14.4 Sport-Related Concussion: Recognition, Return-to-Learn & Graduated Return-to-Sport

14.4 Sport-Related Concussion: Recognition, Return-to-Learn & Graduated Return-to-Sport

[!NOTE] DHA Licensing Competency Focus: Sport-related concussion sits inside DHA's published Sports Physical Therapy coverage topic and is among the highest-consequence decisions a physiotherapist makes pitch-side. Candidates must know the immediate removal rule, the red flags that mandate emergency transfer, which assessment tool matches which age group and setting, the minimum time structure of the graduated return-to-sport strategy, and the point at which medical clearance is required. Note that the guidance changed materially with the Amsterdam consensus statement: answers built on strict dark-room rest, same-day "return if symptoms clear", or the old concussion grading scales are now wrong.

Sport-related concussion (SRC) is a traumatic brain injury caused by biomechanical forces transmitted to the head — either a direct blow or an impulsive force transmitted through the neck or body. It produces a functional, not structural, disturbance: standard CT and MRI are normal, which is precisely why clinical assessment and a disciplined return protocol carry the whole weight of patient safety.

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1. What Changed with the Amsterdam Consensus

The 6th International Conference on Concussion in Sport (Amsterdam, October 2022; consensus statement published in the British Journal of Sports Medicine in 2023) revised several long-taught positions:

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2. Sideline Recognition, Red Flags & the Version-6 Tools

The governing principle is unchanged and absolute: if a concussion is suspected, remove the athlete, and do not allow return to play on the same day. The commonly taught phrasing is "If in doubt, sit them out."

Red Flags Requiring Emergency Medical Transfer

• Neck pain or tenderness (manage with cervical spine precautions)
• Seizure or convulsion
• Loss of consciousness, or a deteriorating conscious state
• Double vision
• Weakness, tingling, or burning in the arms or legs
• Severe or increasing headache
• Repeated vomiting
• Increasingly restless, agitated, or combative behaviour
• Glasgow Coma Scale below 15
• Visible deformity of the skull

Matching the Tool to the Situation

A frequent exam distinction: the CRT6 does not diagnose concussion — it is a recognition aid that tells a non-clinician when to remove an athlete and seek assessment. Only a healthcare professional using SCAT6/SCOAT6 within a full clinical assessment makes the diagnosis.

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3. Acute Management: Relative Rest, Then Early Activity

  Day 0        Days 0-2                 Days 2-10                    > 4 weeks
  |            |                        |                            |
  Remove  -->  Relative rest       -->  Early sub-threshold     -->  Multimodal assessment,
  from play    (limit screens,          aerobic exercise,            cervicovestibular
               light daily activity)    progress by symptoms         rehabilitation

• First 24-48 hours: relative rest. This means reduced cognitive and physical load and limited screen time — not a darkened room, and not complete inactivity.
• After 24-48 hours: light physical activity such as walking is encouraged provided there is no risk of contact, collision, or fall.
• Days 2-10: progressive aerobic exercise at an intensity below the symptom threshold has been shown to aid recovery and reduce the risk of persisting symptoms.

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4. Return-to-Learn Precedes Return-to-Sport

For students and student-athletes, return-to-learn (RTL) takes priority. The RTL strategy progresses from daily activities that do not provoke symptoms, to school-type activities at home, to part-time school with accommodations, and finally to full days at school without adjustments. An athlete should complete RTL before unrestricted return to sport. In practice, this means a physiotherapist coordinating an adolescent's rehabilitation in a Dubai clinic must ask about school tolerance, not only about training tolerance.

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5. The Six-Step Graduated Return-to-Sport Strategy

Rules that items are built around:

• Each step takes a minimum of 24 hours, so the fastest possible completion of all six steps is about one week.
• Steps 1-3 are a treatment phase. Mild symptom exacerbation of 1-2 points on a 0-10 scale during or after these non-contact activities is acceptable provided it resolves within one hour.
• Progression to Steps 4-6 requires resolution of concussion-related symptoms and clinical findings at rest and with maximal exertion, plus medical clearance, and should be monitored by a healthcare professional.
• If symptoms recur, drop back to the previous asymptomatic step and resume after at least 24 hours.
• Typical unrestricted return to sport occurs within one month of injury, with a pooled mean time to return of approximately 19.8 days.

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6. Persisting Symptoms Beyond Four Weeks

Symptoms that have not progressively resolved by 4 weeks warrant multimodal assessment rather than continued waiting. The physiotherapist's contribution is substantial and testable:

• Cervical assessment. Whiplash-type cervical dysfunction reproduces headache, dizziness, and neck pain that are easily mis-attributed to the brain injury. Cervicovestibular rehabilitation is explicitly recommended.
• Vestibulo-ocular screening. A screening battery examines smooth pursuit, saccades, near point of convergence (a value of about 6 cm or greater is abnormal), the VOR, and visual motion sensitivity, with a symptom increase of 2 or more points regarded as a positive response.
• Sub-symptom-threshold aerobic exercise. A standardised symptom-limited treadmill or cycle test establishes the heart rate at which symptoms are exacerbated; aerobic exercise is then prescribed at approximately 80%-90% of that heart rate.
• Screen for modifiers: history of prior concussions, migraine, mood or anxiety disorders, sleep disturbance, and learning difficulties all predict slower recovery.

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7. Clinical Scenarios & DHA Exam Traps

Clinical Scenario: The Tournament Weekend

A 16-year-old rugby player is dazed after a tackle on Friday and reports headache and "feeling in a fog". The team physiotherapist removes him and he is diagnosed with a concussion. His symptoms settle by Sunday, and the coach asks whether he can play in Sunday afternoon's final.

Answer: No. Even if symptoms have resolved, the graduated return-to-sport strategy requires a minimum of 24 hours per step across six steps — a minimum of roughly one week — and full-contact practice cannot occur until symptoms and clinical findings have resolved at rest and on exertion and medical clearance has been obtained. In addition, as a student he should complete return-to-learn first. Symptom resolution is a necessary but not sufficient condition for return.

DHA Exam Traps to Master

1. Same-day return is never permitted after a suspected concussion, regardless of how quickly symptoms clear.
2. Relative rest lasts 24-48 hours, not weeks. An option recommending a dark room until asymptomatic reflects superseded guidance.
3. Minimum 24 hours per step, six steps, so about one week minimum — not "return when symptoms stop".
4. Normal CT or MRI does not exclude concussion. SRC is a functional disturbance; imaging is used to exclude structural injury when red flags are present.
5. Neck pain or tenderness on the sideline is a red flag: apply cervical spine precautions and arrange emergency transfer.
6. CRT6 is recognition, not diagnosis. SCAT6 (13+) and Child SCAT6 (8-12) are clinician tools; SCOAT6 is for later office assessment.
7. Return-to-learn comes before unrestricted return-to-sport for students.
8. Mild symptom exacerbation is permitted in Steps 1-3 if it is 1-2 points on a 0-10 scale and settles within an hour — a distractor stating that any symptom provocation halts progression is wrong.