Prevention & Recovery

The impact of concussions

By: Jackie Middleton

Illustration by Thinkstock Author: Canadian Living Credits: Illustration by Thinkstock

Prevention & Recovery

The impact of concussions

By: Jackie Middleton
Jessica Richards*, a Windsor, ON, schoolteacher, didn't expect that the sport her 11-year-old son Alex* loved would change his life. But in 2012, during a particularly aggressive hockey game, her motherly intuition kicked into high gear. "I turned to one of the dads and said that if the ref doesn't start making calls, someone's going to get hurt," she says. As her words lingered in the cold arena air, her prophecy became a reality.

After clearing the puck, Alex was cross-checked by an opposing player, the impact so violent he became airborne, striking his head on the boards and then on the ice. Instead of calling 911, the team's trainer gave Jessica a thumbs up and moved a woozy Alex to the bench for the game's final five and a half minutes. Alex's symptoms—a headache, blurred vision and neck pain—were ignored rink-side, and it wasn't until Jessica took him to the ER that she learned her son had suffered a severe concussion.

Laura Kohoko, of Toronto, found herself in a similar situation. Her son, Ethan, was doing what 10-year-olds do every day: tearing around the playground with his buddies after school. The spring thaw had erased all traces of snow, but an invisible danger lurked underfoot. Slipping on a patch of black ice, Ethan fell to the ground, hitting his head on the pavement. Feeling embarrassed, Ethan didn't tell anyone until Laura picked him up for karate practice that evening. "He was quiet and said he was headache-y," says Laura. A quick detour to the hospital, and Ethan was diagnosed as concussed.

While professional athletes such as hockey players Sidney Crosby and Eric Lindros score all the newspaper headlines when it comes to concussions, the bigger concern, according to Dr. Charles Tator, MD, professor of neurosurgery at the Toronto Western Hospital and the University of Toronto, is that many Canadian children and adolescents (teens aged 13 to 16) are suffering from concussions and not getting the appropriate treatment. "It's a much bigger problem than is displayed in the media, which focuses on the professionals and not the amateurs and kids," says Dr. Tator. "And the issue is not just confined to sports. People get concussed in many ways: motor vehicle crashes, falls at home." 

The truth about concussions

It's time to bust some long-held assumptions. Did you know that a loss of consciousness doesn't have to occur for a concussion to have taken place? In fact, about 95 percent of concussed patients never pass out. This common misconception was tackled at the fourth International Conference on Concussion in Sport held in Zurich, Switzerland, in November 2012. Attending scientists including Dr. Tator and Dr. Laura Purcell, MD, a pediatric sports medicine physician and associate clinical professor at McMaster University, helped draft a new consensus statement on the management of sport concussion.

The revised definition of concussion describes the injury as a disturbance in mental function caused by a sudden movement of the brain within the skull. This condition can result from a direct blow to the head, face, or neck, as well as from an indirect hit elsewhere to the body that has enough force to jostle the brain. But there's a lot we still don't know. For example, we don't have reliable statistics on the frequency of concussions, and there are major questions outstanding about the physiological damage done to the brain. Unfortunately, dollars devoted to concussion research are at a minimum in Canada, which has left parents somewhat in the dark.

The science of the skull
Researchers don't know if concussions occur deep inside the brain or on the surface. The current suspicion is that the brain's white matter—the message-carrying pathway of the nervous system—is the afflicted area, but scientists don't have the tools to noninvasively peer inside to confirm this hunch. The hope is that improved MRI technology will finally unlock the mystery. Dr. Tator's hospital has just ordered a $10 million MRI machine that promises to improve the diagnostics of concussion, but it won't be installed and running for another two years.

In the meantime, Dr. Tator and his fellow researchers continue with the equipment they  have. "Technologies such as MRI and computerized EEG are being applied [on people who have sustained concussions] to find the part of the brain  that's involved," says Dr. Tator. Once found, it may be possible to determine the exact cause of concussions: Are they a tearing or swelling of nerve fibres, or an abnormality of transferred impulses from one brain cell to another?

