Concussion injuries may be a common feature in school team sports but awareness, education and quick treatment are essential if we are to protect children, writes Áilín Quinlan.
ONCE the new school term kicks off, many second-level students throughout the country will be jostling for a place on the school team.
Whatever your child’s sport of choice — football, hurling, soccer or rugby — it offers a key opportunity to build fitness and friendships. But team sports come with a serious health risk: concussion.
The most common form of brain injury in sport, “concussion must be taken seriously”, says Tony McSweeney, president of the Physical Education Association of Ireland.
The condition is believed to affect about 20% of teenagers according to research published in 2017 in the Journal of the American Medical Association.
However, despite ongoing awareness-raising, there’s still some confusion in the public mind about what exactly causes the condition, says Dr Enda Devitt, Connacht Rugby medical officer, lead doctor for the Galway football team and UPMC nationwide concussion network clinical lead.
“It can also result from a big collision anywhere on the body. It happens where force is transferred to the brain and results in a shaking of the brain in the skull. There is a misapprehension that it has to be a blow to the head.”
Coaches need to be on the alert about the potential for concussion, he says, because it can happen quite easily on the pitch.
“In about 90% of cases it needs to be detected by the coach or reported by the player, because in only 10% of cases does it result in unconsciousness. That’s the scary element — it can happen without being noticed.”
Research has shown that young players, and female players are particularly vulnerable.
“With student athletes, the teenage brain is still growing and undergoing neurological development. If you get concussion at 15, for example, your brain is still growing and is more vulnerable, so concussion can have a more profound effect,” says McSweeney.
He points to a 2019 study in the USA, which found female players not only had twice the risk of concussion as male athletes, but also took longer to recover.
“If there’s any sign of concussion, the safe decision should be made to remove the young player from play,” Devitt says, adding that more awareness is needed around the fact that continuing to play following a concussion can significantly prolong a player’s recovery.
“Research has found that the recovery period for players with a risk of concussion who left the pitch straight afterwards, was 19 days,” he says.
He compares this to the longer recovery period of 28 days experienced by those who stayed on the pitch for between three and 15 minutes after the incident — and to research showing that players who stayed on the pitch for more than 15 minutes following a concussion faced an extended recovery period of about 44 days, even if they did not sustain any other injury.
Devitt references a study carried out by Acquired Brain Injury Ireland and the Gaelic Players Association some years ago on players aged from their mid-teens to their 20s. It found, he says, that more than half the GAA players surveyed had been concussed while playing and 44% of players studied had been concussed between two and five times.
“A particularly worrying statistic was that 58% continued to play with concussion and that 42% admitted returning to play before being symptom-free.”
Educated decisions need to be made on when players were fully recovered and ready to go back on the pitch, he says.
“At the moment there are guidelines drawn up by the sporting bodies giving rest periods and return-to-play policies but we need to make people aware that each concussion also needs to be treated individually.
“We must make sure that someone has indeed fully recovered and is ready to go back.
“As a doctor, I find that one player might take two weeks to recover and another might take six.”
The jury is still out on the long-term effects of concussion, says Devitt.
Although there’s no definitive research linking concussion with neuro-degenerative disorders the suspicion is there, he says, adding further research is needed.
“We don’t know for sure about chronic long-term problems but what we do see is people who have issues around concussion such as cognitive dysfunction, poor concentration, balance issues, mental health issues, dizziness and sleep disturbance.
“In a lot of cases if symptoms don’t improve within a few weeks, they need to be seen by physicians who are experienced in managing concussion, and those who would benefit from rehabilitation should get a targeted rehabilitation programme.”
The GAA recognises the importance of concussion, and has strict guidelines in terms of how to recognise and deal with it. However, the organisation faces a challenge in getting the message across to the players themselves, says Dick Clerkin, chairman of GAA medical and scientific and player welfare committee.
A 2016 study found that a quarter of young GAA players aged between 13 and 25, admitted to playing on even though they knew they were concussed. The survey found that 40% of boys and young men playing hurling and football assumed that continuing to play would relieve the symptoms.
“Doctors, management and coaches must support and educate the player not to play if we think the risk is too high,” says Clerkin
It can be “an uphill climb”, he says, to get players to recognise and acknowledge the symptoms and take themselves off the field during a match because of what he calls “that insatiable drive to play”.
“Quite a high percentage feel they have suffered a concussion but don’t take themselves off because of the drive to play.
