In the world of sport, it is customary for any trauma without loss of consciousness to be considered benign.
The concussion is an example: “ it is sounded, but that goes! “ . Indeed, the KO without loss of consciousness does not appear as synonymous of concussion in the eyes of players or coaches.
A concussion is a disorder of brain function resulting from trauma resulting in an abnormal condition of the subject, ranging from mere confusion to loss of consciousness. It belongs to the so-called mild traumatic brain injury (TCL). It is characterized by an immediate and transient alteration of the higher functions. The post-concussion syndrome remains the main complication in the short and medium term. Unfortunately, only cranial trauma with loss of consciousness is usually considered a serious accident. In cases of craniofacial or cervical trauma of moderate severity associated with a concussion, the concussion is also often ignored. Moreover, for fear of not playing the next match, missing a selection or financial stakes, the athlete tends to mask the symptoms and, in particular, a brief period of loss of knowledge or confusion.
The deleterious effects of concussions are documented and it appears that in many countries (USA, Canada, Australia, New Zealand) recommendations are made and transmitted to the medical and sports management and accessible on the sites of the sports groups.
These recommendations emphasize the caution that must be exercised with regard to concussions, especially in children and adolescents. This is justified when this concussion is unique, but is fundamental in the event of repetitive concussions and, in particular, during the same sporting event (match or tournament).
In view of the latest international consensus on concussions in Zurich, which is not very widely known, and the low awareness in France of possible sequelae after simple or moderate concussions without loss of knowledge (but also in complex forms), the Society French Sport Medicine wishes to produce a document to appear on its website in agreement with the sports movement.
This document has two components, one for doctors with its scientific component and the other for practical use in the field. Its objective is to alert the athlete’s entourage about the possible short, medium and long-term consequences of concussions during the practice of sport.
Cerebral concussion is characterized by a temporary loss of normal brain function due to direct or indirect trauma, with impulsive force transmitted to the head, with or without loss of consciousness. It is characterized by a threshold of dysfunction of neurophysiological functions with immediate and temporary impairment of mental function, spontaneously reversible.
The main signs are:
• altered consciousness and memory;
• confusion or disorientation of concentration difficulties (groggy);
• anterograde or retrograde amnesia which has all its value and functional signs;
• headache, unusual sleep disturbances, impaired visual and gestural coordination, and impaired balance.
Its practical diagnosis is based on neurological examination and, in particular, on the interrogation of the subject and the observers. Consideration must be given to the age of the subject, the degree of severity and the number of concussions suffered by the subject.
Definition of the Zurich consensus:
At the Second International Conference on Concussions in Prague in 2004, a consensus on the definition was obtained and updated in 2008 (the third consensus conference in Zurich):
The concussion may be caused by direct trauma to the head, face and neck or to any other part of the body that transmits an impact to the head.
The concussion results in a brief disturbance of neurological functions regressing spontaneously.
It may be caused by neurological disturbances, but the acute signs are more a malfunction than a structural impairment.
The concussion results in a scale of symptoms and may or may not evolve into loss of consciousness.
The regression of clinical symptoms and cognitive functions usually follows a standardized pattern.
Typically, the concussion is accompanied by imaging without abnormality.
The Prague conference proposed two stages of concussion: simple concussion, resolving between seven and ten days, and complex concussion with persistent symptoms.
In Zurich, authors abandon these two stages to retain the concept. They specify that 80 to 90% of the concussions resolve within seven to ten days, without specifying whether they include the time to return to the game. They specify that this delay is longer in children and adolescents.
It also seems that the concussions are more serious in sports women. In addition, the well-trained and well-prepared athlete would be less prone to complications and heal faster.
In the field, and for ease of communication with the athletes’ environment, it is always the classification in three degrees of gravity based on immediate observation which is the most used, but which will have to be replaced eventually.
Grades 1 and 2 are considered to be a simple or moderate concussion and Grade 3 to a complex concussion.
The loss of knowledge is far from omnipresent (10%) and is therefore not essential to the diagnosis of concussion. The disappearance of signs is progressive.
It is essential to establish this formal degree of seriousness to examine the subject again at 48 or 72 hours in order to determine it more accurately. This precision is based essentially on the persistence or not of the clinical signs and of the time during which they persist. For Cantu, gravity is certainly a function of the duration of the loss of consciousness, but also of the duration during which post-traumatic amnesia persists and post-concomitant syndrome.
