Novak Djokovic steps onto Centre Court today, aiming for his 8th Wimbledon title and 25th Grand Slam victory, adding another milestone to his illustrious career. However, the past few months have posed significant challenges for the Serbian star.

It’s important to note that the following is anecdotal and depends on accurate reporting, but research suggests that management of head impacts can be just as important for both brain and body.

Could this be a case of a predictable coincidence?

10th 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.”

 

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

 

24th 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.

So what are some of the challenges athletes might face post-concussion?

Balance, coordination, concentration, vision.

Research suggests that more than half of sports-related concussions result in vestibular-ocular motor dysfunction. In an arena where even the smallest advantages can be the difference between winning and losing, the restoration of these components is critical.

With improved oculomotor function facilitating fast and accurate motor movements, this approach to training can even enhance sensorimotor abilities and hand-eye coordination. Could this be one of the secret weapons that elite athletes possess?

Post-concussion rehabilitating oculomotor function needs to be considered.

In a fast-paced sport like tennis, where top players rely on exceptional hand-eye coordination, it is likely to performance-critical.

Ever wondered why you never made it to Wimbledon? Maybe it wasn’t just technique.

4th 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.

 

6th 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.

With evidence showing that following a concussion there is a 2.5 times greater risk of sustaining a musculoskeletal injury, a doubling in the risk of lower limb injuries, and the likelihood of a further concussive event occurring, it becomes clearer that challenges can go far beyond the brain.

Regardless of gender, or even the level competition, the risks are relevant. And this increased risk can persist well beyond the typical period for symptom resolution.

While the exact reasons for the changes in risk aren’t definitively known, one theory suggests that deficits in neuromuscular control following a concussion contribute to this increased risk.

However, one thing that does seem apparent is that many lines of thinking are leading us back towards the importance of multimodal, targeted rehabilitation.

So, what to do?

Waiting for symptom resolution alone is no longer appropriate management.

Whether it be visual training, neuromuscular control, balance or coordination; we need to rehabilitate athletes in the quest to both optimise performance and reduce injury risk.

Unsure where to start?

Your Brain Health Level 2 – Comprehensive Concussion Management will delve into the vast array of multimodal assessment options for immediate an on-going evaluation. A 10 hour online course, it is split into easy to manage modules so you can go at your own pace.

Take a deep dive into concussion management today.

You might not like cricket, but as the song goes, at Your Brain Health we love it!

A game that requires considerable physical characteristics, is also one where the players need to consider balance, visual and cognitive capabilities.

With this in mind, we are delighted to announce a project with Middlesex Cricket that will look to enhance both player welfare and performance development across the Men’s and Women’s game.

The collaboration will incorporate two key components; education and technology.

 

The education will focus on a proactive approach to the management of concussion. Whilst not as big a challenge as seen in a number of sports, the development of scoop shots and the acrobatic feats that are seen in the field mean that there is a possibility. The days of rest and return are now past us, and the word rehabilitate now sits firmly at the centre of the pathway.

 

Pete Waxman, Head of Medical Services said of the partnership:

“Knowledge around concussion management has advanced significantly over the past few years and it is imperative that we are at the forefront of understanding and implementing a proactive approach’.

 

As part of the partnership, the club will also be introducing NeuroFlex; a technology that uses eye and head tracking VR technology to both evaluate and train the performance of the Vestibular Ocular Motor System – crucial for balance, visual acuity and co-ordination. The approach will be part of the club’s multimodal screening programme and, in addition to the enhanced concussion pathway, will be used to develop performance markers across both Middlesex and Sunrisers squads.

 

James Fleming, Head of Athletic Performance feels the technology could support performance gains:

“We have seen new research coming out of the US showing the visual differences in certain baseball players. Our role is to develop the physical skills of our players, and if visual training can be then it is something I am keen on to give us a competitive edge.”

 

David Bartlett of Your Brain Health commented:

“We are committed to developing a global network of clinicians who are dedicated to improving brain health. It is exciting to have formed a partnership with the Sports Science and Medical teams at Lord’s, the Home of Cricket, to be part of that community.”

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Jon Patricios on our latest webinar

“Concussion has evolved into a complex evaluation that mirrors what we do with other sport injuries”

The words of Professor Jon Patricios on the recent Your Brain Health webinar discussing the advancements in concussion care.

But how much of this ‘complex evaluation’ has really dripped down into our day-to-day clinical practise?

