Mind Your Head

29 August 2016

Concussion sufferers will tell you that it’s a no brainer to avoid brain injury. However, how does someone prevent one – or multiple – concussions occurring? Unfortunately, little is known about concussions or their potential chronic effects which make prevention and treatment difficult.

A concussion ocurs when a blow to the head causes the brain to shake inside the skull. They’re categorised as concussion or sub-concussion; the difference being that the former involves unconsciousness. The presentation of a concussion’s multiple symptoms vary depending on the magnitude and direction of impact and the areas of the brain injured. Breanna Downes-Smith, a University of Melbourne student and equestrian rider, suffered a severe concussion when her head collided with a wooden pole. Her experience was “pretty awful… almost drunkenness”. Downes-Smith’s symptoms included “loss of motor control, dizziness… confusion and loss of vision”.

However, in some cases the symptoms are subtler. Variation of symptoms makes identification of concussion difficult. Daniel Costello, sideline assessor of concussions for the University of Melbourne Blacks Football Team, cites that the Sports Concussion Assessment Tool Third Edition (SCAT3 tool) is utilised within the club and internationally. It’s a set of cognitive and physical tests which assess the extent of  concussion. However, according to Costello, concussion diagnosis is still a largely subjective call.

What’s clear is that multiple concussions generally have greater detrimental consequences than a single concussion. A study of 11-18 year old patients revealed those who sustained multiple concussions within a year had prolonged post-concussion symptoms. This implies that cumulative concussions within a short timeframe would have injurious consequences. Dr Sandy Shultz, neuroscientist at the Royal Melbourne Hospital, states that experts are still unsure about how long the brain is vulnerable to successive trauma after a concussion.

Scientific controversy surrounds how repeated concussions over a lifetime affect the brain. The debatable condition, Chronic Traumatic Encephalopathy (CTE), is postulated to be a neurodegenerative condition resulting from the cumulative effect of multiple head traumas, such as concussions. CTE results in cerebral damage, leading to motor control problems and dementia diseases like Parkinson’s. Unfortunately, CTE can only be diagnosed post-mortem. Of those who have suffered repetitive concussions throughout life, not all have been diagnosed with CTE on autopsy. This questions CTE’s validity as a medical disorder.

So the problem remains; correlation between repetitive concussions and neurodegeneration does not mean causation. However it’s a potentially dangerous correlation that we need to avoid.

You may believe that helmets are an excellent method of preventing concussion and that the lack of them in sport is pure ethical misconduct. Sadly, helmets aren’t that helpful. “If you’re talking about blunt force trauma to the skull, helmets might help. If you’re talking about forces that cause the brain to move in the skull, whether or not there is a helmet or not, the brain will still move within the skull,” according to Dr Shultz. In addition, helmets may provide players a false sense of security, encouraging reckless behaviour and increasing the likelihood of sustaining a concussion. The International Rugby Board has cited this to be the main motive of why Rugby Union helmet design is restricted to be soft and have a low density.

Alternatively, enforcing “Return to Play” policies when concussion occurs could reduce further damage. Currently, many sports in Australia follow the guidelines of  the Australian Institute of Sport (AIS) and the Australian Medical Association’s (AMA) Concussion in Sport Position Statement which include the SCAT3 tool. It generally advises that patients don’t play after a concussion and while symptoms persist. Adults have to wait at least 24 hours before resuming play; for children and adolescents it’s at least 48 hours. If symptoms persist for more than 10 days, further medical attention is necessary. These guidelines also include a progression of activity performed for patients during their recovery, which ranges from no activity to return to full game play. But given the uncertainty of concussion’s effects, these measures may be insufficient. “If in doubt, sit them out”: the mantra of the AIS and AMA is the safest bet.

How can we know more about the effects of repetitive concussion; the black hole of medical science?  A larger financial investment in sport medical research to investigate concussions methodically and intelligently is necessary. As a country of avid sports people and fans, we need to be informed about the actual effects of repetitive concussions and effective prevention. Given the confusion about concussions, we need to be careful of head trauma. Should a concussion occur, it’s best to rest longer than the AIS and AMA’s recommendations. After all, what have you got to lose?

So exercise caution, rest and please mind your head.

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