The Impact of Concussion

Soccer Player with Head Down on Grass --- Image by © Royalty-Free/Corbis

Health and safety awareness is high in Irish education. But a recent sporting tragedy
has raised new concerns about the dangers of concussion and prompted calls for managers and principals to respond.HEAD injury has always been taken seriously. But only in recent years has the seriousness of concussion as a potentially fatal injury been fully realised. In January 2011, 14 year old Ben Robinson, died after being injured during a rugby match in Northern Ireland. His mother Karen Walton was present at the game and her testimony and subsequent recall of the events of that day has perhaps changed the way concussion is viewed in sport forever. Benjamin sustained an injury in the first half of the match which was serious enough for him to be assessed for concussion. He passed the test and resumed playing. Later in the match he took some more heavy blows. He began to exhibit symptoms of concussion and then collapsed. He never regained consciousness and died two days later. A coroner later determined that the cause of Benjamin’s death was ‘second impact syndrome’ and it is this phenomenon which has sent the major sports bodies in Ireland and around the world to rewrite their guidelines with respect to concussion. Second Impact Syndrome occurs where the brain swells after sustaining a blow. This swelling leaves the brain particularly vulnerable to a later blow which can then cause serious injury. REMOVED The basic lesson to be learned is that if concussion is suspected, the person should be removed from the threat of further injury. Of course, concussion can happen in many circumstances as well as in a sports setting, and schools and colleges have been adjusting their policies since. Ben’s father, Peter Robinson later said, “At schools level we don’t assess, we remove if there is a suspicion of concussion after a head collision. It’s not for them to assess on the pitch and do the memory function. That’s in the IRFU guidelines in black and white. If this is so clearly in the rulebook, then why has a tragedy like this occurred?” The IRFU has responded at all levels of the game and in January this year released guidelines and instructions for their amateur and under-age rugby. Over 500 personnel have attended courses on the guidelines. The GAA were one of the first organisations in Ireland to issue guidelines on concussion in 2007. Some 2 per cent of injuries in football and hurling are head injuries with less than 1 per cent result in concussion. Nevertheless, the association rewrote their rules again in 2013. In Northern Ireland Education Minister John O’Dowd wrote to all schools about the dangers of concussion and included reference to the Concussion Recognition Tool (CRT) which contains a checklist to help coaches, teachers and parents recognise the signs of concussion. In the South a novel campaign by Transition Year students in Cashel Community School highlighted the lack of awareness about the problem across the education system. Their project, ‘Without Your Brain You Have No Game’, won a bronze award at the Young Social Innovators of the Year 2014. THE LONG TERM While much of the recent focus in Ireland has been around the immediate dangers posed by concussion, a potentially much larger issue coming down the tracks is that of long term injury. The centre of attention has been American Football where the issue of longterm injury (particularly Chronic traumatic encephalopathy (CTE)) has led to claims that past NFL players have higher rates of memory loss, depression and suicides. CTE is a progressive degenerative disease and in September 2014 it was revealed in a study that 76 out of 79 deceased NFL players were found to have had ºCTE. In 2013, even before this news, the NFL had agreed to pay $765m to provide medical care to former players. Given the nature of American Football it is perhaps unsurprising that concussive injuries are prevalent, but all contact sports have an incidence of head injury. The treatment of those injuries and the current policies of administrators may well be tested in the courts here in the future. In the meantime, everybody involved with younger people would be well advised to overhaul their thinking and policies around head injuries. The legacy of Ben Robinson should be the protection of young people from short and long-term injury. Coup-Contrecoup-20127.jpg

Guidelines on concussion management in schools WHAT IS CONCUSSION? A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specific signs and/or symptoms and most often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following: • Symptoms (e.g., headache), or • Physical signs (e.g., unsteadiness), or • Impaired brain function (e.g.,confusion) or • Abnormal behaviour (e.g., change in personality).

CONCUSSION MANAGEMENT 1. Concussion must be taken extremely seriously to safeguard the longterm welfare of young athletes (those aged under 18). 2. Any young person suspected of having a concussion should be immediately removed from play and must not resume play in the match or training on the same day as the suspected concussion. 3. Young people suspected of having concussion must be medically assessed. 4. After a concussion, young people must rest and not take part in any form of training or matches for a minimum 14 days. 5. If after a minimum 14 day rest period young people are entirely symptom free, they must then follow a graduated return to play protocol. 6. It is recommended that every young person seeks medical clearance before returning to play. RETURN TO SCHOOL • Concussion may impact on the child‘s ability to learn at school. This must be considered, and medical clearance should be sought before the child returns to school. • It is reasonable for a child to miss a day or two of school after concussion, but extended absence is uncommon. Source: Scottish Government Advice in association with The Scottish Rugby Union, the Scottish Football Association and Sports Scotland.

The science of concussion MOST concussive brain injuries are mild, and generally, people recover fully. The problem of concussion lies in the fact that it is not recognized straight away and in a lot of cases, ignored. The brain is a very delicate and is separated from the skull by a layer of cerebrospinal fluid. The brain swells, thereby lessening the space between the brain and the skull. When a blow is powerful enough, this cushion is inadequate to protect the brain from trauma. The area of impact may not only be the location of the blow but a l so where the rebounding brain hits the opposite side of the skull, shown here. When the brain is moved by the force of the blow, rotational forces are thought to have the greatest effect. Therefore, not only the amount of force should be considered but also how the blow was received. Brain injury may cause symptoms which last for hours or may be life long.