Concussion Management - The Barker Way

Lisa Chalmers Director of Health and Wellbeing

A Abstract

This article serves as an explanation of the Concussion care and support framework at Barker College. It documents the process of the development of the current Concussion care system at Barker under a wholistic framework of student wellbeing and details the collaborative process involving students, staff, medical professionals, and family engagement. This paper outlines the Concussion Clinic’s current place in the School whilst sharing some hopes and aspirations for the future care of students in this arena.

Key Terms Concussion – concussion is a traumatic brain injury induced by biomedical forces to the head, or anywhere on the body which transmits an impulsive force to the head. It causes short-lived neurological impairment and the symptoms may evolve over the hours or days following the injury. . GRTP – graduated return to play GRTL – graduated return to learn

Introduction

As with much of what we do at Barker the concussion care process relies upon an integrated and highly collaborative team approach. It incorporates a strong awareness and knowledge of concussion by our sports coaches and teaching staff embedded into a multidisciplinary care system that seeks to care, educate and guide the student back to full health and function across all aspects of their life following a concussion injury.

The Origins of Concussion Care at Barker Concussion is a complex and often hidden injury of which we have still much to learn. Over the past decade the advancement of concussion research has made significant strides in the identification and management of concussion (Walter, 2017). The Barker Concussion Clinic originated in 2015 when our School physiotherapist and Head of Sport identified the importance of the care and follow up of students with a head injury. At the time this was seen as a ground-breaking care system that followed closely the emerging research and evidence growing about concussion recognition and management in professional contact sports across the world (Evans, 2014).

The changing landscape of head injury management The early recognition of a concussion injury is critical to the correct management and prevention of further injury and long term consequences. (Cassimatis, 2021). Over the years the Concussion Clinic at Barker has evolved and been enriched by the expertise and input from partnerships both within and outside of Barker that assist in enhancing this process. We have improved our concussion assessment tools so that a more systematic and objective concussion assessment process ensures less concussions are missed and that follow up and care is comprehensive and paced at the individual student needs. Barker concussion uses a combination of assessment tools including: • Mechanism of injury/recognition – staff and coach awareness that a head injury has occurred • Injury Reporting – all suspected concussions which occur during training, match play or other school activities, are reported by School Staff through Barker’s injury reporting system (Clipboard and Complispace). Collection of Concussion data is used to track trends and identify potential areas for safety improvement, specific training and conditioning needs as part of the integrated injury management system. • Symptom checklist – Barker Concussion Action Plan (CAP) • Cognitive testing (HeadSmart) that is compared with the students’ baseline test that completed in Term 1 • Student Concussion History – the student medical records contain information about a students’ previous concussions. Knowing about a student’s previous concussions can help to identify students who fit into a higher risk category, may need additional recovery time or support (e.g. learning and/or counselling). • SCAT5 – Internationally recommended concussion assessment tool

Staff Training is undertaken via the Coaches Induction and all Barker teaching staff are encouraged to complete the Concussion Management for Coaches and Support Staff via the Australian Institute of Sport website. The current Barker Concussion Process is based upon the Concussion in Sport Australia Position Statement (Elkington, Manzanero & Hughes 2019). It is a living document that is constantly being reviewed and updated as new evidence emerges. It is held in the Policy Connect App under Student Duty of Care/Health on the Student Concussion Management Page. Key partnerships include: • Northside Physio – most notably Robbie Wright and Jack Penny who oversee the weekly Barker Concussion Clinic and liaise closely with the Schools Sports Department, Health Centre and parents to care for our students. • Dr Corey Cunningham (Sports Physician) who covers the Saturday sport injuries during the Winter season. • HeadSmart – every student at Barker is offered the opportunity to undertake a Baseline cognitive test in Term 1 which can be accessed and viewed by the Health Centre staff and by Northside Physio if a student suffers a concussion injury to assist in the diagnosis and return to their normal cognitive function.

• NeuroCHECK – in 2022 Barker partnered with Neurocheck to participate in a research study for a new method of testing brain function via an electoencephalography (EEG) headset that measures brain signals. • CHISM – Children’s Hospital Institute of Sports Medicine at the Children's Hospital at

Westmead • Vicki Evans AM, Concussion Clinical Nurse Specialist, RNSH, who oversees the

Concussion Clinic at Royal North Shore Hospital and provides guidance and expertise. • Barker Sports Injury Review – weekly oversight by Director of Risk & Compliance,

Director of Sport, Deputy Head (Student Experience) and Director of Health &

Wellbeing.