As a profession, Physiotherapists pride ourselves on our clinical reasoning skills. Utilising evidenced based practise is fundamental, regardless of setting, to delivering best outcomes for patients.

But when it comes to concussion, are we really abreast with current research?

I certainly wasn’t.

And it seems like I am not the only one. In a recent survey that was completed by 92 people from around the world, it was clear that the lowest levels of confidence were ‘Re-evaluation’ just keeping ‘Rehabilitation’ off the bottom of the list with scores of 52% and 51% respectively,

 

So let’s take a hamstring. There would be subjective questioning, objective testing, and a range of imaging options. Clinical outcome markers would be considered and used as a basis for test and re-test throughout the rehab journey.

For those in the high-performance environment, utilising technologies like force plates and isokinetic testing would form part of our battery of tests. Ensuring a player has covered the appropriate number of metres at varying percentage bands of their max velocity would be a non-negotiable for return to performance.

At a less resourced setting, we wouldn’t feel comfortable unless there was minimal asymmetry on single leg bridging or manual muscle testing. We would conduct a gait analysis, whilst assessing the function of the full posterior chain has become second nature.

 

So how do we mirror that in concussion?

How many MSK clinicians would feel confident to conduct a modified VOMS?

When it comes to assessing the Autonomic system, are we doing a Pittsburgh Sleep Quality Index or Buffalo treadmill test to ensure a return to performance?

We know the effects concussion has on mental health. Are GAD-7 and PHQ-9 undertaken routinely post-injury to support player welfare?

Concussion has evolved into a complex evaluation, but in reality how competent are we in assessing the multiple domains that lead to better clinical reasoning?

 

A physiotherapy colleague recently said to me: “it feels like the world has to catch up with how to assess and manage a concussion. I am a convert”.

And it feels like the job now is to support and educate clinicians to feel more confident and competent in proactively managing a concussion.

A ball thuds against Joe Clarke’s helmet at 89mph.

‘Where are we? I ask. ‘Cardiff’ he replies
‘Who are we playing? Oval Invincibles.
‘Who was bowling at you?’ Muhammed Hasnain
‘Who did we play last week? Southern Brave.
‘How did we get on?’ We lost.
‘How are you feeling?’ Bit of a sore head where it clipped me, but I’ll be ok.

He’s desperate to continue. He’s in the middle of English cricket’s flagship franchise tournament and doesn’t want to miss a ball. He’s one of our best players, so no one in the leadership team will want him to miss a minute.

But Joe doesn’t know what I know. The dangers of a head injury are catastrophic, and they are dangers I’ve witnessed first-hand. I’ve also been in far too many inconclusive debates about whether soreness at the point of impact is a strong enough reason to confirm a concussion diagnosis.

So, it’s decision time.

Concussion or decision to play?

These difficult diagnosis decisions will continue to depend on the experience and knowledge of clinicians to make an on-the-spot call in the sporting setting.

Do they know enough to make those potentially life-saving decisions?

Do they know that the real danger lies in a secondary event on top of an unresolved concussion?

Are they meeting the International Concussion Consensus standards?

I’d put all the money I lost at Cheltenham on some of those answers coming back as a no.

And in the improbable event, they’re a yes. Are the likes of FIFA helping by opposing the use of temporary concussion substitutes in football to allow medics time to assess?

In a lightning-fast landscape, the need for CPD amongst medics on concussion care is as critical as it is urgent to ensure all potential domains of diagnosis are managed optimally.

We know that concussion diagnosis is challenging, with so many factors at play.

We know an incorrect diagnosis can be catastrophic in the short and long term.

So, why are we not prioritising giving clinicians the knowledge they need?

I’m proud of our work to educate and inform, and I’m hopeful that progress can be made.

The recent Concussion and Brain Health Position Statement in Australia advocating that every sports club must have a designated trained concussion officer feels like a progressive and pragmatic step in the right direction.

But, as professionals who understand the hidden dangers, we must work harder to make the world of brain health safer.

People’s lives depend on it.

Your Brain Health proudly announces its sponsorship and support for launching an innovative initiative to transform student-athlete safety in South Africa. The Schools Concussion Programme, a collaborative effort between renowned Sports Medicine expert Professor Jon Patricios and cutting-edge technology NeuroFlex, is poised to redefine how schools safeguard their students’ health, drawing inspiration from professional athlete medical protocols.

This pioneering programme offers a comprehensive suite of support services, including education for key stakeholders, integration with Sports Concussion South Africa, baseline testing, post-concussion assessments conducted by Sports Medicine Physicians, and guidance on return-to-play and return-to-sport protocols.