While the anatomy of concussions remains elusive, researchers have confirmed several common symptoms: headache, dizziness, confusion, fatigue, blurred vision, nausea, irritability, memory lapses, concentration problems, poor balance and drowsiness. Only one of these signs needs to be present for a concussion to be suspected. Concussed patients may speak of "seeing stars," or an increased pressure in their heads, but the smallest patients—children from ages five to eight—tend to be vague about their symptoms. "Young children might not complain about headache or nausea. They might complain of tummy aches or their behaviours might be off," says Dr. Purcell.

Another new finding: Symptoms can take many hours to develop. "It's common to have several symptoms like headache, nausea and dizziness at the beginning, but then additional symptoms like sensitivity to light or sound, irritability and sleeplessness can appear hours or days later," says Dr. Tator. In rare cases, severe symptoms can arise such as neck pain, repeated vomiting, seizures, weakness or tingling in the arms or legs, double vision, extreme behavioural changes or deteriorating consciousness, any of which could signal a more serious situation, such as a spinal cord injury or a blood clot in the brain.

If a parent or coach suspects a child has been concussed, they can refer to the new Pocket Concussion Recognition Tool, a small card with a succinct list of symptoms that you can print out. If the child is unconscious, seizing or has a suspected neck injury, call 911 immediately. If the child is awake and stable but exhibiting one or more signs of concussion, seek medical attention. "It's better to err on the side of caution," says Dr. Purcell. In Alex's case, being left on the bench with his teammates meant that his condition went ignored until the final whistle.

How you diagnose a concussion?
While waiting for a physician, parents shouldn't give their child over-the-counter or prescription medications such as Aspirin, sedating painkillers or anti-inflammatories. These meds can mask or even aggravate symptoms, making diagnosis difficult.

Don't be surprised if blood tests, X-rays, CT scans and MRI scans aren't ordered during the medical examination; these tests won't detect a concussion, and in most cases show normal results. The best tool for diagnosing a concussion is the third edition of the Sport Concussion Assessment Tool (SCAT3). Doctors also have a ChildSCAT3 for children under 12. The difficulty with the ChildSCAT3 is that the child must be honest about symptoms. If children hide how they feel, doctors cannot make diagnoses.

How do you treat a concussion?
Following the diagnosis, parents should ignore the old practice of waking the patient every hour. "We don't give that advice anymore," says Dr. Tator. "We want concussed people to get enough rest." While physical and mental rest is the only medically approved treatment for the first day or so after a concussion, new findings show that cognitive rest is equally important. Cognitive activities such as web surfing, video games, texting, watching TV and reading should be avoided until symptoms subside. Schoolwork should also be put on hold.

After the initial 24 to 48 hours, and based upon the child's symptoms, the doctor may recommend a gradual reintroduction of activities. Called a "step-wise protocol," this process allows the child to gently wade back into a regular routine. Diving in too soon can spark new symptoms, aggravate old ones, and delay recovery. The reintroduction period can take days, weeks or, in rare cases, months. This measured return also applies to school.     

"We try to minimize time away from school because you get into other problems, such as social isolation, depression and anxiety," says Dr. Purcell. Accommodations such as a shorter school day, extra time to complete assignments, or permission to skip noisy classes such as music can help the transition. Once the child is symptom-free and able to handle a full academic workload, the doctor will consider increasing physical activity. Recovery should have an emphasis on "return to learn" rather than "return to sport."

Quick fixes, or gimmicks such as hyperbaric oxygen therapy, shouldn't be attempted. "There is no scientifically proven treatment for accelerating recovery from concussion," says Dr. Tator. Parents should be aware that a standard time frame does not exist for the mending of the brain. One child's brain can heal in days, while another child's may take months.

Are concussions preventable?
Parents can help their kids steer clear of concussions at home, in the park, or on the sports field. "It's virtually impossible to protect kids who are very active, but in my view, about 95 percent of concussions can be prevented," says Dr. Tator. Reduce the risk of falls at home by clearing trip-causing clutter, by actively supervising children on playground equipment, and by taking a proactive role in your child's sports activities. Discuss concussions with coaches and trainers to ensure they know the signs, and encourage a safe, nonaggressive style of play.

