The story of Ben Robinson (14), who died after a school rugby match in Co Antrim in 2011, changed what the word "concussion" means to many parents on this island.
Anybody who heard Ben’s parents sorrowfully recount the events around his death, could not help but think it could have been their child. And thanks to their campaigning, there is undoubtedly more awareness of the importance of recognising and managing the condition.
However, "we have to be careful not to move from a position of ignorance to panic", says paediatric neurologist Dr Niamh Lynch, who, two years ago, set up the country's first concussion clinic dedicated solely to children, at the Bon Secours Hospital, Cork. A disastrous outcome is "the very, very rare exception", she stresses. "I try to get people not to fear concussion but to respect it."
She is one of two clinicians supervising a new national concussion network that was launched this summer to promote diagnosis and treatment of the condition, as practised at the world-renowned University of Pittsburgh Medical Center (UPMC).
As a new school year begins this week, whether a child is taking up a new sport or moving up to a higher team, here are questions that may be on a parent’s mind.
What exactly is concussion?
“Concussion is your skull suddenly coming to a halt and your brain continuing to go in the direction it was going and hitting off the inside of your skull,” says Lynch.
It is a common injury and about one in three people will have had concussion of some sort by the age of 21, she explains. In only about 10 per cent of cases has the person lost consciousness.
Concussion temporarily disturbs the functioning of the brain, rather than causing a structural injury, so it can’t be detected by an MRI or CT scan.
Dr Enda Devitt, a GP, doctor for Galway senior GAA football and Lynch's colleague on the network, likens the head to an egg to explain what happens – when you shake it, the yolk is rocked around inside. There are shifts in electrolytes within the brain, he says.
This can occur even without a blow to the head. “It could be a blunt force trauma anywhere in the body and that force is transmitted to the brain – causing that rocking motion.”
Why are children more vulnerable than adults?
“Their brains are still growing and they are undergoing neurological development,” says Devitt. Also, the heads of younger children are proportionately larger to their bodies than adults and a lot of their co-ordination is still developing.
There are studies showing young female athletes are more susceptible; for instance, soccer is one game where girls are significantly more likely to suffer from it than boys. Researchers are still trying to pinpoint why.
What are the symptoms?
Dizziness is a “big red flag”, says Lynch, as is a headache, memory loss, confusion and imbalance – as well as loss of consciousness. If concussion is suspected, the child must be removed from the pitch and not allowed to rejoin the game.
In a bad case, parents are usually advised to bring the child to a hospital emergency department where they will be assessed and observed. On discharge they are given a head injury leaflet and, if there’s vomiting, double vision or general deterioration in their neurological status, says Lynch, they need to go straight back to hospital.
Typically, children will get better without any intervention in about a month, she continues. “If they don’t recover in a certain time period, they don’t really have anywhere to go, which is why I saw that need and decided to set up the concussion clinic.”
Would it be wise to stop my children playing certain sports?
Trying to calculate actual risks as opposed to perceived risks is enough to do anybody’s head in. Anyway, probably the most dangerous part of a child’s activity remains the car journey to and from it.
Even if you decide not to let your children do sports such as horse-riding, rugby, soccer, boxing, hockey, hurling, GAA football, etc, they may well suffer concussion in a simple tumble at home, in a playground or in a road accident.
“Half of the children I see, it hasn’t happened in a sporting context,” says Lynch. “They have fallen over, or got a ball to a head in the school yard, or in a fall off the bike.”
Parents wouldn’t pull their child out of sport for fear they might break their leg, she suggests, so why pull your child about fear of concussion when it is another injury that can be treated?
However, it's hard not to be concerned when you hear forensic pathologist and neuropathologist Dr Bennet Omalu – played by Will Smith in the film Concussion – say that nobody should play contact sports until they reach the age of 18, when they can then make an adult decision to take the risks that go with them.
“All it takes is one season, one concussion and your child’s brain is permanently damaged,” he has warned.
Dr Ciaran Cosgrave, the Irish Rugby Football Union (IRFU) national team doctor and consultant at the Sports Surgery Clinic in Santry, Dublin, says Omalu has done a great job in raising awareness of a potential link between concussion and long-term brain damage.
“Without his work we would probably be in a much worse place.” However, “we’re still a long way away from understanding what that link is because it is definitely not a case of lots of concussions equals long-term brain injury”, he says. “We have got examples of athletes in all different sports who have had many, many concussions and don’t have long-term brain injury.”
Concussion by definition is temporary – if you don't recover from it, it wasn't a concussion
There is one theory that there could be a genetic component to it, he says, in which case it would be a matter of trying to find that gene and possibly advise those with it to avoid contact sports.
Concussion by definition is temporary – if you don’t recover from it, it wasn’t a concussion, Cosgrave says. Some people mistakenly use the term when they are talking about a much more serious brain injury.
If somebody is said to have died from a “bad concussion”, it wasn’t concussion; it was a traumatic brain injury that caused a fracture or brain swelling or a bleed. However, concussion does need to be taken seriously, he says.
Devitt believes “we need to move the conversation from fear around it to managing it properly because the benefits of children participating in sport still far outweigh any potential risks of concussion”.
What about keeping them away from rugby?
There is more fear around rugby because it’s one that is talked about, acknowledges Cosgrave, who points out that collision sports have always brought a risk of concussion. While the risk is higher in rugby than in some other sports, it is not as high as in, say, horse-riding and martial arts such as boxing.
However, he is keen to reassure parents that “concussion is more picked up now and better treated than it has ever been, there is just so much awareness of it”.
The culture of playing on regardless has also changed radically, from grassroots right up to international level.
