Theo Farley is a senior physiotherapist with the English Institute of Sport. He is an expert in treating sports related concussion in athletes and he also leads research on this important subject.
Sports related concussion (SRC) has become one of the highest burden injuries within professional and amateur sports (1-4) accounting for significant time loss from competition (5,6) with evidence demonstrating high risk of musculoskeletal (MSK) injuries upon return to play (6).
Concussion is a traumatic brain injury brought on by forces that transmit impulses to the head (1). These forces do not always come in the form of a direct impact to the head and can result from a whiplash type injury where the head rapidly accelerates and decelerates such as a fall to the ground or a rugby tackle to the body. This leads to a mechanical shake of the brain and is characterised by the rapid onset of changes in neurological function that can last from minutes to months (7).
It is important to remember that it is not necessary to suffer loss of consciousness to have sustained a concussion and the presentation of symptoms can take between seconds and 48 hours to come on. So if you suspect a mechanism that could lead to concussion the safest thing is to remove yourself from the field of play.
Managing concussion can be a complicated balance of rest and activity. Beyond 48 hours it is important not to stay too sedentary but operate at a lower level in terms of physical and cognitive loading, that is to say nothing that aggravates symptoms. If things aren’t getting better within a week to ten days then it is worth getting in touch with someone that has experience in managing concussion to make an effective assessment of symptoms.
When considering the rehab for concussion as a stand-alone pathology, athletes are in luck because the best medicine (like in most cases) is exercise! A group of researchers in Buffalo, New York state have developed a highly sensitive and specific treadmill walking test that is able to identify (reversible) dysfunction in the part of the brain that is responsible for the autonomic function of the body (the autonomic nervous system) - heart rate, breathing rate, blood pressure, sleeping and so on (8).
When this test has been completed by a medical professional you can use the results to formulate a sub threshold bike programme that will gradually re-educate the autonomic nervous system to make appropriate changes to the autonomic function mentioned above. This rehab programme will take you all the way to recovery and the point of starting a Graduated Return to Sport programme.
Other things that I’m often asked by athletes is when can we return to weight training, sprint training and things like plyometrics? The answer to this is unfortunately when your concussion has resolved as increasing rapid head movements and the intra-thoracic pressure (increased when straining during a lift) can bring on concussion symptoms which will lead to a delayed recovery, so it’s really not worth it.
In order to maintain trunk and limb strength the best thing is to do some light body weight exercise focusing on what we would call neuromuscular recruitment (body weight or light resistance bands).
As mentioned above, a significant amount of evidence is now surfacing that demonstrates a strong link between concussion and non-contact musculoskeletal injuries at return to play. Although it’s not yet known what mechanism is at play here, we know the risk exists. Premiership rugby has found that players are 60% more likely to suffer an MSK injury in the remainder of the season than a player that hasn’t suffered a concussion (9). There are many more examples of this in the literature.
As mentioned, we don’t know what the mechanism is at play here but it’s very likely that either through enforced rest or through injury to the nervous system that significant de-conditioning has taken place. The best way to defend against this is not rushing to return to sport. If you have pre-season fitness markers then make sure you’re back to those levels, If you don’t have anything objective then make sure you give yourself sufficient time to build yourself back up. There’s no point in rushing back a week early from a concussion only to spend the following nine months rehabbing from an ACL rupture!
Having a concussion is a confusing and scary time but with the appropriate management it will get better sooner rather than later. Appropriate pacing of cognitive and physical load, targeted exercises intervention and an appropriate period of reconditioning is the key to come back strong and robust to future injury!
Massive thanks to Theo for this blog! If you would like to follow Theo or contact him directly you can find him on twitter: @theo_farley
1. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311-9.
2. Baldwin GT, Breiding MJ, Dawn Comstock R. Epidemiology of sports concussion in the United States. Handb Clin Neurol. 2018;158:63-74.
3. Porter M, O'Brien M. Incidence and severity of injuries resulting from amateur boxing in Ireland. Clin J Sport Med. 1996;6(2):97-101.
4. Zazryn TR, McCrory PR, Cameron PA. Injury rates and risk factors in competitive professional boxing. Clin J Sport Med. 2009;19(1):20-5.
5. Cosgrave M, Williams S. The epidemiology of concussion in professional rugby union in Ireland. Phys Ther Sport. 2019;35:99-105.
6. Rafferty J, Ranson C, Oatley G, Mostafa M, Mathema P, Crick T, et al. On average, a professional rugby union player is more likely than not to sustain a concussion after 25 matches. Br J Sports Med. 2019;53(15):969-73.
7. McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-47.
8. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018 Aug;17(8):262-270.
9. Cross M, Kemp S, Smith A, Trewartha G, Stokes K. Professional Rugby Union players have a 60% greater risk of time loss injury after concussion: a 2-season prospective study of clinical outcomes. Br J Sports Med. 2016 Aug;50(15):926-31.