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ONE BRAIN-SAVING TRUTH: “When in doubt, Sit it out”

It seems that every day we hear of another professional hockey, football or soccer player sustaining a concussion (which is short-hand for “Traumatic Brain Injury”), or of the havoc these brain injuries can wreak even decades later. Controversies swirl around when to allow body contact in hockey and heading the ball in soccer. Huge lawsuits have been filed by players against football, hockey, and other sports leagues. As a society we are starting to pay attention to our brains.  Physical activity, including sports involving body contact, is a vital part of a healthy life. These teach discipline, resilience, and team work. But they also have dangers that we need to be aware of and watch for.

While a growing number of us know a young adult whose brain has been injured playing sports or in a fall or in a car accident, few of us know what to do when a person we care about suffers a concussion. All too often we rely on information about concussions that we learned when we were young, much which has been found to be wrong and to cause more damage.

I’m no expert on brain injuries, but I have talked to a lot of concussion experts over the past few years. They’ve helped me unlearn almost everything that I knew about concussions. Here’s what I came away with.

 

Dangerous Myth 1 –‐ Concussions are caused by blows to the head

The Truth –‐ While many concussions are caused by a hit to the head, concussions can also be caused by body checks and tackles and falls that don’t involve the head at all. Concussions are brain injuries, caused when the jello‐like brain smashes into the hard bony inside of the skull. Some of the most severe concussions can be caused by a blow to the upper body that causes the head to snap on top of the neck. Ignoring body-blows and collisions can lead to many dangerous concussions being overlooked.

 

Dangerous Myth 2 –‐ Concussions only occur if you lose consciousness or see stars.

The Truth –‐ Every concussion is different. Most don’t involve “blacking out” at all. Many times symptoms don’t appear until the next day. (There is a list of common concussion symptoms following Myth 8.)

 

Dangerous Myth 3 –‐ You can “shake off” a concussion and get back in the game or go back to school and work.

The Truth –‐ The new rule is “When in doubt, sit it out”. Risking a further brain injury can have tremendous life-long effects. Once the brain is injured, it is easier for another concussion to occur. The best current advice is for at least a few days of complete rest, followed by a gradual return to physical and mental activity, coupled with close observation to ensure that symptoms aren’t returning.  A “no pain, no gain” attitude and the temptation to “play hurt” can be catastrophic when it comes to brain injuries.

 

Dangerous Myth 4 –‐ After a concussion it’s okay to go to school or work, play video games, and socialize with friends, just so long as you wait to play sports until your concussion symptoms disappear.

The Truth –‐ A concussion is an injury to the brain; school, socializing, reading, work, video games, and other ordinary activities stress the brain. The best advice is to closely monitor symptoms during every type of activity, stopping as soon as you notice a symptom emerging.  It’s much harder to “stay off your brain for the next week” after a concussion than it is to “stay off that knee for the next month” after tearing a ligament. Putting too much stress on a torn ligament before it is fully healed can do permanent damage. Similarly, putting too much stress on a concussed brain can do permanent damage, but there are three major differences.

• There are splints and crutches and physiotherapy for a torn ligament; if needed surgery is available. In contrast, there are no treatments or assistive devices for a concussion.
• Doctors are pretty good at predicting how quickly a torn ligament will heal, but there is no way to predict how quickly a brain will heal itself following a concussion.
• And while a torn or improperly healed ligament can interfere with a few activities, an injured brain can get in the way of success, happiness, and comfort in every part of your life.

“Return to Learn” and “Return to Work” protocols are still being developed. They are much more complex than the “Return to Play” that most coaches are already using. But the core principles are the same:

• Rest the brain – avoid activities that might cause further damage until the brain has healed
• Monitor symptoms
• Gradually add activities, and continue to monitor symptoms
• If symptoms re-emerge, reduce activities
• Create a team of everyone involved: family, teachers, friends, and doctors

The biggest obstacles to safe and rapid returning to learn are often the expectations of the student, and her/his family, teachers, and friends.

• Few students want to fall behind on her/his school work, and most are upset at not being able to take part in favoured social activities.
• The family wants to return to the regular household routine and see the student make steady progress to being an adult.
• Teachers have trouble telling the difference between a student being lazy and having a concussion; they have rules about deferring tests and allowing a student to put his/her head on the desk or walking out in the middle of a class.
• And friends want to socialize.  But too much, too quickly, has been found to set back recovery and perhaps cause further injury.

