Introduction
Concussions in sports have become a serious issue. It affects the brain’s ability to operate and comprehend information temporarily.[1] A concussion occurs when the brain moves rapidly back and forth inside the skull as a result of a force. This might happen as a result of a direct blow or a strike to the body that causes the head to rotate fast.[2] After a concussion, a patient may experience difficulties with balance and coordination, memory, and speech. It impacts all athletes; from professional athletes to minor leaguers, and it occurs in a variety of sports.[3]
In this view, it becomes very important to discuss the concussion protocol guidelines among various sports. The scope of discussion in this article is limited to discussing concussion guidelines issued by the International Cricket Council (ICC), National Basketball Association (NBA), National Football League (NFL), and National Hockey League (NHL).
The Berlin Concussion Consensus: Setting a Benchmark
The 2017 Berlin Concussion Consensus sets the benchmark[4] for the current best practice in concussion prevention.[5] It also provides the world of sports with a global overview of management and diagnosis of concussion in sports which is based on expert consensus and systematic reviews.[6]
All the sports across the world, for instance, Australian football, American football, basketball, along with many others have different rules and settings which is why there is no uniformity on the concussion protocol and each sport sets out its own regulatory environment. The role of the Berlin Consensus Statement becomes more prominent here as it facilitates uniform and superior management and diagnosis along with improving awareness and imparting education regarding the same.[7]
The ICC Guidelines on Concussion Management
The International Cricket Council’s (ICC) guidelines were issued in April 2018 and are based on the Berlin Consensus Statement 2017. The guidelines are discussed as follows:
Raising awareness
As per the guidelines, all the officials, support staff, and players must be aware of the potential risks that concussion can cause to a player’s health.[8] Further, everyone including the ICC and member federations have the responsibility to raise awareness of the risks that are associated with a head trauma.[9]
Diagnosing Concussion
In the event of a concussion, the primary diagnoser is always the doctor and it is the doctor’s final decision that is taken into account. This diagnosis can also be called on-field assessment. Signs and/or symptoms of acute neurological malfunction, disturbed mental state, or cognitive impairment are used to make the diagnosis.
The matter of a sports player suffering from symptoms after an injury and recovery time is very subjective as both things are dependent on what element of the function of the brain has been disrupted. [10]
Baseline Testing
Baseline neurophysiological testing can be used as a secondary diagnoser. It can also be called an off-field assessment. For undertaking such an assessment, Sports Concussion Assessment Tool 5 (SCAT5), cognitive screening tools using pen and paper, or online systems like ImPACT and Cogsport can be used.
The ICC guidelines recommend this testing only for elite sports. There are frequent cases where symptoms of concussion start to appear at a later stage. As a result, a definitive diagnosis can only be determined once a delayed onset concussion has been ruled out at around 48 hours following the injury.[11]
When it comes to community-level sports, there are very few chances of being a medical practitioner there.[12] Thus, the only option that remains in case of even a slight possibility of concussion is that of removing the player and referring him/her to a doctor.[13]
Possible Conditions during Concussion Assessment and their Management
There can be any of the three conditions a player might face during diagnosis:
- When symptoms are clearly visible
If the player after facing the incident and having an injury, shows or doctor observes any symptoms or signs, it would be qualified as having a concussion till the time another diagnosis says otherwise.[14]
In the following situations[15], a clear case of concussion can be declared:
- Where the loss of consciousness is confirmed
- Where there is a suspected loss of consciousness (prolonged immobility > 5 seconds)
- Where the player gets a convulsion or seizure
- Where any limb of the player gets stiffens (also called ‘tonic posturing’)
- Where player loses his motor control or it is a situation of ataxia
- When the player is unable to stagger or stand
- Where a player does a blank or dazed stare
- Where player appears to be in a confused state or disoriented
- Where there is a memory impairment
In the above situations, there should be immediate removal of the player from the match and a SCAT5 can be referred to at a later stage. In such a case, there is also a need to look for and observe in the player, any signs indicating structural damage that require transfer to hospital on an urgent basis.
- When symptoms are unclear
In neck or head injury cases, there might be a situation where there are unclear or unobvious symptoms on on-field diagnosis but signs or symptoms can be seen. In such cases, the player should be taken to the medical room and should then be neurologically assessed, following the SCAT5. It is to be noted that this process takes a minimum of ten minutes. [16]
Potential signs or symptoms of concussion[17] can be:
- Dizziness or headache
- The player does not appear to be their usual self.