Long concussion Symptoms of concussion typically should resolve within seven to ten days. Long concussion or post-concussion syndrome is a complex range of physical, cognitive and emotional/behavioural symptoms that endure for a prolonged period following a concussion injury. Both physiological and psychological aetiologies have been suggested as causes for post-concussion symptoms. Most investigators now believe that a variety of pre-morbid, injury-related, and post-morbid neuropathological and psychological factors contribute to the development and continuation of these symptoms (Broshek et al., 2015) Predictors thought to be associated with protracted recovery include; high severity of acute and subacute concussive symptoms, a high number of concussive symptoms, prolonged loss of consciousness (greater than a minute), post-concussive seizure, previous history of concussion, age of the athlete, female sex and history of depression, anxiety or migraine (Australian Sports Commission, n.d.). Students at Barker who present with symptoms lasting longer than 10 days are referred to the long concussion multidisciplinary clinic at Royal North Shore Hospital or to CHISM for management. The multidisciplinary clinic, composed of adult and paediatric neurologists, clinical nurse specialist and a neuropsychologist, takes a holistic approach to reviewing the students cognitive function, psychological wellbeing and associated post-concussive symptoms. Depending on the outcome they may recommend various lifestyle modifications and suggest appropriate referral pathways to ensure optimal recovery and an efficient return to life.

The Future

In October 2022, the 6th International Consensus Conference on Concussion was held in Amsterdam. The Congress brought experts from around the world to talk about and update the current accepted world concussion guidelines. The purpose of the Conference is to present a summary of new evidence-based research that span the spectrum of concussion, from definition to initial management, investigations, treatment, return to play protocols and prevention. An expert panel group will review the research and develop the consensus from the information presented at the meeting. The second objective is to reach an agreement amongst the expert panel on developing a Consensus Statement on Concussion in Sport. This document will then be used by physicians and healthcare professionals involved in the care of injured athletes at the recreational, elite, or professional level.

The outputs from the 6th Consensus Conference will be submitted for publication following the meeting and will be peer reviewed. It is anticipated that the outcomes of the conference will be available in the second quarter of 2023 in the British Journal of Sports Medicine.

Ongoing Challenges The identification of local GP’s who are ‘experts’ in concussion would greatly support the care process of the Concussion Clinic at Barker. Good clinical care of a patient with concussion is the best prevention of adverse outcomes. Adolescents and children are in the midst of a significant neurodevelopmental trajectory and thus are at a high risk of both short and longer term consequences of concussion. The education and collaboration of clinicians, parents, coaches and players is critical to ensure both appropriate notification of injury and supportive, appropriate care and follow up.

Return to life in a timely and supported manner. There is emerging evidence to suggest that carefully monitored sub symptom exercise can play an important role in a beneficial treatment strategy following concussion (Howell et al, 2019). Broshek et. al. (2015) showed that excessive cognitive and physical rest may actually contribute to a longer concussion recovery. A tailored GRTP and GRTL program that ensures stretch and challenge but not overexertion is key to managing our students.

Conclusion

Concussion is an unfortunate risk in nearly all sports. At Barker we believe the benefits from sport participation far outweigh the potential harm. For children and adolescents, sport increases their physical and mental health, improves social skills, teamwork and confidence while concurrently providing an important connection to Barker. The Barker College concussion strategy aims to ensure a proactive and integrated approach to the prevention and management of student concussions to both maximise student wellbeing and minimise the long term impact of head injuries that occur within our school community.

References

Australian Sports Commission n.d., Concussion in Sport, Sport Australia, Australian Sports Commission, viewed 14 November 2022, <https://www.concussioninsport.gov.au/>. Broshek, Donna K., De Marco, Anthony P. & Freeman, Jason R. (2015) A review of post-concussion syndrome and psychological factors associated with concussion, Brain Injury, 29:2, 228-237, DOI: 10.3109/02699052.2014.974674. Cassimatis, M. et al. (2021) “Early injury evaluation following concussion is associated with improved recovery time in children and adolescents,” Journal of Science and Medicine in Sport, 24. Available at: https://doi.org/10.1016/j.jsams.2021.09.183. Concussion in Sport Group 2017, ‘Sport concussion assessment tool for children ages 5 to 12 years’, British Journal of Sports Medicine, p. bjsports-2017-097492childscat5. Elkington, L, Manzanero, S & Hughes, D 2018, Concussion in Sport Australia Position Statement ‘if in doubt, sit them out’, Australian Sports Commission, Belconnen. Evans, V. (2014) “Recognizing and managing concussion in school sport,” Journal of Neuroscience Nursing, 46(4). Available at: https://doi.org/10.1097/jnn.0000000000000063.

Howell, D.R., Taylor, A. J., Tan, C. O., Orr, R.& Meehan, W. (2019) The Role of Aerobic Exercise in Reducing Persistent Sport-related Concussion Symptoms, Medicine & Science in Sports & Exercise. Vol51, Issue 4. Purcell, L.K., Davis, G.A. and Gioia, G.A. (2018) “What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic review,” British Journal of Sports Medicine, 53(4), pp. 250–250. Available at: https://doi.org/10.1136/bjsports2017-097853. Walter, K. (2017) “Sport-related concussion in children and adolescents,” Paediatric Clinical Practice Guidelines & Policies, pp. 1496–1496. Available at: https://doi.org/10.1542/9781610020862-part05sport_related.