How do you solve a problem like concussion?

Nigel Booth says under-reporting and ‘old-school’ bravado are obstacles to managing concussion in school sport

What is concussion?

Concussion is a heterogeneous injury involving a myriad of physical, cognitive, sleeprelated and affective symptoms, and impairments, says Dr Anthony Kontos of the University of Pittsburgh.

Perhaps it might be better to think of concussion simply as the result of the brain hitting the inside of the skull. In other words: the very thing that’s there to protect your grey matter, injures it.

But as Dr Kontos demonstrates, it’s a bit more complex than that. Any combination of numerous physical, cognitive or mood-related symptoms can point to a concussion having taken place. These include dizziness, headaches, memory problems, difficulty concentrating, depression, anxiety, motor impairment and more.

The appearance of symptoms can be delayed by hours or even days from the moment of injury, making concussion one of the hardest injuries to diagnose. A child doesn’t even have to have taken a knock to the head to sustain a concussion. And the cherry on top? Loss of consciousness (widely considered to be synonymous with concussion) occurs in fewer than 10 percent of concussions. Given all these uncertainties it’s little wonder that people are a bit hazy about how to handle concussion.

Most concussions are like any other injury: rest and recuperation should sort it out. But playing on, or playing the following week whilst still suffering post-concussive symptoms, leaves a child more susceptible to further concussions, further brain trauma and a more serious long-term impact on brain function. There needs to be a sea change in attitude towards this hidden injury not just from coaches and teachers but school administrators, parents and players too. Being concussed is no more a sign of weakness than having a broken leg.

“That’s great, but our school doesn’t play rugby” 

In August 2013, a $765m (£490m) settlement was reached between the NFL and its former players. The basis of the settlement? The NFL’s failed duty of care. There have been numerous cases in the UK and elsewhere of serious injury resulting from multiple concussions sustained whilst students were under the supervision of their teacher-coaches. Some of these were fatal.

Put simply, concussion is not just the reserve of rugby-playing boys – it affects primary and secondary school-aged children of both sexes in all sports.

There needs to be a sea change in attitude towards this hidden injury not just from coaches and teachers but school administrators, parents and players too

What can be done?

Some people have called for concussion-risky elements of sports to be banned – contact in rugby, for instance. This would undoubtedly lower the number of concussions, but would probably kill the sport and, as Dr Colin Michie of the Royal College of Paediatrics and Child Health puts it: “a far greater risk facing Britain’s children is that of becoming an inactive youngster, struggling to tear themselves away from their smartphones.”

So, if banning fundamental aspects of sports isn’t a sensible option, here are three practical areas that schools can focus on:

1. Developing better technique. Whether ducking a bouncer, heading a corner or clearing out a ruck.

2. More information about the risks of concussion and on the lookout for the symptoms. If in doubt, sit them out.

3. Better management. Accidents and injuries will happen but, if managed according to the best guidelines available, the long-term risks should be mitigated.

How to safely get pupils back playing 

Clear guidelines exist laying out the appropriate management of suspected concussion and, importantly, what process needs to be followed before a player is fit to return to play.

For an U19 player this involves two weeks of complete rest, even from academic studies if

necessary. An assessment by a doctor follows. If the player passes, they then begin what’s called Graduated Return to Play (GRTP): a series of activities, each increasing in athletic intensity and to be completed without any recurrence of symptoms. If symptom-free by the end of the GRTP process (which involves a second doctor’s assessment) then a player is considered fit again. The fastest possible progress through this entire process is 23 days.

The key to concussion management is getting the first step right. Recognition. Raising awareness, empowering coaches to remove players from play, and ensuring players are placed on the return to play pathway.

Concussion isn’t going to go away. With greater awareness of the injury there are already more reported cases and more parents demanding the peace of mind that comes from knowing their child’s safety is being taken care of. But it also isn’t a death sentence: amongst U12s the greatest risk of concussion is unsupervised play, not sport. With more information, a focus on safer technique and better management of player recovery, concussion can be just another injury. 

Nigel Booth is a private tutor and Schools & Colleges Business Manager at Return2Play

W: www.return2play.org.uk 

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