- Possibly, the player is unstable on his feet.
If the SCAT5 diagnosis concussion, then a player should be immediately removed from the match and the signs of structural damage should be looked at. In case there are such signs, the player should be transferred to the hospital.
Signs indicating the need for urgent hospital transfer[18]:
- The conscious state is worsening
- Immediate seizure or convulsion
- Double vision
- Symptoms like vomiting or headache
- Neck pain or tenderness
- Altered sensation or weakness in the limbs
- Increasing combativeness, agitation, or irritability
- Asymptomatic cases
If there appear to be no symptoms on diagnosis, it does not act as a green signal that the player is not suffering from a concussion. There are around 10-20% of the cases where there has been a delay in the onset of symptoms.[19] Every possibility of concussion can be ruled out only in a case where even after 48 hours, there are no symptoms.
If a concussion is not diagnosed after an on-field assessment, the player has the liberty to continue with the game. Even after the player resume, there is a need to check if there are any developing symptoms every 4 or 5 hours, and SCAT5 should be done when there is a break in the match when the match ends, and at either 24 or 48 hours. If a diagnosis of concussion is made at any point during the observation or testing, the player should be withdrawn from the competition or training on that day permanently and immediately.[20]
How to Manage a Difficult Concussion Case
It becomes a challenging concussion case if the concussion symptoms last longer than three weeks. In this instance, a specialist having knowledge of concussion management should be consulted.[21] The athlete will almost certainly be subjected to a full neuropsychological test, which may involve a standard MRI to rule out structural brain injury, as well as further investigations based on the neurological examination’s findings.[22]
Role of an umpire and video review
If a player suffers from a head trauma or is showing worrying symptoms because of which he is unable to return to play immediately, it is the responsibility of an umpire to call for medical assistance.[23] Further, a video review becomes important to determine immediate signs of concussion[24] were present or not and if they went unnoticed.
When can a player diagnosed with a concussion return back to play
A player diagnosed with a concussion can return back for competition and full training only after a formal medical clearance. The recovery period should be closely observed for ensuring that symptoms of concussion are not developed again. Usually, 2-3 days are needed for the symptoms to be settled down and after one week the player is ready to return to play. A player might also come back the next day in case of a multi-day match in very rare cases. In both cases, medical oversight during matches is a mandate.
Typical graded return for cricket[25], as has been described by the Berlin Consensus is as follows:
- 24 hours relative rest
- light aerobic exercise
- light training
- full training
- cleared to compete
If symptoms reoccur at any of the above stages, the player should reduce their exercise level. If the athlete is a student, he or she may need to take a few days off from school to relax.[26] If a player is unable to attend school or work without experiencing a recurrence of symptoms, he or she should not return to full training.[27]
Where there are difficult concussion cases, it is the responsibility of the doctor and specialist to give medical clearance to the player to return to the match.
Concussion in Children: How to Deal?
Children’s rehabilitation is more difficult, and the first step should be to withdraw the child from school and monitor symptoms connected to academics, followed by exercise and sports.[28] If the symptoms last longer than three weeks, the child should see a pediatric concussion expert. It is to be noted that the Child SCAT5 is used for 5-12 years child players, while for players above the age of 13 years are eligible for SCAT5.
Concussion Protocols of different sporting leagues conducted across the world
Most of the basic guidelines that have been discussed under the ICC guidelines remain the same across the different sporting leagues. Below discussed guidelines are the ones that are different from the basic guidelines.
National Basketball Association (NBA)
The NBA implemented a concussion policy in December 2011 and that is currently written under Article XXII Section 9 of the NBA-NBPA Collective Bargaining Agreement 2017.
