Concussion: the invisible injury

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The brain is perhaps the most crucial part of a person’s body. Our thoughts, our emotions, our decisions, and for athletes, the part of us that allows us to make decisions on the ice, the field, or the court is so delicate, but yet, hasn’t been treated that way until recently.

In all sports, whether amateur or professional, there are responsibilities from the athlete to the trainer to the coaches and parents. On the Health Canada website, concussions in sport are described as a public health issue; both because they are frequent and have serious potential short and long-term consequences. Health Canada has five focuses on understanding concussions: awareness, prevention, detection, management and surveillance.

In 2013, a high-school rugby player, Rowan Stringer, passed away from Second Impact Syndrome as a result of multiple concussions in a short time span. Rowan had been removed from a game after being tackled and complaining of a headache. Four days later, she played and suffered another head injury, but didn’t tell a coach or trainer that her symptoms had returned. Two days after that, Rowan stepped onto the field again and was tackled, lost consciousness and passed away later that day. This event prompted the initiative for Rowan’s Law, which passed at the Ontario Legislature in June of 2016. Rowan’s Law has 49 recommendations, including, but not limited to: better tools for coaches and trainers to identify concussion injuries, and concussion policies in place at all school boards and sports associations across Ontario. According to Complete Concussion Management, Ontario is the first province in Canada to pass concussion-related legislation.

Since Rowan Stringer’s death — and with the implementation of Rowan’s Law — the awareness and importance of concussion management has skyrocketed in Ontario, and across Canada.

Brock University’s head athletic therapist, Joe Kenny, acknowledged that what defines a concussion is constantly changing.

“There’s so many different definitions right now,” Kenny said., “Any change in mental status from a direct or indirect blow to the head or the body can result in concussion. It’s a series of signs and symptoms which you identify. The hardest thing is that it’s the invisible injury.”

Concussion management can also vary depending on the setting; healthcare management for concussions may differ to that of a university policy. Kenny outlined four different levels of concussion management that he and his staff follow.

“There are three R’s in concussion management, there’s recognizing the concussion, removing them from the game, and refer them to the doctor, and then a fourth R for rehabbing them,” says Kenny.

While protocols for concussions may vary depending on where they occur, Brock University has made efforts to ensure that all students are properly prepared for their recovery period.

Kenny continued to say that at Brock, what has greatly improved are the academic protocols.

“Professor Gale Frost and Melodie Shick-Porter, they got together with people from the registrar’s office to make sure there is a Return to Learn Program here at Brock, which is really unique to us. When a person does get a concussion, and sees one of the doctors in our clinic or at health services, then once they’re identified with concussion, the registrar is made known of this so that the student gets the proper academic accommodation, because we know that mental rest is so important,” says Kenny.

The handling of concussions once diagnosed has changed drastically, even in recent years.

“People thought you would go into your room, not study, not read, not listen to music, but it would cause people to be isolated and further depressed. One of the problems [with concussions] is depression,” says Kenny.

Part of the advantage of the Return to Learn program is that it allows the students to get the proper time to rehab from their concussion.

“If you can’t study because of a head injury, then you shouldn’t force yourself to study,” says Kenny.

Geoff Gamble, a chiropractor at the Niagara Health and Rehab Clinic in St. Catharines, said one of the biggest changes in recent years on concussions is the information available to coaches, athletes and parents — though we still face the challenge of when an athlete is ready to return to play.

“More people know more about it, it’s more recognized and diagnosed. We still run into issues with how a concussion heals so to speak, and when to go back into play. A big misconception is that when your symptoms are gone, that means you’re ready to go back to play, but just because your symptoms are gone doesn’t mean your brain has healed, people are going back too early and are much more susceptible to second impact,” says Gamble.

Some of the challenges when an athlete is going through rehabilitation from a concussion are that the athlete believes they are ready to go back before their doctor does, parents can push their child to go back to playing too soon, and in some cases, the athlete can lie about their symptoms. Kenny recognized that while the awareness is greater, the athlete’s knowledge can sometimes be one of the biggest challenges.

“The athlete is better educated, but at the same time, they know what to say and they know how to hide their symptoms, so we also have to be cognizant of that.”

Gamble echoed that the recovery from a concussion, which is different for every case, is the most important part of the process in getting back on the field.

“It’s the management after the diagnosis that is the most crucial part,” says Gamble. “You break a bone, you know when it’s broken, when it’s healed, you can see it. You can’t do that with the brain, you’re relying on other things.”

In the example of Rowan’s Law, it was the case of going back before the athlete was ready that took her life. Kenny says the bottom line is that going back too early is fatal.

“That’s how serious it is, and that’s why it’s so important for the coaches, parents and teachers to be educated, the consequences are fatal,” says Kenny.

There is also the challenge of educating parents, in both youth and collegiate sports.

“I’ve had meetings with parents because I wouldn’t let the student play, and I’ve had to explain to them why, and the parents want evidence, so some just don’t get it,” says Kenny.

When asked who has the final decision to let the athlete play after their concussion — though Kenny says the healthcare professional should (in most cases) have the final say whether the athlete is ready to play, the coach is ultimately the one who puts the athlete back in to play.

“The coach (for community teams) has a big role to play in minimizing concussions and further injuries, at the end of the day, the coach is the one who puts the kid on the ice, the court, the field,” says Kenny.

A concussion isn’t a broken hand or a punctured lung (not that those two injuries are not serious as well). The brain isn’t as easy to understand, and every concussion and athlete is a different case. The effects a concussion can have on the brain are endless, and can lead to further damage later in life — and even death — if not cared for properly.

“One study in 2015 showed that over 70-80 per cent of students lied about their symptoms so that they could stay in the game,” said Kenny. “We know collegiate athletes lie about their symptoms, so we have to have other tests too, [for] cognition, balance, and so on.”

Though there is still a battle to get everyone to recognize the importance of concussions and rehabbing from them before returning to play, Kenny believes that everyone is getting involved, and that the awareness is there.

“So many groups play a role now, not just the coach, the player, the parent, but the referees, the person who cares for the rink, the ice, the governing body of the hockey associations, the NFL, the NHL, the CFL, and the politicians, because now that we have Rowan’s Law, everyone’s getting on board.”

Gamble, who heads much of the NHRC’s involvement in concussion baseline testing and management for youth sport organizations in the area, said that his goal is to help provide as much information to coaches, trainers and parents about concussions.

“The biggest thing is misinformation, we’re offering to go out to different associations and just educate them on concussions, and we want to be able to provide them the information so that if they think there’s a concussion, they have some idea of what to do with it and where to send their athletes.”

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