Concussion in cricket

It is both ironic and a testament to Cricket Australia’s research and Head Injury Policies, that Steve Smith became the first ever player to be substituted in an international match under the newly devised ICC Concussion Substitute Rule.

In the last 5 years Cricket Australia has rolled out their own Concussion and Head Trauma Policy and introduced concussion substitutes in the Sheffield Shield season 2016-17.

Incidentally, the author of this blog was medical officer on duty at the MCG on the day Tasmanian batter Jordan Silk became the first ever First Class cricketer to be substituted out of a match due to concussion in November 2017.

It is worth noting that he too, was substituted the day after being struck to the helmet by a bouncer, and with the delayed evolution of symptoms, was ruled out under precisely the same guidelines as those followed recently by Steve Smith.

These guidelines combined with clinical assessment tools allow practitioners to assess, manage and expedite a safe return to training and sporting participation.

Symptoms vary enormously in type, severity and timing of onset, and can also vary in duration, meaning practitioners and athletes alike must be wary of a broad spectrum of possible presentations.

Treating practitioners especially must be familiar with the need for ongoing assessment and surveillance for late presentations, whereby an earlier clinical assessment might escalate to a revised diagnosis of delayed onset SRC.

This was the case with Steve Smith in the recent second Ashes test, where his final diagnosis was a combination of sound clinical judgement, risk stratification and adherence to well-structured clinical pathways and policy.

Smith’s return to play later on the day of the incident was scorned by some as unsafe, crazy and for the betterment of the team whilst compromising personal health.

His return however, was only following rigorous assessment including clinical examination, a Standardised Concussion Assessment Tool (SCAT-5) – formulated by an expert panel known as the World Concussion Group, and a CogSport test – a computerised assessment tool focusing on memory recall, reaction speed and accuracy.

Both the SCAT-5 and Cogsport tools are performed pre-season by all Australian first class cricketers as a baseline, from which further post-injury assessments can be compared to aid in decision making when assessing SRC.

It is imperative to understand however, that these tools do not make a diagnosis of SRC in their own right  – this remains a clinical judgement and requires medical expertise.

Smith’s return to the crease was no different to AFL or NRL players returning to the field after being cleared with the same battery of tests and clinical assessment.

History tells us Smith went on to develop delayed-onset SRC, was substituted out, and even missed the following match, but in no way was his return to the field medically incorrect according to current best-practise guidelines.

With heightened community awareness of SRC in recent years, there is growing and justified concern for athlete welfare in both the immediate and longer terms.

The ground-breaking work of Cricket Australia with regards to the introduction of concussion substitutes and their continuing (and ultimately successful) push at ICC level has paved the way for safer management of concussion in cricket.

With no resultant impairment to a team now being ‘a player down’ from a concussed player being ruled out of the match, batters are now more willing to readily report symptoms and medical staff have significant pressures removed in their decision making around a diagnosis of concussion.

This has been a massive win-win for cricket and player welfare in general.

SRC is a brain injury and is defined as a complex physiological process affecting brain function, induced by biomechanical forces.

It may be caused by either a direct or indirect blow to the head, face, neck or body causing an impulsive force transmitted to the head.

In the vast majority of cases, impairment of brain skills such as memory and thinking are only temporarily impaired and show full recovery with no ongoing sequelae. SRC does not involve structural damage or permanent injury to the brain.

SRC can be observed in all manner of sporting activities – typically those involving contact and/or speed.

While the football codes account for the far greater outright numbers of cases of SRC, it is in fact motor sport and equestrian that rank highest ‘risk’ when incidence is adjusted for rates of participation.

While most events typically emanate from a direct head impact, a significant linear or rotational head force sustained as part of contact to a distant part of the body can also result in concussive symptoms.

Of some concern, concussion is also significantly more common in children than any other age group.

Signs of concussion can include:

• Unconsciousness (seen in only 10-20% of cases)
• Unresponsiveness
• Slowness to get up
• Prolonged holding of head
• Glazed or glassy look (like ‘no one home’)
• Muscle rigidity/posturing or even seizure activity
• Slowness in response to questions/instructions
• Slurred speech
• Disorientation
• Balance issues/unsteadiness on feet

Symptoms of concussion can include:

• Headache
• Nausea / vomiting
• Feeling ‘in a fog’/’not quite right’ (very common patient reports)
• Blurred or double vision
• Confusion
• Memory impairment
• Drowsiness/fatigue
• Emotional lability
• Difficulty concentrating on tasks or focusing
• Hypersensitivity to light or sound

The presence of one or more of these symptoms and signs should result in a high index of suspicion for SRC, and athletes regardless of their level of expertise should be removed from play for assessment.

