Concussion Confusion

There is a funny, yet worrying, story told from the 1980 All Ireland football final. As the Kerry players enter the tunnel at half time Mike Sheehy is commended for his contribution with a goal in the opening half.

“Nice goal”, says the Doc.

“Goal? What goal?”, replies Mike.

The team doctor showed concern and advised the manager that the player should probably be taken off, not even remembering the fact he had scored the goal. The manager declined and Mike Sheehy lined out for the second half and Kerry went on to win their 3 in a row.

Personally I can recall two incidents in my own playing career where in hindsight I probably should have been removed from the field of play (whether I’d have gone willingly is another issue, a hurdle I now face as team physiotherapist to similarly minded players). As full back with an eventual Leinster winning under 21 side I was given the unenviable task of marking a rising star in Joe Sheridan in a Leinster semi final. With at least 2 stone and 3 inches on me I came out the wrong side of an aerial tangle with the big Meath man, landing head first from a height into the Tullamore sod. With a shake of the head and some water I was back on my feet after a short delay in play while I got checked out by medics. I was of the understanding that Joe scored one goal from the penalty spot in the opening half. He had in fact scored a second goal from play off me shortly after this collision easily brushing me aside under a high ball en route to blasting to the net.

brain

From a non medical point of view these are funny stories. But as our knowledge and understanding of concussion has improved reflecting back on these stories is frightening. The IRFU have lead the way with guidelines around concussion (IRFU Guide to Concussion) and the GAA have followed promptly (GAA Concussion Information) highlighting what to look out for and what to do if suspected. Concussion is a brain injury make no mistake about it. Concussion is defined as a ‘biomechanically induced brain injury characterized by the absence of gross anatomic lesions’. Early and late clinical symptoms include impairments of memory and attention, headache, and alteration of mental status. The mechanical trauma initiates a complex series of metabolic events responsible for most postconcussive signs and symptoms. Furthermore, if a second concussion is sustained while those concussed cells are still in a vulnerable state they may be irreversibly damaged by the presence of swelling (Signoretti et al 2011). This is the main reason players need to be removed from the field of play if concussion is suspected; the second impact syndrome. If there is any doubt let there be no confusion: they need to be taken off.

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Coincidentally the day before a recent GAA Player Welfare update I was attending, the first controversial Player Welfare call of the year was made in the first round of the National Football League. One of the country’s most experienced GAA team doctors, having carried out his on-field assessment, made a judgement call and allowed one of the players continue playing following a collision. After ten minutes he reviewed his decision and the player reluctantly left the pitch with medical staff for full assessment. But both rugby and Gaelic games need to be applauded for their up-skilling in this area. Less than 5 years ago this player would have continued to play. It would have been deemed a sense of weakness to go off injured with no clear signs of injury. Team medical staff are now faced with challenges. But the onus cannot lie solely on the medical staff. Coaches, parents, partners and the players themselves must be made aware of the dangers associated with head injuries, the signs and symptoms of concussion, and when it is ok to reintroduce the player to activity. Player welfare must be the priority even if it means being without your star player for the second half of that game, or for the next 3 weeks while he or she is on the side lines. Gradual return to play guidelines have been outlined by the GAA and IRFU. These are in place to protect the player from the second impact syndrome, making sure the brain has recovered before being placed in a potentially dangerous situation again. The 6 stages are:

  1. No activity – both physical and cognitive rest
  2. Light aerobic activity
  3. Sport specific activity
  4. Non contact training drills
  5. Full contact practice
  6. Once no symptoms are reproduced – return to play

There is a minimum 14 day rest period. Then the return to activity period starts over a 6 day period for adults, 8 days for children allowing more time for recovery. This is a total of 21 days for adults and 23 for children (under 20’s). If the athlete shows any signs of symptoms they do not move forward and the time from sport can be as long as necessary until symptoms are clear. More detailed information on the IRFU’s Return to Play Protocol can be found here

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As games evolve, rugby specifically, you do have to wonder what the future holds for our athletes. The recent release of “Concussion”, a Hollywood block buster starring Will Smith who plays the forensic neuropathologist who performed the autopsy of Mike Webster, a former NFL star, in 2002 will further magnify the world wide problem. Webster died at the young age of 50 after experiencing dementia and depression, and cross sectional studies carried out on his brain were consistent with chronic traumatic encephalopathy, a degenerative brain disease. This was one of 87 cases of this disease in deceased NFL footballers.

So as I tuck my 2 year old boy into bed tonight (after our usual one hour bed time battle) I think to myself: “Is rugby something I would like to see my boys play like their Dad?”. It’s a thought I am happy to park for a few years. But as sleep deprivation from his teething 5 month old brother has me presenting with signs similar to concussion it becomes clear the life time of worry ahead of us (and many more sleepless nights) has not yet begun.

 

For more information on any of the issues addressed throughout this article please contact Rob via email at mccabephysiotherapy@gmail.com, Twitter @mccabephysio, Facebook at McCabe Physiotherapy or visit http://www.mccabephysiotherapy.com

Rob McCabe MISCP

Chartered Physiotherapist

MSc (pre reg) Physiotherapy, BSc Sport Science and Health, MSc Sports Physiotherapy, PG Dip Orthopaedic Medicine

Orchard House, Moorefield Rd, Newbridge, Co. Kildare

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