Leading this initiative is Professor Jon Patricios, a distinguished figure in sports medicine and concussion management. As the director of Sports Concussion South Africa and Waterfall Sports Orthopaedic Surgery in Johannesburg, Professor Patricios brings a wealth of experience to the table. His leadership of the Wits Sport and Health (WiSH) Research Group and key roles in international sports organisations such as World Rugby, UEFA, the NFL and the International Concussion in Sports Group underscores his commitment to advancing athlete welfare.

In collaboration with Your Brain Health, Professor Patricios has spearheaded the development of an innovative education and screening procedure that leverages evidence-based technology through NeuroFlex. This groundbreaking approach enhances post-injury evaluation by providing objective data for targeted interventions, improving outcomes. Moreover, this data facilitates precise monitoring of recovery progress and informs decisions regarding return-to-play and return-to-learn strategies.

“The launch of the new concussion baseline testing and post-concussion assessment protocols signifies a pivotal moment in concussion prevention and management in South Africa,” remarks Professor Patricios.

With the collective expertise of Your Brain Health, NeuroFlex, and Professor Jon Patricios, schools nationwide are equipped to elevate their commitment to the brain health and safety of their student-athletes to unprecedented levels.

Concussion in schools – some important facts you need to know

  • 27,000 concussions occur in the playground annually. 1

  • A history of concussion in the past 12 months was significantly associated with a higher risk of poor academic standing during the same period. 10

  • Young people hospitalized with concussion had 30% higher risk of not reaching the national minimum standards for numeracy, 40% higher risk for reading. 10

  • In years 3-9, hospitalisation with concussion leads to 64% higher risk of not completing year 11 and 75% not completing year 12. 10

  • Concussion leads to an increased risk of mental health issues 9 with to a 2-fold higher risk of suicide. 8

  • Children who have previously suffered a concussion are four times more likely to sustain another concussion. 7

  • Concussion results in a 65% increase in lower limb injury for up to one-year post-concussion. 3

  • Early reporting of symptoms improves outcomes. 5

  • Early physiotherapy interventions lead to faster return to sport. 13

Your Brain Health support

Concussion in Schools resources

Concussion in Schools References

1. Australian Institute of Health and Welfare. (2023). Retrieved 9 June 2023, from https://www.aihw.gov.au/

2. Art, K., Ridenour, C., Durbin, S., Bauer, M., & Hassen-Miller, A. (2023). The effectiveness of physical therapy interventions for athletes post-concussion: A systematic review. International Journal of Sports Physical Therapy, 18(1), 26–38.
3.  Avedesian, J. M., Covassin, T., & Dufek, J. S. (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), 873–889.
4. Broglio, S. P., Harezlak, J., Katz, B., Zhao, S., McAllister, T., McCrea, M., & CARE Consortium Investigators. (2019). Acute Sport Concussion Assessment Optimization: A Prospective Assessment from the CARE Consortium. Sports Medicine , 49(12), 1977–1987.
5. Bunt, S. C., LoBue, C., Hynan, L. S., Didehbani, N., Stokes, M., Miller, S. M., Bell, K., & Cullum, C. M. (2022). Early vs. delayed evaluation and persisting concussion symptoms during recovery in adults. The Clinical Neuropsychologist, 1–18.
6. Ferris, L. M., Kontos, A. P., Eagle, S. R., Elbin, R. J., Clugston, J. R., Ortega, J., & Port, N. L. (2022). Optimizing VOMS for identifying acute concussion in collegiate athletes: Findings from the NCAA-DoD CARE consortium. Vision Research, 200, 108081.