Accepting that most non-elite level sporting teams do not have immediate access to medical expertise, players (and especially children) should be consulted by a qualified medical doctor at earliest convenience.

This could be a sports medicine or GP clinic, or nearby emergency department.

Collaboration between the Australasian College of Sport & Exercise Physicians (ACSEP), Sports Medicine Australia (SMA), the Australian Medical Association (AMA) and the Australian Institute of Sport (AIS) earlier in the year delivered the ‘if in doubt, sit them out’ initiative including a comprehensive website (link below) with information on sport-related concussion for coaches, parents, athletes and medical practitioners alike.

In cases involving unconsciousness, seizure activity, worsening mentation (increasing confusion/irritability), worsening after injury (e.g. vomiting/worsening headache) or with any neurological concern (e.g. pins and needles, numbness or weakness in limbs) or neck pain – urgent ambulance transfer to the nearest emergency department with spinal precautions/immobilisation is required.

In confirmed cases of SRC, the vast majority (80-90%) of cases settle within 10 to 14 days, provided the condition is recognised quickly and appropriate rehabilitation is initiated.

Complications are rare but can be increased by failure to recognise the condition and/or allowing return to play in a concussed state or with inadequate recovery.

Occasionally symptoms can persist for longer and can even persist for months in severe cases.

It is of paramount importance that each case is treated on its own merits and recovery and rehabilitation is tailored to the individual needs of the patient.  No two concussions are necessarily the same, even in the same patient over time.

There have been links demonstrated between depression and other mental health issues and repeated or prolonged concussion episodes.

Considerable attention has been paid to media coverage of chronic traumatic encephalopathy (CTE), though at the present time there has been no definite link between concussion and chronic brain damage and ongoing research is required.

Unsurprisingly, the cornerstone to effective management of concussion is rest; both physical rest and cognitive ‘brain’ rest.

This mandates a period of no work/school, no ‘screen time’ (TV, computers, phones etc.) and no physical exertion.

In most cases 24-48 hours will be sufficient, though rest should continue until all symptoms have resolved.

Return to school or work should be medically cleared, graduated and subject to ongoing review.

In turn this should be followed by a stepwise return to physical activity, provided successful completion of each step and ongoing medical review.

This is outlined below:

1. Rest until symptoms resolved
2. Light aerobic exercise (e.g. exercise bike, walking)
3. Light, non contact training (e.g. running, ball skills)
4. Progression to more complex non-contact training drills and light resistance work
5. Full contact training
6. Return to play

Each step should require 24 hours as a minimum before progression to the next level, and only if symptoms remain absent.

Occasionally symptoms can re-appear and this then mandates return to the previous level at which there were no reported symptoms.

With developing brains and the requirement for learning, children and adolescents typically require longer to recover from concussion and should be slowed down in their rehabilitation.

Perhaps one of the fundamental differences in SRC management between children and adults is the emphasis for children to return to school for ongoing learning rather than to sport.

An initial rest period of 48 hours is often recommended and return to sport should in most cases be a minimum of 14 days.

Liaison between the patient’s doctor, parents, school and sporting coaches are imperative and require flexibility in dealing with transition through rehabilitation stages and dealing with difficulties as they arise.

Consideration may be required for class attendance, examinations, driving lessons etc.

Persistent symptoms beyond 10 days, highly troublesome symptoms, or worsening over time should result in assessment by highly specialised experts in the field of concussion.

Occasionally recommendation may be made for consultation with specialised neuropsychologists, psychiatrists and there are specialist centres available for specific post-concussive physiotherapy rehabilitation.

Useful links for further information on this topic

• https://sma.org.au/resources-advice/concussion/
• https://concussioninsport.gov.au
• https://ama.com.au/position-statement/concussion-in-sport-2019
• https://bjsm.bmj.com/content/51/11/838

It should be noted that none of the content in this article replaces proper medical assessment and specialist consultation. The information is provided as an educational guide only. Return to work/school and/or physical activity should only commence on the recommendations of a qualified medical practitioner.