Here’s a thought. What if most of the little we thought we knew about concussion was wrong? What if the good intentions we had, as doctors and as coaches and as parents, when telling kids and others to pull the blinds and climb into bed until the bad stuff stops was making the problem worse rather than better?
We’re all learning but the lessons come at a cost.
Shane O’Donnell didn’t think much of it when he shipped an innocuous tackle at a Clare hurling training session over a year ago. If he lost consciousness, it was for a few seconds. No-one seemed alarmed when he was discharged from hospital the next morning with a mild concussion.
It took O’Donnell ten weeks to get back on the pitch but 12 months to recover fully from the trauma. His girlfriend, a clinical psychologist, said he was presenting as someone with mild PTSD after the event. Talking about it to this day still evokes the experience and how he felt at the time in the most vivid of colours.
The first few days were fine, he was active and spent a weekend out and about. It was on the Monday, his first day in a new job, that “things really began to come down around my ears”.
He awoke on the Wednesday to a “catastrophic” pressure in his head and a nausea he rated as a nine out of ten.
Two and three weeks went by and nothing changed. O’Donnell’s brother and wife are both GPs, he had access to medical help via the GAA, he was young and fit. Nothing changed. Everyone told him Father Time would do his thing. To rest. He began to miss chunks of work and had all but “given up” on sport.
He wasn’t anxious at first. It was scary, sure, but something to get through. Then the vicious circle of improvement-activity-crash began. “That’s when the fear really started to kick in,” he recalled. “I don’t know what’s going on. I don’t know how to resolve this. I don’t know what’s causing this cycle.”
Being referred to Dr Enda Devitt was the turning point.
Team doctor with the Galway footballers, and medical officer with Connacht Rugby, the other string to his bow was that of concussion network clinical lead with UPMC, the Pittsburgh-based health care company that has established itself in Ireland.
Dr Devitt’s words were music to his ears. ‘This is normal. It’s going to be okay. This is what you are experiencing and why. Here’s how we deal with it’.
Hope. Relief. And a course of action that, for many of us exposed to outdated beliefs, took him in a surprising direction.
O’Donnell was speaking at a UPMC concussion conference in UCD on Saturday, six years after their first here in Croke Park, and Dr Michael ‘Mickey’ Collins, clinical director of the UPMC Sports Medicine Concussion Program, referenced the quantum leaps made in their area of expertise in just that short time.
Their clinic in Pennsylvania records 20,000 patient visits a year and 300 papers have been published on the area since 2016. The understanding of a three-pound organ that is notoriously difficult to unravel has undergone a sea change with lessons learned from earlier mistakes.
“If you saw us lecture in 2005… I couldn’t watch that,” he squirmed.
Concussion is not a one-size-fits-all problem. Patients present with different symptoms – mood and anxiety problems, migraines, vestibular, ocular and cognitive issues. One in four athletes show delayed symptoms. A 2014 study showed that 40% continued to play on following a concussive event.
Misconceptions are another complication.
The idea that rest is the cure for all ills is high among them. Not just wrong but harmful. Like the idea in 17th century London that children should smoke tobacco to ward off the Black Death. Dr Collins posed the question: for what other injuries do we not prescribe some form of exercise by way of rehab? It makes sense.
A realisation has dawned that active, monitored treatments are the answer. Patients should be in busy environments. They should not be turning down lights and noises. They need be exercising, not retreating from the world. “The point being,” Dr Collins explained, “there are no dark rooms in our clinics.”
“Exposure obviously is a huge part of it,” said O’Donnell. “Even though physically I felt worse after the exposure and doing the things that were causing the symptoms, knowing that was helping meant I could view the whole thing through a different lens altogether. So even though I felt worse I felt better about it, if that makes sense.”
It does. So does another finding.
The concept of repeated concussions has been linked to CTE (chronic traumatic encephalopathy), a brain condition that has been found in post-mortems on some athletes who competed in contact sports. It has also been blamed for athletes suffering from early on-set dementia.
Calls have been made to ban children under 14 from playing contact sports, and from heading footballs, but Dr Collins labelled these as “unreasonable, misguided, uninformed and not evidence-based”. More long-term studies are needed on CTE, he said, adding that the concept does not “resonate” with the improvements they see in their patients.
One recent UPMC study found that recovery rates for a second concussion were better for patients who had received timely and effective treatment after their first. That counters the set belief that these are classed as cumulative injuries and informs their stance that kids and adults can return to play after concussions.
“This is a treatable injury,” Dr Collins insisted.
The opposite holds equally true: if patients are left untreated or ordered to rest then the effects of the first are compounded. It’s a body of evidence that inevitably colours our take of high-profile incidences in the past and, in an Irish context, there has been none more high-profile than Johnny Sexton’s.
The Ireland captain has made plain his annoyance at what he believes is misinformation about his concussion history. A neurosurgeon who treated him while in France claimed last year that he had suffered 30 before rowing back on it and O’Donnell referenced the Dubliner when stressing the need for a better, nuanced understanding.
“Everyone knows what concussion is but do they know what it entails? I definitely don’t think they do. The conversation on the cumulative effect is so important. If you talk to anyone when they talk about Sexton playing after the number of concussions they think: ‘Why is he doing that? Why are they letting him out there?’
“It’s only when you realise that if you treat them one at a time as they come that you can go out there and if you get another one we can treat that as well, but the media would have you believe – and this is the general consensus out there – that if you have two or three or four then, regardless of how you are treated, you should stop playing.”
No-one has all the answers. Dr Collins and his colleagues know the same encouraging results hold for a third concussion when the patient is treated quickly and effectively after the first two, but what about after a fourth or a fifth? The simple answer, as with so much else, is that they don’t know. Yet.