Some of the aspects of NBA guidelines are discussed as follows:
- Imparting concussion education to every player, health care provider, and coach is necessary so that proper management and diagnosis can be undertaken. The education would include topics like basic mechanisms and presentations of concussion, possible complications of the injury, etc.[29]
- Under the baseline testing, pre-season testing has been mandated via cognitive and neurological assessment.[30]
- Evaluation of a suspected concussion has to be done by medical personnel in a calm, distraction-free setting favorable to a neurological examination.[31]
- Cognitive and physical exertion should be limited to a player diagnosed with a concussion. Gradually, the player can be encouraged to become active and make progress. All this has to be done under the direction of his medical team.[32] Along with this, the use of electronic devices and games should be limited and the player should refrain from encountering large groups of people such as media or meeting fans.[33]
- Many activities from a stationary bike, to jogging, to agility work, to non-contact team drills have been provided under the guidelines which have to be undertaken as a part of the return to play process.[34] The activities are arranged and executed by a step-by-step increase of exertion.
- Return-to-play final decision lies with the physician of the medical team, who has to first discuss it with the NBA concussion program’s director.[35]
It should be noted that there is no set schedule for returning, and the decision depends on the recovery time of the injured player. For instance, Kobe Bryant returned to play three days after suffering a concussion in 2012, but Chris Kaman’s concussion required four weeks of rest.[36]
National Football Association (NFA)
The NFL Game Day Concussion Diagnosis and Management Protocol was developed in 2011 by the NFL Head, Neck, and Spine Committee, which is made up of independent and NFL-affiliated physicians and scientists, as well as advisers to the NFL Players Association.[37] The Concussion Protocol is reviewed every year and was last amended in July 2020.
Preseason Assessment
The NFA guidelines provide for Preseason Assessment, which includes imparting education and undertaking physical examination. The physical examination has to be done by a physician for reviewing and answering questions relating to the previous concussion of a player, imparting how important is it to report about the signs and explaining in brief, the diagnosis, and management protocol of concussion.[38] Baseline neurological evaluations which include neurological examination, baseline NFL Locker Room Comprehensive Concussion Assessment and baseline neurocognitive testing also have to be executed.
Responsible Parties on game day concussion management
- Booth Certified Athletic Trainer Spotter (Booth ATC): Each Club is allocated an athletic trainer who is stationed in the stadium booth with access to various views of the video and replay to have aid in injury detection.[39] Booth ATC Spotters have the responsibility of watching a live game and watching it through a video feed also for identifying players who may need further medical attention.[40]
- Unaffiliated Neurotrauma Consultant (UNC): A UNC is a physician who is unbiased and unaffiliated with any Club. Each Club is allocated a UNC to be present on their sideline at each game, whose responsibilities[41] are discussed as follows:
- Focusing on the identification of any symptoms or signs of concussion.
- Concentrating on the mechanisms of injury that asserts concussion assessment.
- Implementing the concussion evaluation and management procedure during the game after consulting with the Head Team Physician or his designee.
- Being present on the field for the purpose of observing the SCAT performed by Club medical staff.
Assessment Protocol
60 minutes before every NFL game, a critical meeting takes place between game officials and key medical personnel to establish familiarity with one another while reviewing essential injury-related procedures.
A player is removed off the field if he is suspected of suffering a concussion. His helmet must be taken from him[42], and he must then undergo the NFL’s Sideline Concussion Assessment Tool, which is derived from the SCAT testing. Medical personnel are obliged to carry electronic tablets with programmes that aid team physicians in their assessments.[43]
Furthermore, the NFL Locker Room Comprehensive Concussion Assessment is a standardized acute diagnostic technique designed by the NFL’s Head Neck and Spine Committee to be utilized by Club medical staff and designated UNCs to assess suspected concussions during practices and games.[44] The SCAT 5 was used to make this assessment.
Return to play
The return to play protocol involves five phases[45], which are discussed as follows:
- Symptom Limited Activity
- Aerobic Exercise
- Football Specific Exercise
- Club-Based Non-Contact Training Drills
- Full Football Activity or Clearance
Who takes the final decision
Each club is required to engage an independent neurological consultant (a physician and concussion specialist who has been approved by the league and the players union) to make the final decision. The INC must collaborate with the team’s chief physician and medical personnel to collect all of the information needed to make an informed judgment.
