Key Points

• Concussions are frequent in New Zealand sports like rugby, soccer, and basketball, and not all involve loss of consciousness.
• Concussion is an acute neurophysiological event resulting from blunt force to the head or body, causing a temporary disturbance of neurological function.
• In New Zealand, common concussion causes include falls, collisions, and sports-related incidents, especially in rugby union.
• Concussion results from sudden impacts that cause the brain to shift in the skull, leading to nerve cell damage and chemical changes.
• Symptoms of concussion are diverse, including headaches, dizziness, confusion, cognitive changes, and emotional shifts.
• Some initial signs of concussion can include loss of consciousness or feelings of being confused and dazed, confusion, nausea and vomiting.
• Subtle and delayed symptoms may emerge days or weeks later, emphasising the need for ongoing monitoring, however, this is fairly rare.
• Concussion management in New Zealand involves clinical evaluation, rest, symptom monitoring, gradual return to work/school, and education/support.
• During the first 24 hours after a concussion, rest is crucial, and individuals should not be left alone; avoiding alcohol and certain activities, which could result in another concussion, should be avoided.
• If symptoms persist beyond two weeks, individuals may require referral to ACC's Concussion Service for rehabilitation.
• The ACC883 referral form is available on the ACC website for direct referrals to Concussion Service providers like Active Plus.

Introduction

Concussions represent a surprisingly frequent phenomenon.

Let’s look at the causes and mechanisms of concussions, explore the complex spectrum of symptoms, and discuss how to recognise immediate signs – with particular reference to sports injury.    We’ll take a detailed view of the subtle and delayed systems, and provide insights into what comprehensive concussion management and recovery looks like in New Zealand.

What is concussion?

Concussion can be defined as "an acute neurophysiological event resulting from the impact of blunt force or other mechanical energy applied to the head, neck, or body, leading to a transient disturbance of neurological function"¹. 

In medical literature, the term is used interchangeably with mild traumatic brain injury (mTBI). While all concussions fall under the category of mTBIs, not all mTBIs qualify as concussions. Concussions tend to fall at the milder end.

In New Zealand, the most frequently reported causes of concussion include falls, collisions with objects, impacts from individuals (or animals), and accidents involving vehicles, including bicycle accidents².  Sports-related concussion accounts for approximately 20-30% of cases overall³.  Notably, a tenth of sports-related concussions in New Zealand involve individuals participating in rugby union⁴.

Demystifying concussions: causes and mechanisms

Before we dive into the specifics, it's important to understand what causes concussions, and how they affect the brain.  In very simple terms, they often result from sudden blows, falls, or accidents that cause the brain to shift within the skull.  In sports, athletes are often subject to a series of impacts; for example, the rugby player who is involved in a high impact tackle, who then takes a fall – increasing the risk-factor significantly.

When a forceful impact takes place, the brain can twist or bounce inside the skull, leading to damaged nerve cells and chemical changes in the brain.

The complex spectrum of concussion symptoms

Concussion symptoms are different for each individual with varying levels of severity.  Common symptoms include headaches, dizziness, and confusion, but they can also extend to more subtle cognitive and emotional shifts.

You may come across cases where people experience persistent concussion symptoms that affect their work performance, mood, and overall well-being.  These symptoms can be challenging to detect without proper awareness and monitoring.

Signs of concussion

Immediate signs of a concussion can be apparent right after the injury occurs. In a sports context, it’s important to be aware of these symptoms so prompt medical attention can be sought.  Things to look out for include:

• Loss of consciousness, even briefly
• Confusion and a feeling of being dazed
• Memory loss for events pre and post accident
• Nausea or vomiting
• Slurred speech
• Unequal pupil size
• Irritability
• Balance problems and dizziness

Understanding these immediate signs is crucial for effective intervention and care.

Subtle and delayed concussion symptoms: the importance of ongoing monitoring

Concussion symptoms can sometimes emerge slowly in the days following the initial injury. Therefore, going monitoring is important, especially when playing sports or participating in types of work that are prone to head injuries.

