What my personal experience with concussion has taught me

BY: KAROLINA URBAN

Summer is here and with it comes the inevitable concern for safety and injury prevention. From organized sports such as soccer and rugby, to recreational activities such as wakeboarding, tubing, biking or your friendly match of volleyball, there is always a risk of a concussion.

Concussions are not limited to a direct hit to the head. They can also be the result of a large biomechanical force, known as a acceleration-deceleration injury, which causes the brain to move within the skull.

The rate of concussions occur in 754 per 100 000 for boys and 440 per 100 000 for girls. Nearly one-third of these injuries are the result of falls, while skating and hockey account for the greatest number of sports related concussions in Canada.

photo credit: UPEI Panthers at Saint Mary’s Huskies (Nov 27 2010, Halifax NS) via photopin (license)

The difficulty with assessing or recognizing a concussion is the wide range of symptoms that vary as a result of the heterogeneity of injury. These symptoms can range from being physical in nature (i.e. headaches or dizziness), to cognitive (i.e. difficulty concentrating), to behavioral (i.e. depression, anxiety) or sleep-related (i.e. difficulty falling asleep or sleeping too much.)

80  per cent of adults recover from a concussion within two weeks. For children, the recovery process tends to be slower, but despite the longer recovery period, it has been shown that most of the pediatric population does not continue to have long-term difficulties. However, around 14 per cent of the children who sustain a concussion continue to have symptoms beyond three months after injury. As a parent, guardian, coach or friend it is critical to recognize the impact of concussions, know how to prevent them and how to promote recovery.

Throughout my hockey career I always had this willingness to do whatever it took to win. In the face of injury I would shrug off the pain and continue to compete. In my second year of hockey at the University of Toronto I sustained a concussion in the last season game. From what I recall, the puck came out of a scrum in the neutral zone and the next thing I can remember is sitting on the bench feeling ‘out of it.’ My line-mate asked whether I was okay and I simply responded, “Oh yeah, lets go.”

Rowan Stringer; Image via Facebook

Luckily there were only few minutes left in the game as I continued to play. That evening I began to feel worse, more anxious, dizzy and fatigued. But as I had always done, I continued on until the next evening, I went to class, wrote an exam (which I did horribly on) and continued onto practice. As we began to do skating drills, I began to feel nauseous and dizzy and finally agreed to get an official diagnosis. Although I took this step, I quickly got cleared to play again as game one of playoffs was eight days later.

It was quite evident I was no were near ready to return to play. I missed the puck several times, my reaction times were slower, my head was hurting and I was dizzy every time I turned. To be honest I probably hurt my team more than helped. I was, however, extremely lucky to have not sustained another hit to my head. This is called ‘second impact syndrome’ where you undergo another hit to the head when you haven’t given your brain time to recover from the first injury. Impact to the brain during this vulnerable period may result in devastating consequences, such as with the recent death of high school rugby player Rowan Stringer.

If you or someone you know has sustained a concussion, there are return-to-life and play guidelines to help. The Ontario Neurotrauma Foundation has produced pediatric concussion guidelines and has information on persistent concussion symptoms. Parachute has return-to-play guidelines which are also a valuable guide for concerned parents and athletes.

These guidelines are the most up to date and based on research. However, I would like to impart some of the things I have learned throughout my career and the few concussions I have had:

1. Remove yourself from the activity you are doing. I know this is hard but you are probably putting yourself at risk for a longer or more complicated injury. If you want to get back out there as quickly as possible and avoid more serious injuries, it is critical to stop what you are doing. 
2. Give yourself time to rest – some of the symptoms of concussion can develop up to 24-36 hours after the injury occurred. So jumping right back into a high risk activity can put you at more risk.
3. If something doesn’t feel good, stop. If you hurt a muscle and felt the pain when you began running you would stop, so don’t treat your brain any differently. I think this is particularly important when you are trying to get back to your life and sport. Monitoring how your brain feels when you are beginning to re-integrate yourself into all your activities is key.
4. Be patient – For me this was the most difficult one. Some days you begin to feel better and think that you have recovered and then the next you feel worse again. This can be extremely frustrating, especially if you want to get back to school or back to what you love doing. As long as you are aware that it’s not going to be a straight forward recovery, then maybe you can lower that frustration.
5. Rest, but don’t sleep all day. Previously it was thought that it was important to completely isolate yourself, stay in a dark room until you felt better and your symptoms were gone. However more recent research has shown that full rest can have a negative effect on brain health and recovery. After the suggested 24-hour rest period, begin to get back into what you are doing, slowly. Go for a walk or try cooking dinner, but whatever it is, make sure you’re moving in small steps.
6. Define your priorities. One common symptom for  people is fatigue and difficulty to concentrate. If you overwhelm yourself you could hinder your recovery.
7. This so-called ‘invisible injury’ is nothing to hide, nothing to be ashamed of and it is okay to not feel comfortable doing something that everyone else is. All that matters is taking care of your brain and you need to do whatever it takes to take the appropriate steps.

 Karolina Urban is a former University of Toronto and Canadian Women’s Hockey League player. Currently she is a PhD student at the Concussion Centre in Holland Bloorview Kids Rehab Hospital. 

New pediatric concussion guidelines – what you need to know

By: RICHARD HASKELL

Whoever said, “Youth is wasted on the young,” was probably envious of all their energy and exuberance!

Indeed, these attributes are ones that children and adolescents seem to have in abundance, clearly demonstrated by the myriad of physical activities and contact sports they enjoy both on and off the playground. As healthy as these activities are – and they should most definitely be encouraged – there is always the danger of injuries, including broken bones, sprained ligaments or tendons, and, probably the most serious of all, trauma to the head.

photo credit: stevendepolo via photopin cc

What we’ve known up to now

Head injuries fall into two categories, external and internal. While an external injury may appear more frightening, it is actually considerably less dangerous than an internal injury. There may be heavy bleeding followed by a ‘goose bump’, which eventually disappears within a few days or a week.