“From a medical point of view, I would hate to have a player with concussion play on,” says Cosgrave who regards it as his job to make sure players don’t stay on.
“Sometimes that can be a hard sell to a player who is less concerned about their health in the heat of the battle,” he admits. “But it’s an easy sell to the players and the coaches to say, one, there is a high risk of another injury if they play on and, two, their performance will be inhibited. So, while, yes, I want to protect the player, there are other reasons not to let this person play on.”
The players recognise this now, he says, and they are much more inclined to say they are not feeling right.
“It’s not perfect – obviously there are still players who might choose to hide things – but there is a much greater openness to discuss it now and much less stigma to a player coming off the pitch who to everybody else looks perfect but the medic is just not comfortable to let them play on.”
Is there any kit I can buy that will reduce the risk?
In a word, no, say the medics, despite some manufacturers’ claims to the contrary. Helmets and face guards protect against facial injuries, eye injuries, skull fractures and cuts to the scalp but can’t stop concussion.
The same goes for rugby scrum caps: they can help prevent scrapes, cuts and longer term “cauliflower ears” but not concussion. Indeed, research has found that scrum caps can give players a false sense of greater protection, leading to more reckless tackling, thereby increasing the risk of sustaining concussion.
There has also been a persistent myth that mouthguards offer a degree of protection, through helping to absorb the shock of a blow, despite the lack of scientific evidence.
Is there anything I can do as a parent?
It’s important that children and teenagers are told to be honest about symptoms but, as Lynch points out, that message is more likely to be heard if it comes from a coach at the beginning of a season rather than a parent.
If you don't respect this injury, it could cause you trouble for much longer – exactly the same if you sprained your ankle or hurt your knee
After a concussion, a youngster may think they will get back playing quicker if they deny lingering symptoms but they will probably end up delaying their recovery and missing more matches.
“The message I have for the sports-mad teenager,” she says, “is if you don’t respect this injury, it could cause you trouble for much longer – exactly the same if you sprained your ankle or hurt your knee.” She refers to it as “the sprained brain”.
While the advice used to be total rest for two weeks, there are now active rehab programmes. “There is no point in covering up the injury because you deny yourself the treatment and deny yourself the place on the team.”
With the launch of the national concussion network, parents can now consider organising baseline testing for a child. In a suspected case of concussion, the test can be repeated and the two sets of data on neurocognitive functioning compared to help in diagnosis and treatment.
The UPMC has created the network here in partnership with nine Affidea diagnostic clinics around the country and the Bon Secours hospital group. They're using the ImPACT concussion test, which was developed by UPMC and was the first to be approved by the US Federal Drug Administration in 2016.
Baseline testing is mandatory in some US states for players at certain levels before they start a season of contact sport, explains Devitt. He piloted baseline testing with the Galway senior footballers last year and has since been able to make it available to the senior and under-21 hurlers and also the under-18s on the minor hurling and football teams.
“It is giving you a robust measurement of a number of components within it – your visual memory, motor skills, reaction times and verbal memory, so you know what somebody should be like. If they sustain a concussion, we have objective measurements to establish that they have recovered before sending these players back to play.”
Galway GAA got a sponsor to cover the cost of the blanket ImPACT testing for these teams and it is something clubs – or schools – could consider, says Devitt.
For an individual booking online at one of the Affidea clinics, the 20-minute baseline test costs €40.
What if they say they’re fine after an incident and they’re not?
“You never ask the child,” says Lynch. “The last person you ever ask is the concussed person because they are confused; they are the least-best placed to make that decision, so that decision has to come from the coach, or the teacher or even the parent [saying] ‘I really don’t like the look of her – I want her off.’ People have to listen to the parents because they know them best.”
“If in doubt, sit them out” is the mantra that’s promoted in sporting circles.
“There are lots of guys appropriately removed because there is a suspicion of concussion and, unfortunately, there are guys who are going to be removed because there was a suspicion of concussion and it turns out there wasn’t any concussion,” says Cosgrave. “But better that than leave people on.”
Devitt agrees that those working in sports at the highest level have a big responsibility in raising awareness of managing concussion properly.
“Leaving somebody on the field for another minute, five minutes, 10 minutes, that ties in with increasing time to recover.” Then, at the extreme end of the spectrum, there is the risk of catastrophic second impact syndrome, as suffered by Ben Robinson.
What is the recovery process and how long does it take?
The advice used to be rest until the symptoms had disappeared. But a statement issued after the Fifth International Conference on Concussion in Sport in Berlin in 2016 recommended that 24-48 hours after the injury, patients be encouraged to become gradually more active as long as it did not exacerbate symptoms.
Guidelines from sporting bodies differ. For example, the GAA’s concussion management guide, updated last February, says that players under the age of 18 should not return to competitive action or full contact training without medical clearance. And this should be at least two weeks from when a diagnosis was made.
The IRFU’s new post-concussion care protocols for the amateur game, that were issued last March, stipulate that players under 20 must have a minimum of 23 days out of competitive action.
However, even within differing timeframes, it is always about players successfully completing the six-stage Graduated Return to Play Protocol and being signed off by a doctor.
There are six main types of concussion and the top three are the ones that affect your balance, your vision and cause headaches, says Lynch.
“Once you can talk to the patient and examine them and narrow it down to the type of concussion they have, you can narrow down the treatment.”
As a clinician it is very helpful if somebody has had a neuro-cognitive baseline test done because otherwise you can only estimate where they should be but you don’t actually know, she explains.
However, it is still only a tool, she adds. The clinical examination and the account of what happened to the child is still the most important part in diagnosis and treatment.