If a concussion is experienced while playing sports recreationally, these symptoms can start to show when the person has returned to employment, due to the thinking required and the pace of work.  Some of the problems include persistent headaches, mood swings, difficulty concentrating, or increased sensitivity to light and noise.  Being aware of these symptoms can make a significant difference in an employee's recovery and well-being.

Concussion management and recovery: a comprehensive approach

Managing concussions involves initial assessment and a comprehensive approach to ensure the well-being and successful return to work of affected employees.  New Zealand's ACC Scheme plays a crucial role in supporting individuals through this process.

Proper concussion management includes:

• Medical evaluation:  Timely assessment by a qualified medical practitioner.
• Rest and recovery:  Adequate rest for the brain to heal especially in the first 24-48 hours and then  activity levels should be gradually increased
• Symptom awareness: However, balancing this with the knowledge that  most people recover well within several weeks or months. 
• Gradual return to work and school: A structured plan to reintegrate employees into their roles and young people into school.
• Education and support:  Ensuring clients and their support people are well-informed and supported throughout the recovery journey

How treatment for concussion works in New Zealand

In the event of a concussion, seeking medical attention from a doctor is required.  The first 24 hours following a head injury are vital, as this is when serious complications are more likely to arise.  It’s imperative that you’re not alone during this period, and someone should closely monitor your condition.

During the first 24 hours following a concussion, you must:

• Rest as much as possible, but avoid falling asleep within the first 4 hours. After this initial period, aim for a regular night's sleep at the usual time.
• If there are concerns about the severity of the injury, it is safest to gently wake the individual every 2 hours on the first night and ask them a simple question. If they cannot be awakened normally, seek urgent medical assistance.
• Refrain from consuming alcohol, sleeping pills, or illegal substances, as these can mask potential developing issues.
• Use paracetamol if necessary to alleviate headaches.
• Avoid operating a motor vehicle.
• Steer clear of engaging in physical activities which have a reasonable potential for resulting in a concussion.

Following a medical evaluation, most individuals with concussion recover without the need for specific treatment, but adequate rest is essential.  If your doctor advises you to take time off work or refrain from sports activities, follow their recommendations until your symptoms have completely resolved, and your doctor clears you for a return. However, you should be gradually increasing our activity levels during this time

Should your symptoms worsen at any point or more severe symptoms develop (as outlined in the warning signs above), seek immediate medical attention.

If your symptoms persist beyond a two-week period, consult your doctor once more. Individuals with ongoing symptoms may require a referral to a Concussion Service.

• ACC's Concussion Service offers early intervention rehabilitation services for ACC clients who have sustained mild to moderate traumatic brain injuries.
• The referral form (ACC883) is available for download from the ACC website. 
• Referrers can directly refer individuals with diagnosed or suspected concussions to a Concussion Services provider like Active Plus without the need for prior approval from ACC.

Summary

In New Zealand, concussions are common in sports, with rugby, soccer, and basketball players frequently affected. Understanding that concussions vary in presentation and may not involve loss of consciousness is vital. 

They result from sudden impacts causing the brain to shift within the skull, leading to diverse symptoms that can manifest subtly or weeks after the injury. Recognizing immediate signs and monitoring for delayed symptoms is crucial, particularly in sports settings. 

Comprehensive concussion management encompasses medical evaluation, rest, ongoing symptom tracking, gradual return to work, and robust education and support. In New Zealand, ACC's Concussion Service offers essential rehabilitation for those with persistent symptoms, streamlining referrals for timely intervention.

Reviewed by: Kris Fernando

Sources:
¹ Ontario Neurotrauma Foundation. Guideline for concussion/mild traumatic brain injury & prolonged symptoms. (Accessed Sept 2023).
² Reducing Traumatic Brain Injury (ACC) (Accessed Sept 2023).
³ Reducing Traumatic Brain Injury (ACC) (Accessed Sept 2023).
⁴ Concussion/TBI dataset obtained from the Accident Compensation Corporation (ACC) 2021. (Accessed September 2023).