7.van Ierssel, J., Osmond, M., Hamid, J., Sampson, M., & Zemek, R. (2021). What is the risk of recurrent concussion in children and adolescents aged 5–18 years? A systematic review and meta-analysis. British Journal of Sports Medicine, 55(12), 663–669.
8. Fralick, M., Sy, E., Hassan, A., Burke, M. J., Mostofsky, E., & Karsies, T. (2019). Association of Concussion With the Risk of Suicide: A Systematic Review and Meta-analysis. JAMA Neurology, 76(2), 144–151.
9. Ledoux, A.-A., Webster, R. J., Clarke, A. E., Fell, D. B., Knight, B. D., Gardner, W., Cloutier, P., Gray, C., Tuna, M., & Zemek, R. (2022). Risk of Mental Health Problems in Children and Youths Following Concussion. JAMA Network Open, 5(3), e221235.
10. Lystad, R., McMaugh, A., Herkes, G., Browne, G., Badgery-Parker, T., Cameron, C., & Mitchell, R. (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, S36–S37.
11. Memmini, A. K., Popovich, M. J., Schuyten, K. H., Herring, S. A., Scott, K. L., Clugston, J. R., Choe, M. C., Bailey, C. M., Brooks, M. A., Anderson, S. A., McCrea, M. A., Kontos, A. P., Wallace, J. S., Mihalik, J. K. R., Kasamatsu, T. M., McLeod, T. V., Rawlins, M. L. W., Snedden, T. R., Kaplan, M., … Broglio, S. P. (2022). Achieving Consensus Through a Modified Delphi Technique to Create the Post-concussion Collegiate Return-to-Learn Protocol. Sports Medicine . https://doi.org/10.1007/s40279-022-01788-8
12. Quatman-Yates, C. C., Hunter-Giordano, A., Shimamura, K. K., Landel, R., Alsalaheen, B. A., Hanke, T. A., McCulloch, K. L., Altman, R. D., Beattie, P., Berz, K. E., Bley, B., Cecchini, A., Dewitt, J., Ferland, A., Gagnon, I., Gill-Body, K., Kaplan, S., Leddy, J. J., McGrath, S., … Silverberg, N. (2020). Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury. The Journal of Orthopaedic and Sports Physical Therapy, 50(4), CPG1–CPG73.
13. Reid, S. A., Farbenblum, J., & McLeod, S. (2022). Do physical interventions improve outcomes following concussion: a systematic review and meta-analysis? British Journal of Sports Medicine, 56(5), 292–298.
14. Teare-Ketter, A., Ebert, J., & Todd, H. (2023). The Implementation of a Return-to-Play Protocol with Standardized Physical Therapy Referrals in a Collegiate Football Program: PT’s Role in Return-to-Play, A Clinical Commentary. International Journal of Sports Physical Therapy, 18(2), 513–525.
15. Waltzman, D., Daugherty, J., Snedaker, K., Bouton, J., & Wang, D. (2020). Concussion reporting, return to learn, and return to play experiences in a sample of private preparatory high school students. Brain Injury: [BI], 34(9), 1193–1201.

Your Brain Health aims to provide awareness and support around brain health

We provide a baseline screening service and building a network of like-minded health professionals who can provide an equivalent service for concussion assessment and treatments around the globe. Your Brain Health supports an ‘end to end’ solution to concussion management, with expert clinicians, state-of-the-art technology, and education/support.

Baseline Screening

With improved community awareness around the end to end management of concussion, the demand for baseline concussion screening is growing rapidly. Your Brain Health offers efficient and informative multimodal baseline screening for sporting organisations, clubs, and schools. This has already begun around Australia, with plans to expand further. These baseline tests are supported by expert clinicians who can interpret the assessments and provide information and guidance to people’s individual health professionals such as GPs to support optimal recovery in the event of a concussion.

Expert clinicians

We are currently making links with clinicians with an interest in concussion management around the world as part of a professional network. Together we can provide consistent best practice to people who suffer a concussion. In addition, we would like to promote concussion research and link these academics with clinical practitioners. Email us at info@yourbrainhealth.io if you would like to learn more.

State of the art technology is enhancing our assessments.

Your Brain Health is an authorized user of NeuroFlex®, a virtual reality and eye tracking technology used to assess vestibular-ocular function, an important part of our multimodal testing. We are also using Balance Mat to improve our balance assessments and specialised electronic hand reaction time devices. Together with our specialist clinical assessments these technologies enhance our standardised concussion tests and screens (such as the SCAT-6).

Education

Your Brain Health provides a complete update on concussion for health professionals with application of multimodal assessments and treatments for optimal care. If you or your staff are building expertise in concussion, we have both online and face to face courses. Upon completion of the courses, you are eligible to be part of a community of practice through Your Brain Health that provides professional mentorship and support.

Community Awareness

If concussion care is to improve, everyone needs to update their knowledge. Watch this space for further developments in our online courses for parents, teachers, trainers and coaches who would like an update on concussion. Further community education is also provided via face to face or online to assist with developing concussion protocols, ‘return to learn’ and ‘return to play’ plans. For more information, contact us at info@yourbrainhealth.io

Associate Professor James McLoughlin, (Codirector Your Brain Health)