"Instil sportsmanship and make sure your kids follow the rules," says Dr. Purcell. It's also important for parents to acknowledge that certain sports put children at higher risk. "Hockey, football and soccer have high concussion risks," says Dr. Purcell. "[Parents should] weigh the pros and cons of those sports, and possibly look at others with lower risks, such as running, tennis or swimming." Boxing, skateboarding, rugby, horseback riding, speedskating, cycling, skiing, snowboarding, cheerleading, wrestling, gymnastics and martial arts all involve a risk of concussion.

Can a helmet prevent a concussion?
Hockey, football and cycling helmets don't prevent concussions. During a fall or hit, a helmet can't thwart the brain's accelerated movement within the skull. "A helmet is designed to prevent other head injuries, like skull fractures or bleeds in the brain," says Dr. Purcell. Some helmet manufacturers claim otherwise, but Dr. Tator advises parents and coaches to be wary of such declarations. "We don't want people to have false information about what they can expect from these devices," he says. "Today, there's no such thing as a concussion-proof helmet. Maybe there will be tomorrow. We want to encourage companies to develop better helmets." Until a breakthrough is made, Dr. Tator recommends that helmets be worn to reduce the risk of other serious head injuries.

The long lasting impacts of a concussion
The vast majority of patients with a first concussion get better within 10 days. However, it has recently been discovered that adolescents take longer to recover than adults and small children. It has also become evident that some concussed individuals—Dr. Tator estimates about a quarter of patients (usually those with multiple concussions)—experience long-term symptoms (including depression and anxiety) that can last months or years. "The emotional effects of concussion can be profound," says Dr. Tator.

It was previously believed that a concussed patient felt sad or despondent because they couldn't play sports or follow their regular routines, but it's now believed that the concussion itself creates this depressed or anxious state. "We think that [concussion-induced] depression and anxiety is a neurological condition. Fortunately, it can often be treated effectively," says Dr. Tator.

The scientific community is still unclear as to whether a child with a concussion can mature into an adult with brain degeneration such as chronic traumatic encephalopathy (CTE), Parkinson's disease or Alzheimer's. Dr. Purcell says that concussion research on kids has been limited—so far, most studies have been done on donated brains of deceased pro athletes who suffered multiple concussions, which doesn't necessarily correlate to a child who has suffered only a single concussive event.

As for Ethan and Alex, the recovery processes couldn't have been more different. Ethan's recuperation was swift. "After the first 24 hours, he seemed to be feeling much better," says mom Laura. "And there were no long-term effects." By comparison, Alex continues to make slow progress a year after his hockey injury. "I didn't realize it would be so severe and debilitating, and that it would have such an effect on his personality," says Jessica. "He's now a very different child than he was before. He's getting better, thankfully, but he's easily frustrated, impatient, and he struggles in school." While several cognitive issues remain—he still experiences severe headaches and sensitivity to light—Alex's physical symptoms continue to slowly fade away.

Fortunately, researchers keep making breakthroughs. Among the new discoveries: Girls and women are more susceptible to concussions than boys and men, possibly because females have less neck strength.

Also discovered: A second concussion, regardless of age or sex, requires less force than a first concussion, and the life-interrupting effects of that second concussion last longer. "Ten years ago, we didn't know that," says Dr. Tator. "If you got over your last concussion in a month, it may take you a year to get over your next one. And the more concussions you have, the more likely you'll carry effects from one concussion to another. We use that finding as evidence that there's some residual effect on the brain that can last forever in a lot of individuals, but we don't know if it's true for all people." While many of these discoveries are frightening, they are helping experts inch closer to solving the concussion puzzle. With luck, future Ethans and Alexes will be spared this painful malady.  

*names have been changed

For more information on brain health, check out how carbs could be destroying your brain.
This story was originally titled "Head on the Latest on Concussions" in the April 2014 issue.
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Prevention & Recovery

The impact of concussions