highlighting the need for ongoing education. Australian Guidelines now recommend clubs and schools appoint a concussion officer to manage concussions.

How can Your Brain Health help?

Your Brain Health offers education on concussion, including the online Level 1 course “Concussion – Are You Ready?” This 45-minute course is designed for those at elevated risk of concussion or who wish to become designated concussion officers.

We were delighted that Simon Shepard was joined by Associate Professor James McLoughlin alongside Liz Jemson-Ledger as the latest guests in the final of our 2024 concussion webinar series.

Watch back as we discussed:

* How patients with persistent concussion symptoms often present

* What interventions can have a positive impact on outcomes, including real life case studies

* The importance of early intervention in preventing persistent symptoms

We explored all of this, and much more besides, in what was an interesting and lively update on the current research in concussion care, followed by a live Q&A.

You’re at the top of your game, both mentally and physically, tackling life head-on. Then, bam! You suffer a concussion, and suddenly, everything feels off.

Headaches, dizziness, memory loss – the usual suspects.

But what about those silent saboteurs lurking at the bottom of the SCAT score sheet?

Anxiety, irritability, sadness – the uninvited guests crashing the post-concussion party.

The link between concussions and mental health struggles isn’t a mere coincidence; it’s a well-established fact. Studies reveal that over 65% of concussion survivors battle with depression and anxiety post-injury. And if you’re among the unlucky 20-30% stuck with lingering symptoms for more than two weeks, those odds skyrocket to a staggering 76%.

Now, let’s put things into perspective. The World Health Organization defines mental health as ‘a state of mental well-being, that enables individuals to cope with difficulties in life, understanding their abilities, and working towards the betterment of themselves as well as for the community.’  But what happens when a concussion disrupts this delicate balance?

In adolescents, a history of concussion in the past year increases the risk of suicidal thoughts and actions. Considering that suicide ranks as the second leading cause of death among U.S. teens, and an estimated mind-boggling 33 million children worldwide suffer concussions yearly, the gravity of mental health post-concussion becomes painfully clear.

Mental health matters. And post-concussion, it really matters.

So, what’s going on inside our heads after a knock to the noggin? Let’s explore four potential culprits:

First up, the physical aftermath of a concussion have been proposed to affect the neural mechanisms of mood regulation circuits. When your brain’s emotional control centre takes a hit, it’s no wonder your mental health takes a nosedive.

Secondly, concussions aren’t just about physical pain; they’re a psychological rollercoaster. Factors like social isolation, fear of re-injury, and decreased participation, compounded by concerns over selection or contracts, as well as the dread of letting teammates down, can create a downward spiral into mental health challenges. This combination can morph into a vortex of despair, leading to significant mental health consequences.

Thirdly, your family and personal mental health history might increase your susceptibility to poor mental health post-concussion. It’s like having a genetic predisposition to a double whammy of emotional turmoil.

And let’s not forget the sleep-depression connection. With persistent concussions throwing your sleep regulation out of whack, it’s no surprise that executive function, working memory and processing speed take a hit, dragging your mental health down with them.

Now, here’s the kicker: despite the glaring mental health implications, a whopping 50% of concussions reportedly go undiagnosed. With no definitive test in sight, concussion remains a clinical diagnosis. So, when a patient waltzes into your office with nothing but mental health symptoms, are you equipped to connect the dots?

Tools like GAD-7, PHQ-9, and the Pittsburgh Sleep Quality Index might just hold the key to unlocking the silent suffering of concussion survivors.

Because mental health matters, today and every day.

Muscle capacity, Yo-Yo, Counter movement jump. Tick

Heart, lungs, liver and kidneys. Tick

Gait analysis, technical analysis, biomechanics. Tick

Now the brain.

Such a drag, and something that bores the players. A common response from colleagues who work in sport when discussing concussion baseline testing.

But before resigning our interest let’s consider the why, the what and the how.

Why

In simple terms screening is a reference point, an opportunity to gain some insight.

Is it the best a person can be? No.

Is it how the person is functioning on that particular day – no more no less.

Sporting endeavour can require exceptional musculoskeletal capability, cardiovascular attributes that blow the mind (let alone the lungs), and technical nuances that provide a foundation for consistent performance –understanding some of the data that that underpins these super human feats can be valuable.

Additionally, sport can require cognition, balance, emotional control, eyes that work accurately and at speed.

It makes sense that gleaning a rounded view on these factors may have its uses too.

Whether used as a reference point for comparison in a time of challenge (concussion being one of the more obvious possibilities); or to provide an understanding of functional capabilities (something that can be used to identify areas to be worked on), or simply used as a comparison between peers (one that may provide a layer of insight when it comes to talent identification) the insights gained are there to help.

What

Tests come and tests go, sometimes led by research, sometimes by fashion.

As the brain does so many things, a better baseline test is one that is multimodal.

And the insights are not simply a list of numbers and objective markers. Understanding the subjective and the history is important too. If you know that someone suffers from migraines, or is challenged by poor sleep quality, that can only help if evaluating symptoms post a possible concussive episode.

How is the persons mental health? Do they have any learning challenges? Is ADHD an issue? Further things that help complete a holistic picture.

How

Well, that will be down to you – there are a range of tests that can be used.

Considering the amount of time that is spent looking at muscle balances, joint range, speed, power and technique, it is ironic that looking at the very organ that controls these things is considered such a chore.

Baseline screening

We have removed time and cost limitations by designing fast and cost-effective multimodal screens that focus on key measures monitored and compared at an individual level to inform best care following a concussion.

Education

We have developed a world class programme of three critical courses for anyone involved in concussion management. From parents and teachers through to medical practitioners wanting evidence-based updates. Knowing the most up to date developments saves lives.

Support

We facilitate support by providing opportunities for global networking within our custom designed online community of experts. Knowledge around concussion continues to evolve rapidly from the fields of neurology, vestibular, musculoskeletal and sports rehabilitation. Collaboration and sharing are key to innovation and best practice moving forward.

Technology

We are at leading the way in the selective use of the very best technological advances. From specific software, apps, virtual reality, eye-tracking, balance, movement, heart rate and cognitive testing devices, we know what people need and when.

We were delighted that Millie Bishop was joined by Nicola Hunt alongside Head of Medical and Research at Neuroflex, Dr David Stevens as the latest guests in our 2024 concussion webinar series.

Watch back as we discussed:

* The development and research behind Vestibular-Ocular motor technology

* How the technology works

* How NeuroFlex can be used in practise to improve clinical care and patient outcomes.

We explored all of this, and much more besides, in what was an interesting and lively update on the current research in concussion care, followed by a live Q&A.