Internal injuries can include a fractured skull, torn blood vessels, or damage to the brain. They are considerably more serious and can lead to a brain injury or a loss of life. Concussions are the most common type of internal head injury. Derived from the Latin concutere (to shake violently), the word concussion is defined as “a traumatic brain injury which may alter the way the brain functions.”

Concussions can be caused by any blow to the head, face, neck or anywhere the body that results in a sudden jarring of the head. A person doesn’t need to be knocked out or lose consciousness to have had a concussion. Immediate symptoms may include headaches, difficulty falling or staying asleep, nausea, dizziness, confusion, issues with concentration, memory and problems with balance and coordination. These symptoms can last anywhere from a few minutes to several weeks after the injury.

photo credit: Paul L Dineen via photopin cc

According to Dr. Sherilyn Driscoll, a physician with the Mayo Clinic in Boston, concussions in children and adolescents can lead to serious health risks, particularly if the symptoms aren’t noticed immediately after the injury.

The risk magnifies if a person returns to physical activity too soon after the injury before the trauma has had time to heal. Worse, a second incident of head trauma shortly after the first may result in brain swelling, a condition known as Second Impact Syndrome (SIS). Once a child has suffered an initial concussion, he or she has a much higher risk of sustaining another, and the effects of multiple concussions over the years can be cumulative. There can be dire consequences. Rowan Stringer, an Ottawa high school rugby player died as a result of SIS shortly after a game in May of 2013.

Recent Findings

In June, 2014, Dr. Roger Zemek, a scientist at Ottawa’s Children’s Hospital in Eastern Ontario, presented the first guidelines on the effects of concussions on children and adolescents. Zemek teamed up with the Ontario Neurotrauma Foundation and chaired a 30-member panel, which reviewed 4000 papers with the latest evidence about concussions in children.

photo credit: cellar8 via photopin cc

Stemming from Zemek’s conclusions were three recommendations for children suffering from concussions:

• longer rest periods
• no physical activity for up to 30-days
• a limited amount of time devoted to cognitive brain activity with limited or no recreational time spent on television or computer games.

The guidelines recommend that if a player demonstrates a concussion-like symptom such as vomiting or a failed memory test, he or she should be removed from the game immediately.  Another discovery: researchers found that in addition to the usual physical symptoms, young people also frequently experienced signs of irritability, sadness and anxiety following a concussion.

Zemek wrote in an email to BIST:

In my opinion, concussion has only been recognized as potentially serious in the recent past since there was so little concussion research even just five-years ago.  When we looked at all of the published literature, there was extremely limited high quality concussion research in children and teenagers more than 5 and 10 years back. Like in so many other illnesses, children are not just little adults.  

10-year-old Sam Barton became one of the 900 children and teens who show up with a concussion at the Children’s Hospital of Eastern Ontario emergency room last year after he banged his head on the floor during gym class. Without any signs of brusing or nausea, Sam’s parents took him to the ER after he complained of a headache.

Tests soon confirmed that Sam had a conscussion. The knock had also affected Sam’s ability to concentrate. Sam was lucky. Zemek’s findings show that only one in four medical practitioners are using concussion tools to measure the severity of injuries and to track recovery.

Zemek writes:

For parents, caregivers, teachers and coaches, the guidelines provide a ‘one-stop shop‘ in order to best monitor and manage ongoing symptom management, specifically the stepwise ‘return-to-learn’ and ‘return-to-play’ tools.  

For parents, the guidelines offer suggested alternative activities since their child may be unable to play sports while recovering, and also offer step-wise advice on how to return to school.

For teachers, the guidelines include templates letters that could be used to implement doctor-school communication describing recommended level of activities to facilitate communication with the school.   

For coaches and schools, the guidelines provide resources in order to improve the whole community response to concussion recognition and management, and offer tools to track recovery and to ensure safe removal from play in the event of a suspected concussion. 

The guidelines include a pocket Concussion Recognition Tool for use in schools by coaches and parents. The toolkit outlines various symptoms (such as loss of consciousness, convulsions, problems with balance or headaches) and which steps to take following an injury (such as removing the player from the game, checking his or her memory, or calling an ambulance).

DR. ROGER ZEMEK;  photo credit ERROL MCGIHON via OTTAWA SUN

 

 

 

 

 

 

 

 

What to do if your child has a head injury

There are a number of steps you should follow should you think your child has suffered a concussion. If he or she has any of the following symptoms, call 911:

• unconsciousness for more than a few minutes
• abnormal breathing
• obvious serious wound
• bleeding or clear fluid from the nose, ear, or mouth
• disturbance of speech or vision
• pupils of unequal size
• weakness or paralysis
• neck pain or stiffness
• seizure

If your child is unconscious:

• do not try to move your child in case there is a neck or spine injury
• call for help

If your child is conscious:

• do your best to keep your child calm and still
• if there’s bleeding, apply a clean or sterile bandage
• do not attempt to cleanse the wound, which may aggravate bleeding and/or cause serious complications if the skull is fractured
• do not apply direct pressure to the wound if you suspect the skull is fractured
• do not remove any object that’s stuck in the wound

Finally …

Concussions are serious matters, not to be taken lightly. If you suspect a child, colleague, or player has suffered a head injury, insist he or she seek medical attention immediately. Rest – both physical and mental – is crucial. If not treated, concussions can lead to much more serious issues such as SIS or acquired brain injuries.

The brain is a complex and marvellous organ, we human beings can’t exist without it, and young brains are particularly vulnerable. So let’s give it the respect it deserves. Indeed, concussions are more than “just a bump on the head.”