This is why its quotation is made only a week later.
In field practice, the Zurich classification is retrospective, taking this factor into account. However, the ten-day period is questionable; recent studies show that this delay seems insufficient.
Clinical and neuropsychological evaluation in two stages resolves this problem.
In the United States, there are about 300,000 concussions per year among athletes, representing 20% of total concussions. These are most often reported only when they are associated with a loss of consciousness.
Almost 75% are simple concussions and 15% retain sequelae at one year. The French study Epac shows a headache in 13% of sports accidents. In the practice of rugby, in particular, between 10 and 15% of the injuries are located in the cephalic segment, mainly in the veneers (plate and veneer) and about 5% are accompanied by concussion, many of which are ignored. Skiing is a provider of concussions in children and recommendations are made by mountain doctors.
Toth takes over the epidemiology and location of neurological damage in every sport in Canada, and thus specifies high-risk sports: hockey, American football and team sports, boxing and winter sports.
The signs encountered are in 17% of the cases a loss of knowledge. Concerning the repetition of concussions, out of 104 commotions encountered among academics, one finds 67% of first concussion, 32% of second and 12% with more than two.
Guskievicz followed 2905 college football players from 1999 to 2001. The majority of concussions reported (69.8%) were Grade 2 (US Neurologist Scale). The most frequent symptoms were headache (85.2%) followed by disturbances of balance and gait (77%), while memory disorders and loss of consciousness were encountered in only 24 , 1% and 6.2%. The mean duration of post-concussive symptoms was 82 hours.
The strong incongruity of the loss of knowledge was also noted in rugby where the most frequently found signs are amnesia, headaches and balance disorders.
When comparing post-concussion duration studies, there is a major difference in whether patients are high-performance athletes or not. Indeed, according to Guskiewicz only 8.1% of high-concussed players have seen their post-concussion syndrome persist for more than a week and 1.6% more than 15 days.
In the practice of boxing and in other combat sports (savate), the regulation specifies the duration of practice after concussion (KO in Boxing English: 30 days, non-combat in boxing savate: 60 days) with written ban on sports passports.
The International Rugby Board (IRB) recommends a 21-day stoppage, without written obligation, adaptable after written expert advice from a neurologist or neurosurgeon and provided that athletes are asymptomatic. These recommendations are reflected in the regulations of the French Federation of Rugby and National Rugby League. This is not defined precisely in other sports.
The International Olympic Committee, the International Amateur Football Federation, the International Ice Hockey Federation and the IRB participated in the third conference in Zurich and encouraged the dissemination of the Sport Concussion Assessment Tool 2 (SCAT 2).
Scales of gravity:
In the initial trauma, general level scales such as those of mountain physicians or the Glasgow score are used to monitor evolution and classify trauma, field questionnaires such as Patel’s or Patel’s Maddocks. Associated symptoms and follow-up of neurological signs (graded symptom checklist [GSC ] , Galveston orientation amnesia test [GOAT], balance scoring system [BESS]. Recommendations specify the signs requiring hospitalization.
In practice, many standardized forms are proposed, and more recently “ online ” questionnaires , which are not always easy to use in the field.
In fact, two types of questionnaires exist: those assessing the existence or severity of the concussion with associated signs and those investigating the presence or absence of neurocognitive and postural impairment and the time to resolution of symptoms.
We retain in the literature some of these assessments, mostly included in the SCAT2, and detail those that seem to us most usable.
The usable tools are described as follows:
• a mountain physician’s field rating of the overall severity of trauma on a scale of 1 to 10 and the Glasgow scale less used in sports trauma, pathological below 15/15;
• Patel field questionnaire;
The questions are addressed to the athlete shuffled on the field.
• initial post-traumatic clinical record;
• hospitalization criteria;
After the synthesis of numerous articles and after consulting the experts, it seems that the criteria below are relevant and recommendable. They specify that any suspicion of intracranial lesion or any risk of cerebral hematoma justifies from the outset a hospitalization.
• GSC; GSC looks for the unusual neurological signs associated with follow-up of the trauma and their evolution over time. The rating of 1 to 6 of the items according to the severity of each sign is however random as a function of the observer, but already specifies the use of specialized advice if necessary.
• GOAT: memory impairment test;
• BESS or equilibrium test, complex on balance platform;
• standardized mental assessment of sports concussion (SAC), a global test of mental functioning. Mc Crea and his team were interested in cognitive abnormalities detected early after the concussion to see if any prognostic elements could be established.