National Hockey League (NHL)
The protocol provided by the NHL on Concussion Evaluation and Management (based on Berlin Consensus Statement 2017), as well as Article 34 of the Collective Bargaining Agreement, govern the regulations controlling concussions. The guidelines are discussed below:
- The education programme required to be undertaken as per the NHL guidelines is very broad. It includes clubs’ requirement to show the ‘Concussion Educational Video’ to every player, manager, and medical personnel on the first day of training itself, providing FAQ brochure to the video attendees, posting a concussion poster at every place in the club, showing visible signs video and executing educational meetings.[46]
- Similar to the NFL, league spotters in the arena and at a central league office observe games and help clubs identify players exhibiting visible signs of a concussion after a direct or indirect blow to the head.[47] A player is required to be removed and evaluated if a central league spotter determines that an evaluation is necessary.[48]
- Return to play protocol is a 5 stages protocol: Symptom-limited activity, daily activities, introduction of aerobic exercise, progression of intensity and duration, on-ice non-contact activity, non-contact drills, and Controlled body contact.
- The final decision of return-to-play lies with the team doctor. The doctor has to work in conjunction with the team neuropsychologist to incorporate data post-concussion neuropsychological evaluation data for taking the final decision.
- All of the test data is centralized, and when a player transfers to a new club, the data follows him, giving the new team doctor access to the player’s whole history.[49]
Conclusion
Needless to say, players are assets for their respective teams, and therefore it is an obligation of the team management to consider players’ health concern with paramount importance. It is imperative for every team to follow the guidelines and regulations in place, and for regulation authorities on all levels to make sure that the rules are complied with. A concussion often seems harmless but can end up in a disaster ignored- which is not an uncommon phenomenon in the least. It is therefore also necessary to spread awareness on concussion protocols in state level sports as well as community driven sports which are characterized by a lack of infrastructure and oversight.
[1]Rick Wilkerson & Wayne J. Sebastianelli, Sports Concussion, ORTHOINFO (June 2017), https://orthoinfo.aaos.org/en/diseases–conditions/sports-concussion/.
[2] Ibid.
[3] Ibid.
[4]Srinivasan Ramani, What is the concussion test in cricket?, THE HINDU (August 25, 2019, 00:12), available at https://www.thehindu.com/sport/cricket/what-is-the-concussion-test-in-cricket/article29247137.ece.
[5]Jon S Patricios, Consensus Statement in contact and collision sports: a joint position statement from 11 national and international sports organizations, PUBMED (May 2018), https://pubmed.ncbi.nlm.nih.gov/29500252/.
[6] Ibid.
[7] Supra Note 6.
[8] Concussion Management Guidelines, International Cricket Council (ICC) (April 2018).
[9] Ibid.
[10] Ibid.
[11] Ibid.
[12] Ibid.
[13] Ibid.
[14] Ibid.
[15] Ibid.
[16] Ibid.
[17] Ibid.
[18] Ibid.
[19] Ibid.
[20] Ibid.
[21] Ibid.
[22] Ibid.
[23] Ibid.
[24] Ibid.
[25] Ibid.
[26] Ibid.
[27] Ibid.
[28] Concussion Policy Summary, National Basketball Association (2017-18 Season).
[29] Ibid.
[30] Ibid.
[31] An overview of concussion protocols across professional sports leagues, LAWINSPORT (Wednesday, 05 November 2014), https://www.lawinsport.com/topics/item/an-overview-of-concussion-protocols-across-professional-sports-leagues.
[32] Ibid.
[33] Ibid.
[34] Ibid.
[35] Ibid.
[36] Howard Beck, NBA Concussion Policy Becomes Major Factor in Series, NEW YORK TIMES (17 May 2013), https://www.nytimes.com/2013/05/18/sports/basketball/concussion-protocols-loom-large-after-injury-to-pacers-george-hill.html.
[37] Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol, National Football League.
[38] Supra note 53.
[39] Ibid.
[40] Ibid.
[41] Ibid.
[42] Ibid.
[43] Ibid.
[44] Ibid.
[45] Ibid.
[46] Concussion Evaluation and Management Protocol, National Hockey League, 2019-20 Season.
[47] David Schoen, Here’s how the NHL concussion protocol works, LAS VEGAS REVIEW-JOURNAL (February 7, 2020, 12:07 pm), https://www.reviewjournal.com/sports/nhl/heres-how-the-nhl-concussion-protocol-works-1953072/.
[48] Ibid.
[49] Supra Note 48.
YLCC would like to thank Aditi Aggarwal for her valuable insights in this article.
