Crick­et has be­come the lat­est of ma­jor sports in which con­cus­sion is re­ceiv­ing keen at­ten­tion. The un­der­stand­ing of con­cus­sion and its man­age­ment have changed to the ex­tent that even the hal­lowed rules of crick­et have been mod­i­fied to suit.

The In­ter­na­tion­al Crick­et Coun­cil in Ju­ly 2019 an­nounced new rules that al­low ‘like for like’ sub­sti­tu­tion of con­cussed play­ers for men and women’s in­ter­na­tion­al and first-class crick­et.

Since that an­nounce­ment, test crick­et has seen two such re­place­ments. Aus­tralia’s Steve Smith and the West In­dies’ Daren Bra­vo were both re­placed one day af­ter they pre­sent­ed with symp­toms of con­cus­sion.

In both cas­es, there was a vis­i­ble head in­jury af­ter which the play­er ap­peared un­af­fect­ed. Yet, by the next day, they had to be re­placed.

Di­ag­nos­ing a con­cus­sion is chal­leng­ing, giv­en that the signs and symp­toms can be very sub­tle. Of­ten, it presents with dizzi­ness, woozi­ness, hazi­ness in front of the eyes, or slight lethar­gy, or in­abil­i­ty to make quick de­ci­sions. The play­er may not feel this till the next day.

The ac­tu­al in­jury is not some­thing that shows up on an MRI or CT scan like a frac­ture would on an x-ray. It doesn’t have clear tell-tale signs that med­ical per­son­nel can use to con­firm the di­ag­no­sis.

Some­thing as sub­tle as a change in per­sona could be the on­ly sign. And what’s more, it may not be­come ev­i­dent un­til 24-48 hours lat­er, so it re­quires close mon­i­tor­ing of any­one who gets a hit on the head.

Giv­en the dif­fi­cul­ties with di­ag­no­sis and re­turn to play de­ci­sions, guide­lines have been de­vel­oped to im­prove the stan­dard of de­ci­sion mak­ing in this area.

The con­sen­sus state­ment put for­ward by the Con­cus­sion in Sport Group in 2016 at the Fifth An­nu­al Con­fer­ence on Con­cus­sion in Berlin is one of the main guid­ance doc­u­ments that ex­ist to­day.

The doc­u­ment em­pha­sis­es the im­por­tance of base­line as­sess­ments so that sub­tle changes can be matched against the ath­lete’s per­son­al “nor­mal.”

This is done by ad­min­is­ter­ing the Sport Con­cus­sion As­sess­ment Test (SCAT5) (avail­able at https://bjsm.bmj.com/con­tent/bjs­ports/ear­ly/2017/04/26/bjs­ports-2017-097506SCAT5.full.pdf) at the start of the sea­son, and many times af­ter the in­jury un­til the re­sults match the base­line. This should be done by qual­i­fied med­ical per­son­nel.

The SCAT5 is used to as­sess ath­letes 12 years and old­er whilst the child SCAT5 as­sess­es chil­dren ages 5-11.

In re­al­i­ty, there are many sit­u­a­tions where no med­ical per­son­nel is present (school and com­mu­ni­ty com­pe­ti­tions) and in these cas­es, train­ers, coach­es and phys­i­cal ed­u­ca­tion teach­ers, with ap­pro­pri­ate train­ing, can use the Con­cus­sion Recog­ni­tion Tool (CRT5) to iden­ti­fy pos­si­ble con­cus­sion and seek med­ical at­ten­tion for the ath­lete.

Most sport­ing ac­tiv­i­ties are fast-paced and the re­strict­ed field of view of the med­ical team im­pos­es lim­i­ta­tions on side-line ob­ser­va­tion which ad­verse­ly im­pact the di­ag­nos­tic process.

In Oc­to­ber, the Sport Con­cus­sion Group re­leased their con­sen­sus state­ment re­gard­ing signs that one should look for on video re­view of a match to de­ter­mine whether a con­cus­sion oc­curred. These in­clude ly­ing mo­tion­less for more than two sec­onds, un­steadi­ness (mo­tor in­co­or­di­na­tion), stiff­ness of any limb (ton­ic pos­tur­ing), flop­pi­ness, or a blank, va­cant look.

So, a con­cus­sion has been de­tect­ed. What next? Man­age­ment of the play­er fol­lows a six-stage grad­u­at­ed re­turn to play strat­e­gy, be­gin­ning with 24 to 48 hours of phys­i­cal and cog­ni­tive rest, fol­lowed by ac­tiv­i­ties of dai­ly liv­ing, light ex­er­cise, sport-spe­cif­ic ex­er­cise, non-con­tact train­ing drills, full prac­tice and re­turn to com­pe­ti­tion.

Each stage has at least 24 hours be­tween it, but longer if the pre­vi­ous stage is not cleared. The SCAT5 test is per­formed pe­ri­od­i­cal­ly in tan­dem with clin­i­cal ex­am­i­na­tion and oth­er in­ves­ti­ga­tions if need­ed.

To date, this has shown to lead to the least long-term ef­fects and al­lows the quick­est re­turn to sport. Yet, it re­quires a min­i­mum of six days (and some­times up to many weeks). If symp­toms are still present af­ter ten to 14 days for adults or one month for chil­dren, they should be seen by a con­cus­sion spe­cial­ist.

Chil­dren re­quire spe­cial con­sid­er­a­tion and a grad­u­at­ed re­turn to school pro­to­col is rec­om­mend­ed. Re­cov­ery be­gins with short pe­ri­ods of dai­ly ac­tiv­i­ty at home that do not ag­gra­vate symp­toms fol­lowed by school­work be­ing done at home, part-time re­turn to school and full-time re­turn.

No child should re­turn to play­ing sport with­out full, symp­tom-free re­turn to school. Schools must be ac­com­mo­dat­ing and be pre­pared to pro­vide the sup­port to help the child ‘catch up’.

Play­ing sport is an es­sen­tial part of child de­vel­op­ment and the rel­e­vant min­istries must work with the schools to en­sure that sport-re­lat­ed con­cus­sion poli­cies are in place. Teach­ers, coach­es, stu­dents and par­ents must re­ceive con­cus­sion ed­u­ca­tion.

Hap­pi­ly, more and more sports to­day treat con­cus­sion in­juries with the se­ri­ous­ness it de­serves and are mak­ing safer de­ci­sions.