 

Dangerous Myth 5 –‐ Young brains are like young bones; they are stronger and heal faster than older brains.

The Truth –‐ Research indicates that pre-teen and teen brains are more prone to concussions than adult brains. The experts don’t yet know why this is, but they all recommend that special care be taken to protect young athletes from brain damage, and to give young injured brains lots of time to heal.

 

Dangerous Myth 6 –‐ You can spot a concussion using base‐lines, MRIs, or CTScans.

The Truth –‐ Unfortunately, there is no reliable “objective” test for a concussion. The only test is detailed careful observation over time (which is why “when in doubt , sit it out” so important). Concussions don’t show up on MRI’s or CTScans or blood tests or x-rays. Base-Line tests (particularly the fast DIY tests) aren’t definitive and are very controversial among specialists. “Hit-indicators” in helmets don’t measure body hits that result in whiplash, and can’t tell what parts of the brain are injured when it smashes into the inside of the skull. A positive result on any of these tests should be used to start a concussion-recovery protocol, but it is important to remember that a negative result does mean a clean bill of brain health.  Always be alert to symptoms of a brain injury, and take action as soon as you see any.

Relying on base-line testing of teenagers is particularly problematic. The teenaged brain and mental functioning are naturally changing rapidly, often invalidating a “base-line” from even a few weeks earlier. And there are reports of athletes of all ages deliberately under-performing on the “base-line” so that later testing won’t show diminished brain function that will keep them from playing the game they love.

 

Dangerous Myth 7 –‐ A good helmet and mouth-guard prevents concussions.

The Truth – Helmets and mouth-guards help a little, but helmets are designed to protect the skull and mouth guards protect the teeth.  Neither is designed to protect the brain from crashing into the inside of the skull. Isaac Newton wrote the rule and he got it right –‐ you can’t ignore inertia.

If the head stops suddenly, the brain will keep going until it crashes into the inside of the skull. If the head moves suddenly, the brain will stay still until it crashes into the inside of the skull. If the torso gets hit hard, it can create a whiplash effect through the spine and neck that slams the brain onto the inside of the skull.  And after the initial crash, the brain will likely bounce around for a while, crashing into the skull several more times, twisting and being stretched as it goes.

A good helmet and mouth guard will do nothing if the brain-skull collision is caused by a body blow and whiplash. Even with blows to the head, the best a helmet and mouth‐guard can do is to absorb some small amount of the force, but in the end the brain will crash into the inside of the skull. (But keep in mind that helmets can be very good at preventing bone-crushing skull injuries that can do catastrophic damage to the brain, and mouth-guards help prevent broken or lost teeth.)

One thing that does seem to provide a measure of protection against concussion is a strong neck.  The brain is like a fragile ball balancing on the tip of a long stick (the spine).  The stronger the connection between the brain and the spine, the less likely the brain is to careen violently into the skull.  Neck muscles strengthen the connection.

 

Dangerous Myth 8 – All concussions are the same

The Truth –‐ The brain is an incredibly complex organ. Every brain is different. And every brain-skull collision is unique. So it is inevitable that every person will show different concussion symptoms.

Some of the common symptoms include:

• loss of memory, forgetfulness, inability to learn
• headaches, emotional volatility, outbursts of anger, personality change
• blurred sight, slurred speech, loss of balance
• depression, anxiety, difficulty sleeping, suicidal thoughts
• confusion, in a fog
• fatigue, nausea, neck pain
• sensitivity to light, noise, movement, colours.

And to make it even more confusing, there may be no symptoms for a few days, after which symptoms may can come and go for several weeks or months afterwards.  Even something as simple and enjoyable as sitting around and talking to a group of friends takes up a lot of “brain-power”. Paying attention to the subtle social dynamics involved, picking up emotional cues and body language, and figuring out how best to respond is hard work. These and other everyday activities can cause relapses and/or symptoms to flare up.

 

Dangerous Myth 9 –‐ There are reliable treatments for concussions.

The Truth –‐ This is perhaps the cruelest truth of all.

At the moment there is no drug, no exercise, no therapy, no surgery that can be used to reliably treat a concussion. The best medical advice is to manage the concussion through rest and close observation, and give the brain time to heal itself. That means rest, followed by gradual increase of mental and physical activity, interrupted as needed by reduced activity and increased rest whenever symptoms flare up. “Pushing through” the symptoms all too often causes more damage, and sets back recovery.