David Hughes is a sports physician. He's a professor too. And he got together with two of his colleagues, Lisa Elkington and Silvia Manzanero, to sift through the joint consensus statement on concussion in sport that went through its most recent update in Berlin in 2016 and come up with a position statement on concussion in sport for Australia. The position statement was a collaboration between the Australian Institute of Sport (AIS) and the Australian Medical Association (AMA); so this is big stuff. 

The three authors thought a bit more about it and penned an update to the AIS-AMA position statement on concussion in sport and published it in the Medical Journal of Australia in April. I read it. And I quite liked it because it not only outlined the what of concussion management but also the how and why.

This is really important because there is a lot of back and forth discussion about how to implement the various concussion management guidelines and it can often seem like only professional sports people with the backing of a full team will be able to access the resources needed to effect a safe return to competitive sport.
Not so.

In fact it is all quite achievable.

It is also good to read their acknowledgement and addressing of some of the concerns that many clinicians and clinical support professionals have about some of the diagnostic and therapeutic modalities for concussion.

So it seemed a good idea to track these authors down and put them on the podcast. I managed to get hold of Prof Hughes, in between busy lectures, clinical appointments and academic commitments.

Now go and read the 2016 joint consensus statement on concussion: http://bjsm.bmj.com/content/51/11/838 

Then go and read the update article. It's here: https://www.mja.com.au/journal/2018/208/6/update-ais-ama-position-statement-concussion-sport

Now you are ready for the podcast. Actually, it's two podcasts, as despite only tackling about three-quarters of the material, we still went for over an hour and after editing I've had to split it into two episodes for ease of downloading.

Here are the key items that we address....
1) Who makes up this expert panel that issues the joint consensus statement every couple of years? It's quite a broad range, drawn largely from contact and field sports. There's no motorsport representation, but then there is no representative for snooker either and to date we haven't generated much hard data to get ourselves invited to the party.

2) Why are we hearing more and more about concussion over the past 6 years or so? Are we unmasking it by fixing other problems or have we just admitted its presence and started to look at it properly?

3) There seems to be pathophysiological differences in the manifestation of concussion in men and women, and between adults and children. Women and children take longer to recover, but we don't know why really. This is an evolving area and management guidelines may change as more data is unearthed.

4) Not everyone needs a CT, MRI or formal clinic based neuro-psychological assessment. Thank Christ for that. Triggers to think about referral include:
  • The usual head injury red flags; e.g. Canadian Head CT Rules 
  • Prolonged symptom duration: adults > 14 days, children > 4 weeks; though this may yet evolve further.
  • Significant symptom burden
  • Consideration of a prolonged break or a career end because of concussion

5) Trackside tests like SCAT, ImPACT and K-D are good screening tests, though their results should not be used in isolation to determine the presence or absence of concussion. Clinical judgement is part of the process. Knowing the athlete (e.g. team physician) helps. Additionally, it seems that between athlete gaming, ceiling effects and a degradation in utility over only 3 to 5 days (for SCAT anyway), it is not yet recommended practice to use these tests to determine fitness to return to sport. This is interesting as this does happen around the world and it may also have impact upon some of the studies that are being run to determine the validity of a variety of diagnostic modalities.

6) There are biomarkers of brain injury. They are not yet ready for real time clinical use. They've been covered on the Rollcage Medic site here - Concussion biomarkers, the new brain troponins. There may be more up to date information now as this piece was written 4 years ago.

7) There are a handful of devices that are being developed as expertise-independant trackside diagnostic tests, most of which have little or no publicly available peer reviewed evidence to support their widespread adoption yet. I admit that I really hope the iPAS system works out. It does have some evidence behind it though this is not publicly available (personal communication with developer), however a number of its component tests have received FDA approval. The iPAS system is currently undergoing trials through IndyCar in the USA and the MSA-UK with Naomi Deakin and Peter Hutchinson. So, fingers crossed.

8) Second impact syndrome is still very controversial with strong opinions (and little hard evidence) on both sides. It may be a moot issue as David argues that if a concussion episode is managed correctly, we should never see an acute second hit because the competitor should already have been removed and be under clinical supervision.

9) Chronic traumatic encephalopathy. What a hot potato! Still. Decide for yourself about this but make sure you have appraised the available evidence. Maybe the Boston and now also Sydney-based brain bank will be able to shed some light. Here's the JAMA article with the two videos that David mentions in the podcast: Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football

10) Complete physical and cognitive rest for the immediate 24 hours after a concussion is no longer recommended. Woo hoo! Try getting anyone to comply with that bit of advice. It is now recommended that deliberate rest for 24 to 48 hours should be the aim, accepting light exertion and cognitive activity that does not worsen the concussion symptom profile. Beyond 48 hours, the evidence does not support complete rest and a graded return to full activity is the main strategy.

11) We didn't get into this in the podcast but a predominance of vestibular features appear to be associated with a more prolonged course and worse outcome and there is increasing focus on using occulo-vestibular retraining exercises in the management of concussion. The keen-eyed among you will spot that this is a key target of the King-Devick and iPAS testing systems, as well as the BESS test component of SCAT

12) What if you do need to sit an athlete down and discuss the future of their chosen professional sport? How does one approach that difficult conversation? There is no hard evidence to guide you, according to David and we are not the sports police, so we can only offer the best advice that we have. For those who do step down permanently, assistance with readjustment to life outside of professional sport will be critical. Watch this SBS panel discussion on "Life after sport": 

Here are the podcasts with David

Here's Part I - Concussion and its assessment

Here's Part II - Consequences of concussion and concussion management: 

Attribution: The intro sound clip is the opening bars from Soundgarden's track "Head injury" from their 2017 re-issued album "Ultramega OK". The outro is my own recording of a rally car starting a stage of the National Capital Rally of Canberra in NSW, Australia.

References and resources
Dario Franchitti's videos on retiring from motorsport due to concussion