Out of 2385 players selected, 91commontions of the brain (3.8%) were recorded. The Standardized Concussion Scale (SAC) was established to assess the degree of severity of the concussion at the first concussion.
The SAC contains a total of four items: two of memory (immediate and delayed), one of concentration and one of orientation. The total score must be 30. It is associated with a neurological study (strength, coordination, sensitivity and coordinated complex movements).
SAC was performed in all subjects before, immediately, 15 minutes, 48 hours and 90 days after the concussion. The SAC score was immediately decreased in the concussed subjects even in the absence of loss of consciousness (PC) or amnesia.
Three groups were individualized at the time of the concussion: those victims of a PC, those without loss of consciousness, those without amnesia. At the time of trauma, players with a loss of consciousness had a more impaired SAC. Significant differences were in the same direction at 15 minutes, but at 48 hours no difference was found between the three groups. The presence of a PC initially leads to neuropsychological disturbances not found in the absence of PC or amnesia. McCrea emphasized the value of carrying out the SAC as soon as possible, this test being able to standardize at the 48th hour;
• the concussion assessment tool 2 (SCAT 2) defined in Zurich and accessible on-line comprises the majority of these tests. It is very comprehensive and achievable in 20 minutes, but requires an initial assessment of the strength at the beginning of the season to serve as a reference;
• Many on-line tests with subscriptions allow players to be defined at the beginning of the season, then, in the event of a concussion, to assess their severity and, by successive tests, to allow, in association with the clinic , the sporting recovery. They last 15 to 20 minutes and must be realized and validated at the beginning of the season. They are undoubtedly complete and allow an effective follow-up. They also provide a suitable orientation for persistent symptoms.
Classifications according to the degree of seriousness of the concussion:
It seems essential and fundamental for the experts to review the concussioned athlete within 48 to 72 hours in order to confirm the degree of seriousness and to guide the care program. It seems to them that the persistence of signs is the essential element of classification in degree of severity, which is aggravated by the duration of persistence of the clinical and neuropsychological symptoms.
These classifications had up to then three recognized levels of scale. In Zurich, the recommendations are to retain two levels of concussion. We quote for the record:
• Cantu scale, reference of the American football:
◦ grade 1: no loss of consciousness (PC) and post-traumatic amnesia of less than one hour,
◦ grade 2: PC less than five minutes and / or amnesia less than 24 hours,
◦ grade 3: PC more than five minutes and / or amnesia more than 24 hours,
◦ with the reservation of a follow-up examination;
• scale of American neurosurgeons:
◦ grade 1: mild concussion, no PC, transient neurological disorders,
◦ grade 2: moderate concussion, PC followed by recovery in less than five minutes,
◦ grade 3: PC greater than five minutes;
• US neurologist scale, relatively more severe and taken over by the coaches’ association:
◦ grade 1: transient confusion, no PC, disappearance of symptoms in less than 15 minutes,
◦ Grade 2: transient confusion, no PC, symptom duration of more than 15 minutes,
◦ grade 3: any PC, short or prolonged;
• definition of Zurich 2008:
◦ simple concussion: concussion recovering between seven and ten days,
◦ complex concussion,
◦ this last definition perfectly integrates the short-term and retrospective follow-up of the patient and allows a diagnostic approach according to the opinion of the experts.
Concussion in Children and Adolescents under 20 and Second Impact Syndrome
The concussions of the young are more frequent than in the adult, especially in the adolescent, with a risk of 180 to 250 per 100,000, five times more than in adults.
Only 6% of concussions in young people, considered to be severe, require intensive care, with the majority remaining untested.
The second impact syndrome, although discussed, is nevertheless responsible for the deaths of 19 children or adolescents. The delay between the two causal concussions may be as long as four days.
The brain during growth is particularly vulnerable and the child always tends to diminish the signs and not to be aware of the potential severity of the lesions, sometimes dangerous negligence. Many authors report the increased risks of deterioration of cognitive and memory functions in repetitive commotions of children and adolescents, particularly for particularly sensitive structures such as the hippocampus (learning and memory).
Cognitive impairment in tests is a function of the age and number of concussions of the subject. The younger the subject, the greater the risk of cognitive impairment after a concussion.
