Dr Marwan Al-Dawoud – Concussion in Rugby – Injury Rehab Network Event

The June 2023 Injury Rehab Network event with BASRaT featured Dr Marwan Al-Dawoud, Sport & Exercise Medicine Doctor. The online event took place on the evening of 12th June, with over 220 sports rehabilitation professionals in attendance.

Marwan is a Sport and Exercise Medicine Doctor specialising in tendon problems, musculoskeletal ultrasound, and interventional therapy.

The recording of Marwan’s presentation is available to watch here

Marwan

Dr Marwan Al-Dawoud, Sport & Exercise Medicine Doctor

Dr Al-Dawoud qualified from the University of Manchester Medical School and went on to do GP training, followed by more specialist training in Sport and Exercise Medicine. He has worked in elite sports since 2007 in the Rugby League Super League, Premiership Rugby Union, Premiership Football, UK Athletics, England Rugby League, and England Football.

Although he has worked across a vast range of sports, he has extensively worked in rugby as Head of Medical Services for Leeds Rhinos, Lead Doctor for Sale Sharks and Lead Doctor for England Rugby League Men’s. He is a reviewer for the British Medical Journal for Sport and Exercise Medicine and is the National Sport and Exercise Medicine Doctor for Connect Health, the UK’s largest independent musculoskeletal healthcare provider. He works in NHS musculoskeletal services across Yorkshire and the North West of England.

Concussion in Rugby

Dr Al Dawoud’s presentation, “Concussion in Rugby”, drew on his experience in both rugby union and rugby league. Marwan discussed the management and prevention of concussions in sports, longer-term consequences and what the future of concussions may look like.

Marwan provided an overview of what his presentation would focus on, including:

Concussion overview
Decision making in the pressurised environment
The impact of concussion
Technology and research
What about the NHS?

Dr Marwan Al Dawoud

Marwan provided a brief overview of his career as a Sport and Exercise Medicine Doctor and GP. His roles include work in primary care, community MSK, Hospital NHS Trust MSK, elite sport, private practice, and management.

In professional and elite sports, Marwan has gained significant experience in rugby union and rugby league at top-level clubs and with England teams in both codes. He has also worked in football, elite sport, and athletics.

Disclaimer

Marwan provided a disclaimer that his presentation is based on his experiences of concussion in sport and does not replace guidelines from National Governing Bodies of sport.

Rugby Head Injury

What is concussion?

Marwan described that concussion is a disturbance in brain function caused by direct or indirect force to the head, resulting in a variety of vague signs and symptoms. He noted that concussion most often does not involve loss of consciousness.

Dr Al Dawoud described how symptoms usually start shortly after the incident and get better with time, appropriate rest and recovery but can be delayed. Concussion does not show up on any scans. The majority of cases (80-90%) resolve in around 7-10 days but may take longer.

Symptoms

Marwan discussed concussion symptoms, including those listed in the SCAT (Sport Concussion Assessment Tool). The primary symptom is headache, which is present in 95% of concussion injuries. Dizziness occurs in 74% of concussions, with difficulty concentrating in 56% of cases. Marwan considered symptoms that may be more difficult to identify and athletes may be less willing to disclose or be aware of, including being more emotional, nervous/ anxious and having trouble falling asleep.

Why is concussion important?

Dr Al Dawoud explained that concussion accounts for 25% of all rugby injuries and is important because of the potential for structural brain injury. If athletes return to sports too soon, symptoms can be prolonged and more troublesome (second impact syndrome).

Marwan described how an athlete’s performance before full recovery is likely to be poor, with a 60% increased risk of other injuries after a concussion. There can be a possible long-term change in brain function and mental health. Repeated concussions place athletes at higher risk of long-term problems.

Awareness of concussion in sports and associated potential long-term issues has grown, and Marwan described recent media coverage.

Recognition – Definite Concussion

Dr Al-Dawoud discussed recognition of concussion with the following signs and symptoms indicating a definite concussion (even if the athlete looks and feels ok after):

Loss of consciousness (knocked out)
Traumatic convulsion (fit/ seizure)
Tonic posturing (stiff limbs/ jerks)
Ataxia (unsteady/ off balance)
Disorientation or confusion

For any of the above, treatment = removal from the field of play with no return.

Recognition – Suspected Concussion

Marwan described how concussion should be suspected in any one or more of the following:

A significant blow to the head
Symptoms or physical signs
Impaired brain function
Abnormal behaviour
Incorrect/ struggling with Maddock’s Questions

Treatment = removal from the pitch for assessment

Marwan noted the importance of the principle, “if in doubt, sit them out”.

Rugby Head Assessment

Medical room assessment

Marwan discussed the process (part of SCAT5) once an athlete has been removed from the pitch for assessment. Athletes undergo an initial 5-minute rest period followed by testing, which takes around 10 minutes. Tests focus on and may include:

Symptoms
Orientation
Balance
Memory
Concentration
Coordination
Computer-based neurocognitive tools

Management – immediate

Marwan described the immediate steps for the management of concussion as follows:

Rest (body and brain) for 24 – 48 hours
- - Including exercise, use of devices/ screens and thinking in general

Remain supervised by a responsible adult
Avoid dehydration
If headache
- - Take paracetamol (not aspirin or ibuprofen)

Do not
- - Drink alcohol
  - Take sleeping tablets
  - Drive

Management – next steps

Marwan discussed the next steps for the management of concussion following the initial rest period:

Graduated return to play over a period of time (as defined by NGB for sport and age)
- - Supervised at an elite level
  - Unsupervised at grassroots level
  - Transition from rest to light exercise, sport-specific exercise, non-contact training, full contact practice and finally return to play
  - Athletes should only transition to the next stage if no symptoms are present

Marwan described how the Buffalo Concussion Treadmill Test could also be used where the relevant equipment is available.

