Recovering from a concussion – The trials and tribulations of getting it right.
Concussion is never an easy injury to deal with both as a therapist and a player.
Firstly, with any possibility of concussion there can be uncertainty around the diagnosis/player truth-fullness. In addition there can be a struggle to manage the return to play properly with limited contact time with the player ( especially in a senior team set up).
Managing any concussion and the return to play protocol requires trust between player and medical staff.
A case study
During the past university season (2017-2018) I managed a university players Graduated Return Protocol (GRTP) following a game concussion.
(I would like to point out that this concussion could have been avoided had the player not been swung round by his face cage, which was not penalised. Thank goodness there was no serious neck injury!)
The player presented acutely with dizziness, neck ache and unsteadiness on their feet. 24 hrs later the players symptoms of dizziness and nausea were still present.
The player had a mandatory 14 days of rest, and was only allowed to begin the GRTP once no signs or symptoms were present.
Over the course of this players return to play we encountered several challenges.
The first was the varied return to play guidelines: BAFAs rules to follow the RFU guidelines (minimum 2 weeks +); the Universities own guidelines (which at the time was 24hrs symptom free then into GRTP); or more recent updates from the SCAT5 (Sport Concussion Assessment Tool – 5th Edition) developed by the Concussion in Sport Group that a few days of rest is usually sufficient before gradual introduction of exercise . Ultimately, which guideline do we follow? Is it the National Governing body which the sport falls under; is it the universitys because the student is one of theirs or is it the most recent up-to-date research?
In the end we followed the most conservative guidelines of a minimum 2 weeks rest before starting the GRTP.
The second problem we encountered was the limited contact time to conduct the 4 stages of the GRTP. As the Sports Therapist managing the recovery living and working a good 25miles away from the player, meant that the GRTP stages had to be conducted during training sessions. This was because it is advised that the protocol be followed and the player assessed by a health care practitioner. It is unfortunate that coaches are unable to take a player through a GRTP as they have the most contact time with a player, yet do not have the necessary health care training. But not all teams have therapists working with them each week (let alone during the week) or have the necessary knowledge to administer/follow the protocol.
So what is the best approach for teams in these circumstances? Ultimately a less rushed GRTP would not have been detrimental to the players health, but perhaps not ideal for the teams performance.
During a stage of the GRTP our player fell unwell with a cold.Unfortunately for the recovering player this paused a stage of the GRTP as symptoms of recovery could have been made worse, and not distinguishable from the head injury or from being unwell with a cold.
Upon completion of the GRTP with no symptoms, the player was required to see their GP to be cleared to return to play. Unfortunately, as is the way the NHS works, our player was unable to get an appointment until 9 days following the successful completion of stage 4 (Stage 5 being clearance from a GP). This meant the student athlete missed our semi-final game.
The question is, is seeing a GP at Stage 5 a waste of time? It is most probably a waste of the NHS’s time. GP’s don’t see players in the first incidence following a concussion, nor are they specialists in this area. If each team had a doctor on hand this would be far more beneficial, yet that is not the case for teams or universities.
Returning to the Field
Thankfully a week prior to our national final the athlete was cleared to play by our university sports doctor. He was happy the GRTP had been thoroughly followed and the athlete was not at risk from returning to the game.
After 6 weeks recovery our player returned to the field to have a successful end to the season.
I must applaud the student athlete for his patience and hard work whilst in the concussion protocol.