The experts stressed the need for a rigorous program for the under 20s: complete cessation of activities for one week at any grade, then a gradual return without contact, and a return to play after 21 days, if the subject is asymptomatic.
The last conference in Zurich did not find consensus on this subject. However, some authors consider that there is a cumulative effect of the lesions and that the repetition of the lesions has deleterious effects in the long term.
Others find no correlation between the severity of the concussion and the duration of recovery of brain function. It is shown that a concussed subject is more likely to repeat concussions and that the risk of recurrence increases with the number. In the same season, 92% of the second concussions occurred less than 10 days after the first, confirming the need for rest at least one week after the first episode. Iverson shows that athletes who have undergone repetitive concussions have seven times more memory disorders than those who have suffered only a concussion and have a susceptibility to repeat concussions; if a player had more than three concussions in his past, his risk of developing a new concussion was multiplied by three.
For experts, grade 3 or grade 2 concussions with a history of concussion must be strictly restored for at least one week and the athlete must be reviewed before any sport is resumed. When the athlete presents two concussions during the same season, whatever the grade, he must be at rest for a month.
Finally, in the event of a third concussion in the same season, it must be put to full rest for the whole season, and be examined by a neurologist before any decision to resume the sport.
Deleterious effects of concussions:
Recent and recent studies have drawn attention to the secondary syndrome of concussions, sometimes as a result of a single concussion, with short or medium-term development of a chronic depressive syndrome (Auerbach syndrome).Recent findings show this in high-level players. This requires follow-up of concussioned athletes and special attention in the event of depressive syndrome or negative performance labeled “ mental “ with reflections of type: it no longer wants!
Deleterious effects in the medium-term and long-term may in certain cases (20% according to the authors) lead to an ante-pituitary involvement with growth hormone deficiency mainly, or overall exceptionally.
These disorders require a targeted assessment of these attacks at three and 12 months after the concussion, whatever the degree (TSH, prolactin, TSH, FSH and LH, GH, IGF1, ACTH). This screening is even more essential in young children. Follow-up of the growth curve and IGF-1 seems necessary. Behan et al. show that in the acute phase, 80% of the concussions have hypothalamic-pituitary disorders, partly reversible, and that at one year, 25% show signs of deficiency, mainly somatotropic.
The follow-up recommendations are to make a growth curve in children, to detect early biological abnormalities in acute, even if they have no predictive value, and to make in case of signs of call hypopituitarism the useful dosages at three months and one year. They recommend a prolonged follow-up of the traumatized or at least recommend to make them aware of the possible deleterious effects of the concussion they have undergone and to consult in case of clinical disorders.
In boxers, a sport whose goal is to provoke a commotion (KO) in the opponent, Tanriverdi et al. show that they have a high risk of pituitary dysfunction (25%) and predominantly on growth hormone. During urinary tests, we observed elevations of LH after the so-called “ hard “ fights, indicating this attack.
Decline of brain function:
In a contested study, De Beaumont et al. a long-term decline in functions among former concussed youth. Chermann evokes in the sportsmen groups of patients suffering from post-traumatic encephalopathies (pugilistic dementia, Parkinson, Alzheimer, certain depressions). A wider entity known as chronic traumatic brain injury (CTBI) or cognitive disorders related to repeated cranial trauma has been individualized. It encompasses both classical dementia and Alzheimer’s disease, as well as mild cognitive impairment, behavioral disorders and chronic depression. Pugilistic dementia is characterized by the occurrence of early cognitive disorders with memory disorders, ataxia and Parkinson’s syndrome consisting of akinesia, ideo-motor slowdown and dysarthria.
Head and extremity tremors, pyramid syndrome and behavioral disorders are readily associated with this.
Imputability of disorders:
A number of cases are subsequently assessed for appraisal due to the sequelae attributed to the concussions, which is not without problems of accountability, particularly in professional sports where it is a job. It is not possible, as it is, to recognize, as for the “ shaken infant syndrome “ , a third causal responsibility to these pathologies. The subject must be informed of the consequences of the concussions and the coaching (coach, educator, manager, president) must apply the recommendations of the sports bodies according to each discipline, ensure the safety of the practices and recommend the rules of Fair Play (Play Hard – Play Smart of American Football) and safeguarding the physical integrity of its players.
Complementary tests usable:
These examinations attempt to seek the anatomical, on the one hand, and functional, consequences on the other. In particular, they try to appreciate the effect on cerebral function. They are decided by the sports doctor or the neurologist specialist concerned.
