Introduction
Sports-related concussion (SRC) is an evolving injury in the acute phase with rapidly changing clinical signs and symptoms and is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage.1
In recent years, there has been a significant increase in attention to the consequences of SRC in community level athletes.2 Much of this research is conducted on adults and there is limited SRC research into the effects of concussion on children and adolescents in rugby.3–5
Currently, there are no defined, evidence-based age groups for the management of youth SRC. Davis et al recommend that child-specific paradigms for SRC management should apply to children aged 5–12 years and adolescent-specific paradigms should apply to those aged 13–18 years.6
Although SRC management guidelines are largely derived from studies in adults,1 there is evidence that adolescents have poorer outcomes after SRC compared with older athletes.7–10 It is hypothesised that during the phase of cognitive maturation, the developing brain may be more susceptible to both acute and chronic complications from concussions and/or repetitive head impact.11
Adolescents tend to have a greater number of and more severe postconcussion symptoms than younger children and tend to take longer to recover and return to school and sport than younger children. Additionally, students with a greater number of symptoms and more severe symptoms tend to take longer to return to school and require more academic accommodations as well as taking longer to recover and to return to sport.6 The expected duration of symptoms in this age group is defined as up to 4 weeks vs 10 days in adults>18 years.6
In 2014, the US Institute of Medicine and National Research Council released a report titled ‘Sports-Related Concussions in Youth: Improving the Science, Changing the Culture’, which considers risk factors, screening, detection, treatment and management recommendations and long-term consequences of repetitive concussions in the developing brain.12 This area was also systematically reviewed at the Fifth International Conference of Concussion in Sports.6 These studies provide an important foundation for understanding the consequences of concussion in children and adolescents.
The assessment of SRC should aim to identify specific pathologies that may be contributing to the persistence of symptoms using a detailed multimodal assessment, which includes a comprehensive history, symptom score, focused physical examination (including assessment of cervical spine), balance, neck strength,13–15 vestibular and oculomotor function and a systematic evaluation of exercise tolerance.1 16 17 This assessment may facilitate classification of phenotypic injury subtypes and coupled with fluid biomarker,18 proteomic19 20 and genetic signatures21 22 may allow development of targeted interventions for cases of persistent symptoms following SRC.23
To date, most studies investigating the domains that can be affected as a result of SRC use diagnostic tools in isolation. However, it is likely that a combination of diagnostic tests as compared with individual tests will improve diagnostic accuracy of concussion.24 Currently there is insufficient evidence to determine the best combination of measures to improve identification of concussion.
In this study, we aim to investigate how concussion affects adolescent rugby players and how a variety of diagnostic tools interact with each other as participants recover from their injury; which in turn will inform the development of a framework for the safe management of schoolboy rugby athletes postconcussion.
In addition, schoolboy rugby players often participate in multiple sports and/or in multiple teams within the same sport over the course of their lives. This study will also determine the logistics and optimal format of recording an individual’s concussion history, including number of concussions, severity of concussions, results of investigations and duration of recovery on a virtual ‘Concussion Passport’ that would remain with the individual throughout their sporting career, which will provide a better platform for future research and ultimately improve how concussion is managed.
Aims and objectives
To determine the incidence of SRC in schoolboy rugby in Ireland.
To establish a normative data set of clinical, biomarker and physiological markers used in the assessment of a schoolboy rugby population at preseason baseline.
To determine the extent and temporal changes in balance, oculomotor function, vestibular function, exercise physiology, biomarkers and neck strength following SRC.
To understand the logistics of a detailed screening programme and establish a ‘Concussion Passport’.