Dr Al Dawoud also discussed how vestibular exercises are increasingly being used to manage concussion (with support of clinicians with appropriate knowledge).

Pressurised Decision Making

Marwan discussed a case study from his experience as a team doctor at an international rugby league match. Unfortunately, the video replay system was broken, so the medical team couldn’t review footage of a collision and potential injury.

Marwan assessed the player on the field but, without being able to review footage of the incident, could not identify any concussion symptoms and the athlete was allowed to continue to play. By halftime, a viewer of the incident had tweeted a recording which clearly showed symptoms. Marwan then discussed the incident with the manager and player, with the player removed from play and the injury managed accordingly.

Factors to Consider

Dr Al Dawoud discussed important factors that practitioners should consider for the recognition, assessment and management of concussions, including:

Professional registration
Standing by clinical decisions – job to safeguard the patient
Balance with pragmatism
There is no substitute for experience (and knowing individual players, their history and personality)

What are the long-term effects?

Marwan discussed the long-term effects of concussion, including:

10% – 15% develop persistent symptoms
- - Vestibular
  - Somatic
  - Cognitive
  - Emotional

Multiple concussions risk cognitive impairment and mental health problems
There is a growing body of evidence to suggest the link between multiple concussions and neurodegenerative disease (Dr Willie Stewart et al.)

Technology and Research

Dr Al Dawoud is involved with research for Instrumented Mouth Guards (iMGs):

iMGs can quantify head acceleration events
Validity and feasibility between iMGs is being investigated
Potential to enhance concussion assessment both live and retrospectively
Collect key head impact metrics
- - Angular acceleration
  - Location and direction
  - Count
  - Collision workload

The Future?

Marwan considered the elements associated with the future of concussion in sports:

Concussion assessment
- - Observation/ video
  - Clinical assessment
  - SCAT
  - iMG
  - More tech/ science?

What about the NHS?

Dr Al Dawoud discussed the treatment that the general public is likely to receive for a concussion:

Patients may typically present to A&E/ UCC or GP
A&E aim to exclude a structural brain injury, may observe onward for 24 hours and discharge with head injury advice
GP will refer to A&E if a structural brain injury is suspected and may refer to secondary care if there are persistent symptoms (longer than three months)
Secondary care is variable, with generally poor and disjointed services, including neurology, neurosurgery, rehabilitation medicine and psychiatry

Marwan described how there is hope for the general public through Acute Soft Tissue Management Clinics, which include:

SEM/ EM/ Physio
In emergency departments
Links with wider MDT (neurology, radiology, vestibular physio, psychology)

Marwan also discussed NHS concussion research:

What is the current understanding and provision for concussion
Long-term monitoring of concussive symptoms

Summary

Marwan provided a summary of the key points from his presentation as follows:

A concussion is the most common rugby injury ahead of ACLs and neck injuries
Signs and symptoms can sometimes be obvious, but more often can be subtle and challenging to detect in the high-pressure environment
If in doubt, sit them out!
Repeated concussions can cause long-term physical and psychological problems
Technology, appropriately harnessed, can begin to play an important contributing role in diagnosing and monitoring concussion
There is a long way to go for NHS services in recognising and supporting people suffering from concussion

Q&A

Marwan kindly answered questions put forward by the practitioners who attended the session.

Q1. Is management different for players with serial concussions?
A1. Practitioners should screen all athletes but be more vigilant, have a lower threshold and spend more time with athletes with a history of multiple concussions. In addition, a one-to-one session with the athlete is advisable. It’s therefore important to build trust with athletes so they are open and honest regarding any issues.

Q2. Is evidence building in relation to screening of saliva proteins?
A2. Research is in its infancy and has been delayed due to covid. Saliva testing can be done at baseline and post-concussion assessment.

Q3. Are there any preventative measures for concussion, such as neck strengthening, which may be effective?
A3. Research findings are variable, but there is no harm in having good neck strength.

Q4. Should practitioners approach and manage concussions in the same way for women and men?
A4. Yes, the approach/ management is the same for women and men. The presentation would be the same. The topic would make for interesting research and a potential future presentation.

Q5. Is SCAT6 due to be available soon?
A5. The date for SCAT6 is to be confirmed but is due to be published imminently.

Q6. Are iMGs available for sports teams to buy?
A6. The best advice is to be part of a research trial affiliated with a university. Various brands are available and being tested, so there isn’t currently a standardized iMG that has been validated and is recommended.

Q7. What’s the best guidance for youth academies for the management of concussion?
A7. Academies often have the least service provision/ resource but the greatest need for the management of concussions. The best advice is to follow NGB guidelines for your sport, to work with a university for research and ensure concussion management is integral to your practices for the treatment and management of injuries.

Presentation Recording