It is essential, simple and reproducible. It is based on the usual tests of balance and coordination: walking with a turn, Romberg test, index deviation test, cerebellar puppet test, finger-nose test with open and closed eyes, Fukuda or walking test star, Broglio balance test or double leg stance in unipodal support, hand on knee hips flexed at 45 ◦ , nystagmus search, pupillary examination.
Both GSC and brain function records (balance, cognition, memory) allow for essential clinical follow-up, especially in view of the return to the field.
It will be used in the case of signs of severity, or aggravation, during associated lesions and in the slightest doubt in the child. Sometimes these exams are performed in high-level adults to allow a “ secure “ recovery in shorter time frames. Examination protocols are specific to each emergency unit. They are intended to eliminate a possible complication and prevent any forensic problem. It should be noted that the professional French boxers must carry out an angio-MRI to obtain their license.
According to experts, except in the case of certainty of benignity confirmed during the second medical examination, imaging (CT, MRI) is necessary within an acceptable delay estimated at one week.
Many other exams are feasible but have not provided any relevant information to manage the concussion. It should be noted, however, that functional MRI and cerebral perfusion tomoscintigraphy may show abnormalities, but these examinations are not feasible on a large scale.
Usually and by definition, there is no visible imaging abnormality in simple concussion. Normal imaging is insufficient to decide a sporting recovery and only the mental performance tests make it possible to make this decision, in accordance with the results of the clinical examination.
Some studies have shown a secretion of tau proteins and amyloid beta proteins in the cerebrospinal fluid following fighting in boxers (markers of Alzheimer’s disease), testifying to the non-safety of the trauma. A restriction polymorphism at apolipoprotein E, as in Alzheimer’s disease, appears to exist. The number of alleles epsilon 4 is a risk factor for developing post-traumatic chronic encephalopathy. Studies are underway on a larger scale to determine whether in the future genetic tests for this protein will or will not be necessary in risk sports for concussioned athletes.
It might be interesting in a specialized consultation to look for these anomalies. The presence of these markers would result in increased sensitivity to the deleterious effects of concussions and could help in making a career termination decision.
Memory and Learning Test:
The authors emphasize the need to validate cerebral function tests to assess the state and degree of recovery of memory, cognitive and executive functions.
It is true that SCAT 2 contains some of them (SAC). They think it necessary to use tests of executive functions such as paper and pencil tests, Trail Making tests A and B or the test of commissions as well as tests evaluating the memory as the test of Hopkins.
The healing criterion is the recovery of neurocognitive, executive and learning functions, healing that will allow the return to progressive play under control.
Programming of the return to competition:
Once the concussion is diagnosed and its severity is quantified, questions arise as to the duration of the sport stop, the methods of recovery and the authorization to return to competition.
It is essential for experts to remotely evaluate the concussed athlete within 48 to 72 hours in order to search for persistent symptoms despite rest and to classify with certainty the degree of impairment of brain function. From this retrospective analysis will depend the prognosis and the recovery program. Whatever the degree of concussion, it is highly desirable that an examination of the neurocognitive and functional functions be performed by a neurologist trained in concussion.
This is formal when a request for early resumption is made by the sports management, especially at a high level.Indeed, the recommendations of the IRB are 21 days of stop of competition, and often this request is made by the sports management, and in this case, it seems fundamental to us to apply this recommendation.
The different works carried out in simple concussions are contradictory in terms of relative rest periods, from immediate return to high-level adults (Zurich conference) to a delay of seven to ten days for others and with precautions child and adolescent. This delay is guided by the degree of gravity of the concussion, simple or complex.
A strict 48-hour rest is formal for the experts, followed by a new clinical evaluation. For Collie et al., Subjects with a simple concussion but with functional signs never recovered before 11 days, 14 days during impact test follow-up. This teletransmission study shows that, although the subject appears to be “ good “ at seven days, cognitive functions remain disrupted for at least 14 days.
Consider the age of the subject and the cumulative effect of concussions.
It remains true for the authors that the child and the adolescent must remain out of competition 21 days for rugby and combat sports or team sports.
Simple adult concussion (grade 1 or 2):
After a full 48-hour rest, a moderate recovery of activity for one week, a conditional recovery is allowed if there are no symptoms: headache, concentration disorders, feeling of being in cotton , awkwardness, drowsiness or unusual sleep disorders. In their presence, a new rest of 48 hours is requested, with again a resumption of a progressive program of return to competition.