“However our guidelines are very clear — if in doubt take the player out of play.
“There is no grey area,” he says.
The GAA is conducting a pilot study with UPMC on concussion and the efficacy of new neurological testing.
UPMC’s internationally-recognised concussion management programme starts with an FDA-approved baseline test that evaluates and documents multiple aspects of a patient’s neurocognitive state, including brain processing, speed, memory, reaction time and visual-motor skills.
Clubs and teams across the country have had their players tested using the programme. In the event of a suspected concussion, the patient repeats the test and his or her post-injury data is compared to baseline test data to help determine the severity and effects of the injury, in addition to the course of treatment and rehabilitation.
The study, which has been going on for two years, is due to be reviewed at the end of this year to determine its overall efficacy
“It is our long-term vision that this type of test would be available to all clubs in the country,” says Clerkin.
Cork paediatrician and paediatric neurologist Niamh Lynch, who runs a weekly concussion clinic at which she sees patients from all over the country, says about 60% of the concussion cases she sees result from sports.
Know about concussion and respect it, but don’t fear it, advises Lynch, who is regularly requested by GAA clubs to give talks about the condition.
There’s no doubt that many parents are worried about the risk of concussion, particularly in the light of the story of 14-year-old Ben Robinson, who died following a school rugby match in Co Antrim in 2011.
Reports of his death, shocked many parents into a greater awareness of the condition, and its consequences. The subsequent awareness campaign by the boy’s parents, undoubtedly heightened the profile of the condition and the importance of recognising and managing it. However, Lynch, one of a number of clinicians who form a national concussion network, is concerned that fear of the condition could result in some children not playing sport.
“My big worry is that parents will stop their children playing sport because of fears they might be concussed,” she says
A study by UPMC last year showed that just over one-in-five of adults whose children who play sports say they’ve considered preventing their child playing certain sports or engaging in certain activities because they fear the risk of concussion.
She points to a 2015 survey from the USA which has shown that between 15% and 20% of parents would stop their children playing all sports because of fears of concussion.
GUIDANCE IN EDUCATION
This is something which was recently highlighted in the RTÉ Prime Time programme during which one mother recalled feelings of guilt after her son suffered concussion during a rugby match.
But parents should not prevent their children from playing sport because of fears around the condition, says Lynch: “If this happened it would be terrible — sports play a very important role for physical fitness and mental health. It’s important to meet concussion with a proper response and to keep things in context.
“Sport can help combat many of the serious conditions in children today, from obesity to mental health and anxiety issues, to high blood pressure.
“We have to recognise that physical activity is very important, and also to respect and recognise concussion.
“Despite every club’s best efforts, accidents will happen but the main thing for people to hear is there is a pathway to treatment. Most children will start to feel better within about two weeks.
“If this does not happen they might go into chronic concussion symptoms and that is why I started the concussion clinic.”
Although a national Concussion Guidance document for schools, clubs and sporting governing bodies is in the process of being drafted by the Department of Sports, says McSweeney, the national governing bodies of the different sports have developed sport-specific guidelines for concussion.
“The more educated we are about concussion the more confident we are in dealing with it and putting in place strategies and more and more stringent protocols on how to deal with it,” he says.
The Department of Education’s new course in exam-orientated Physical Education, which will be coming on-stream in September 2020, will further highlight the issue.
“One of the topics of study is concussion in sport, so students will become more aware of it,” says McSweeney.
“We’ll be educating pupils about the risks associated with it, and about the signs and symptoms of the condition which will be of great benefit.”
We need to get better at identifying concussion, says Devitt. “Making the decision to remove some players from play and then making better decisions about when people should return to play.
“There are tools which can help us make objective decision and that is where the neurocognitive testing can help.”
“Remember that the last person who will want to leave the game is a young player so it is very important that coaches medical staff and parents are familiar with what to watch for,” says Tony McSweeney, president of the Physical Education Association of Ireland.
“This is a symptom that people tend to dismiss but according to the research, on-field dizziness is one of the strongest predictors of prolonged recovery,” says concussion expert Enda Devitt. “If a player is visibly dazed or showing any elements of confusion or complaining of headaches nausea or vomiting they should be immediately removed from play and seen by a doctor.”
“Each sport has laid down criteria governing a player’s return to play following concussion, for example, there are different time frames for different sports,” says McSweeny.
- For more information on concussion visit: www.upmcconcussionnetwork.ie