How do you solve a problem like concussion?
Concussion awareness in schools has never been better. The “old-school” attitude of toughing it out and turning a blind eye just to field the strongest side is fortunately no longer wide-spread. But with admin-heavy guidelines and confusion over how best to implement them, there’s still some way to go before schools can start getting over this most complex of headaches.
What is concussion?
Concussion is a heterogeneous injury involving a myriad of physical, cognitive, sleep-related and affective symptoms, and impairments.
So says Dr Anthony Kontos of the University of Pittsburgh.
Are you confused yet?
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 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 also 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% of concussions. Given all these uncertainties it’s little wonder that people are a bit hazy about how to handle concussion.
Out with the old – in with the new
The “old-school” attitude to concussion doesn’t help. Tough it out; there’s nothing to report. No blood. Nothing’s broken. Plough on.
This is dangerous. Most concussions are like any other injury: rest and recuperation should sort it out. But playing on, or playing again before you’ve fully recovered, 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”
Concussion is not a rugby injury. Rugby’s governing bodies have done a great job at increasing awareness and educating the public, but in turn they has accidentally taken ownership of the problem. Concussion is a risk in nearly all team sports and is almost certainly under reported in games such as football and hockey. Not only that, but in certain age groups concussion is just as likely to occur in the playground than on the sports field.
Return2Play data from the Christmas 2016 term backs up this view. While it is no surprise that rugby had the highest rate of injury during what is the traditional rugby term, non-sporting concussions had the second highest incidence followed by hockey and then football. On top of this, the senior players – who most would flag as being most likely to sustain a concussion – had the lowest concussion rates. Indeed, 90% of concussions occurred in children who were 16 or younger.
Put simply, concussion is not just the reserve of massive rugby-playing boys – it affects primary and secondary school-aged children of both sexes in all sports.
So, 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 3 practical areas that schools can focus on:
Developing better technique. Whether ducking a bouncer, heading a corner or clearing out a ruck.
More education. Administrators, parents, teachers, coaches and players all need to be more informed about the risks of concussion and on the lookout for the symptoms. Concussion identification is a tricky business but when it is accepted that the risks of playing on outweigh the benefits things suddenly seem a lot simpler. If in doubt, sit them out.
Better management. Accidents and injuries will happen in sport but if managed according to the best guidelines available the long-term risks should be mitigated. Know the guidelines.
“This is all very interesting, but concussion is not an injury we have much of a problem with …”
Well, I’m afraid you probably do. You just don't realise it. The key to concussion management is getting the first step right. Recognition. Raising awareness, empowering coaches to remove players from play, and ensuring a player’s return to play is managed properly.
Data from across the schools already using Return2Play shows very consistent rates of concussion. With an average rate of 5.1% in Christmas term 2016, a school of 500 pupils could expect to have had around 25 concussions in the same period.
The guidelines in real life practice
Clear cross-sport guidelines exist and have been well publicised. In short, a player suspected of concussion should have 2 weeks of complete rest from sport, followed by the Graduated Return to Play. For school age children, the minimum time they must have off before returning to match conditions is 23 days. At the end of the process a doctor is required to approve a players’ return to play.
Sounds simple. But, in real life practice there are many places where players can fall through the net and many schools have been discovering them through bitter experience. There is a high administrative burden when things are done properly, and accessing doctors willing to undertake assessments is difficult.
How can you ensure all the relevant people are informed when a concussion occurs (assuming you can’t rely on a dazed adolescent to pass the message on)?
How can you make sure the right advice reaches the right people?
How can you demonstrate to parents that you comply with the guidelines?
How can you guarantee those involved in the welfare of a player outside of school (e.g. a club, county or academy) are informed so that the player isn’t put in to play elsewhere…and vice versa?
How can you efficiently track a player’s symptoms during recovery?
How can you ensure they don’t return to play until an appropriately trained doctor has certified them fit to do so?
And perhaps of equal importance: who takes care of it all?
What does Return2Play do?
Return2Play was born out of the frustrations I experienced first-hand as a school sports doctor and as chairman of a community rugby club. We use technology to remove the barriers which can prevent best care being provided as well as offering training and education packages to staff, parents and pupils.
Our online system provides:
A live register of all players at an organisation showing each players’ current playing status (safe to play, not fit, in GRTP etc) - access can be granted to as many staff members that an organisation wishes and can be viewed in "real time" on smartphones.
Ability to log a concussion against a player which automatically changes their status in the live register and communicates with all parties linked to that player (parents, clubs etc)
Automated and regular concussion advice is sent to the player and parents during their recovery
Linking of players to sports-friendly doctors to undertake return to play assessments
Automated communication of the doctor’s decision (i.e safe to start GRTP/Safe to return to play) with immediate updating of the live register
Audit trail of evidence to prove an organisation's compliance with the guidelines
Data reports showing trends in concussive injuries
And finally…
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. With more information, a focus on safer technique and better management of player’s recovery concussion can be just like any other injury.
This is not a new injury, but we’re now recognising it and managing it properly. In reality, sport is safer than ever.
For more information..
on how Return2Play may be able to assist your school please contact
e: hello@return2play.org.uk
t: 020 3773 1045
Dr Sam Barke is Medical Director at Return2Play – a concussion management system that handles the entire return to play process. As a sports doctor, he has worked with numerous top independent prep and senior schools to ensure they provide the best care to their pupils following an injury.