What everyone needs to know about concussion in sport

In 2011 Ben Robinson, a boy of 14 years of age, from County Antrim, was playing a rugby match for his for his school, Carrickfergus Grammer. This was an important game for Ben and for Carrickfergus, it was the second round of the prestigous medallion shield in Northern Ireland. Ben is all action. Very committed. Brave. Honest. No stranger to hard tackles. He was knocked to the ground during his first collision early into the second half. He stays there for 90 seconds before being helped to his feet. Soon after he was involved in a clash of heads. He walks over to his coach, who holds a few fingers up in front of his head and decides he can resume playing. This time however Ben is hobbling, holding his head, walking away from play. A further stoppage in play after another tackle results in more finger counting tests for Ben. He doesn’t remember the score in the game, but is passed fit to resume. He was sucked back into action as the ball comes his way. Another stoppage. Now he is out cold. He never regains consciousness.

Ben died from “second impact syndrome”-a very rare but catastrophic brain swelling resulting from repeated mild traumatic brain injuries ie concussions.

Concussion recognition and management has progressed since Ben’s untimely death but it is still not perfect. Recognition is imperative but it is not enough, if those involved are not courageous enough to withdraw a suspected concussed player from the field of play.
Everyone involved in sport (players, coaches, officials and supporters) should try to educate themselves in order to spot the signs associated with a concussive injury. Despite popular belief, more than 90% of concussions occur without a loss of consciousness. Any symptom suggestive of a concussion eg memory problems, balance problems, “fogginess”, not “feeling right” must result in an automatic immediate removal from the field of play with no chance of return that day.

At elite level sport, medical teams are assisted by video analysis to try to identify the concussed player. In the ongoing Six Nations Rugby tournament we frequently see players being taken into the dressing room for their head injury assessment (HIA) where live video analysis of any recent incidents is evaluated to see if the player exhibited any signs of concussion on video eg transient loss of consciousness/ jerky movements/ falling in an uncontrolled manner etc. Video analysis is obviously not available at a local level but it should be replaced by diligent well-informed supporters and officials keeping alert for possible concussive signs and reporting their concerns appropriately.

In children and adolescents the symptoms are sometimes even more subtle- the only sign may be that they feel more irritable and fatigued at the end of the day or the days after. Alarmingly, the risk of second impact syndrome is greater for them and for female players of all ages.

Decisiveness is important. If a concussed player plays on for even 15 minutes, not only are they at unnecessary risk of second impact syndrome but it also exacerbates their symptoms and can double the length of time to recover. They tend to be at risk of increased anxiety and depressive symptoms over the following days, weeks and possibly months; they may suffer with sleep disturbance and their concentration and memory may also be impaired which has a knock-on effect on work/college and other personal commitments.

Longterm, the risk of CTE (Chronic traumatic encephalopathy ie a form of dementia) has not been proven yet however there is a lot of circumstantial evidence to propose a link; there has recently been research published showing that American football players in the NFL have a 19 times higher chance of developing dementia than those who don’t play contact sport. Draw your own conclusions!

Despite telling this to players, trying to convince them regarding the risks of concussion is sometimes very difficult. Anxiety, memory problems, sleep disturbance and a remote risk of second impact syndrome sometimes don’t resonate with players. In these circumstances it useful to remind players of what happened to Ronan O’Gara in the second test for the British and Irish lions against South Africa in 2009. Here, O’Gara sustained a concussion in the second half but he plays on, his concussion not spotted by medical staff. The Lions needed at least a draw to keep the series alive. In the last play of the game he received the ball in his own 22. The score was 25 points all. He needed to retain possession and allow the big ball carriers to control the game. But O’Gara kicks and chases his own up and under and tackles Fourie du Preez in the air recklessly to concede a penalty. Morne Steyn converts and South Africa take the series 2-0. Most players identify with this message- if you play on with a concussion your decision making is impaired and you become not only a physical danger to yourself and others but also a danger to your own team’s chances of success!

Standardised protocols to recognise concussion (SCAT 5 for health professionals or CRT for coaches/mentors etc) are available for free download online from many resources including from the GAA or IRFU website and all involved in contact sports should educate themselves in these easy to use protocols. Once diagnosed a graded return to play needs to be followed over at least 7 days for adult males but at least 14 days for all female players and males under 18 (sample graded return to play guidelines are again available on the excellent GAA or IRFU websites).

A Doctor, ideally one familiar with sport and trauma, should be consulted prior to a return to contact sport. School children need smaller steps. A graded “return to learning” before a graded return to sport should be followed strictly. This means a graded reintroduction to school work with half days initially before full days back at school.

So keep a close eye for concussion. It is more common than you think; on average 20% of players in contact sports this year will get concussed. It is an evolving injury so even if it doesn’t cause symptoms immediately watch out for symptoms developing over the days following injury. With more education and ultimately more recognition there will be no more tragic cases like that of the late Ben Robinson.