Concussion of complex adult or grade 3:
After a strict rest, intellectual and physical one week, recovery program as in a simple concussion with a formal impossibility to resume competition before 15 days, if the clinical and neuropsychological examinations are normal.
For experts, grade 3 or grade 2 concussions with a history of concussion should be strictly restored for at least one week and reviewed prior to any sports recurrence. When the athlete presents two concussions during the same season, whatever the grade, he must be put to strict rest for one month. Finally, in the event of a third concussion in the same season, it must be put to full rest for the whole season, and be examined by a neurologist before any decision to resume the sport.
Concussions of the child and the under 20s:
• Formal prohibition of return to immediate play.
• Medical examination at 48 or 72 hours and physical and intellectual rest for one week.
• Formal competition and contact stoppage of 21 days, followed by a progressive program.
Scheduled return conditions:
They are based on medical advice and clear information from the athlete about the risks associated with concussions.The athlete is also informed that in case of recurring symptoms or particular symptoms to a few months of the traumatism, he must ask for a medical opinion.
The asymptomatic athlete with a normal brain function takes the activities gradually, step by step, and if, at a degree of effort, the symptoms reappear, it returns to the previous degree of activity.
Proposals for take-back times are mock-ups to meet the demands of athletes, parents and their coaches.Unfortunately, it is impossible not to give them an estimate of the probable duration of the sport stop, in the context of “competitive pressure “ . Again, this authorization is based on the normalization of clinical examination and normality of memory functions, concentration, coordination and balance. The neurological and neuropsychological examination at 48 or 72 hours is essential to be able to pronounce.
Physical preparers may also subsequently observe, during contactless recovery, persistent disturbances in coordination or motor efficiency with unusual blunders or concentration problems. They must take this into account in the back-to-game stages.
It is clear that the adult subject is aware of the consequences of an early recovery and that he must have understood the potential risks. This information will enable it to take a decision which it will assume responsibility. This is completely different for a minor.
It is a step-by-step program of traumatic duration (48 hours per stage in general), which makes it possible to return to the previous level when symptoms described previously (abnormal fatigue, somnolence, disturbances unusual sleep, headache, lack of concentration, memory impairment, clumsiness …):
• phase 1: complete rest 48 hours, then if there are no symptoms at rest, no memory impairment, no balance;
• phase 2: mild aerobic work (cycling, swimming, walking);
• Phase 3: normal physical training;
• phase 4: contactless drive;
• Phase 5: contact training after medical advice and complete clinical examination, after approximately 10 days;
• phase 6: return to play, with as few contacts as possible.
Following the last consensus conference in Zurich, giving a retrospective assessment of the severity of concussion in adults, simple in ten days and complex for any other picture, we believe that in the field we need indicators precise warnings and practical guides for the many sportsmen practicing on non-medical grounds and for their supervision.
CSG clinical assessment forms are relevant once the concept of concussion is accepted. The simple concussion will be effectively defined by the presence of symptoms of disorientation, without memory impairment or loss of consciousness. Complex commotion or cranial trauma will be defined as soon as there is a loss of consciousness, even a very brief one, or associated manifest signs.
It will be treated according to medical advice in the field or in specialized settings in the absence of immediate medical advice.
Surveillance and follow-up and management recommendations are a key determinant of the concussion prognosis. A 48- or 72-hour examination of the trauma is fundamental to the experts and imaging should be considered for any concussion for medico-legal reasons.
The traumatized person’s knowledge of possible deleterious effects in the short or medium term is important.
The specific element of the simple concussion is the fact that it is a disorder of functioning, connectivity of the brain outside any anatomical lesion.
It is this function that should be evaluated and monitored, especially in children and adolescents under 20 years of age whose brain is growing. This monitoring is based on an evaluation of concentration, memory, efficiency, learning and executive functions during the concussion, but above all at a distance from it.
This pathology is frequent but too often neglected and considered “ banal “ .
It is strongly recommended to do neuropsychological tests at the beginning of the season to all players.
These initial data will make it possible to compare them with the results obtained after the concussion, this confrontation will allow, if necessary, the player to resume the potentially traumatic activity.
There are still very few specialized consultations that can address the issues of concussion. There are no recommendations on French sites or on federal sites. It is the object of this work to propose a model of practical behavior for this traumatic pathology.