A recent study at the University of Stellenbosch found that concussion caused during rugby matches can damage a young player’s brain and inhibit his academic performance.
The study, conducted by senior clinical psychologist, Debra Alexander, found that the academic performance of young rugby players who had suffered concussions, was lower than those of non-players. The performance of the players, measured three years apart, also declined with time.
"Concussion is becoming a more widespread problem, as there are simply more kids playing. The level of competitiveness is also on the increase," according to Dr Ismail Jakoet of the South African Rugby Scientific and Research Committee. "Concussion has become a critical issue that requires attention if serious injury, disability and death are to be prevented."
According to Jakoet, concussion is the result of a severe knock to the head/face, or the jerking of the head or neck, which causes the brain to take a knock.
“The most important thing doctors and officials need to know is the difference between a minor or a major case of concussion. A serious case of concussion could lead to brain trauma and death.”
Dr Gert Pienaar, medical officer for Netcare 911 agreed with Jakoet. He mentioned that most neurosurgeons actually claim that there is no such thing as a “mild concussion” - only cases that are considered less serious than others. The first concussion a player sustains is usually does not cause permanent damage, but a repeat injury to the head soon after this can have serious consequences. He added that the second injury did not have to be severe to have permanently disabling or deadly effects.
Jakoet mentioned that some experts think that the effective use of preventative measures can reduce the risk of concussion. This would include the strict application of the rules of the game and regularly doing neck-strengthening exercises.
“There is no consensus on the use of properly fitting mouth-guards. However, the International Rugby Board (IRB) continues to recommend its use. There is also no scientific evidence that the headgear currently used in rugby offers any protection against concussion,” according to Jakoet.
According to Pienaar the wearing of proper equipment such as helmets is essential, but they must fit properly. Safe play is also important and athletes must obey the rules and officials must enforce them.
Guidelines for schoolboy rugby
Pienaar said the guidelines on safety and sports are vitally important to all schools and clubs.
“Coaches and sports physicians of teams must take all players for a medical evaluation if any of the danger signs are noticed, or if a serious injury is suspected.
He added that sending players onto the field after an injury could be lethal - any player who loses consciousness has to be taken to hospital. He also stressed the importance of sticking to the guidelines before sending players back onto the field. they should not be allowed to compete again before the rest period is over.
Lastly he said that all players diagnosed with concussion should return to hospital after 24 - 48 hours for a review by the same healthcare provider. The follow-up examination is very important and often overlooked.
Look out for these symptoms
- Typical symptoms:
- Confusion and amnesia
- Unsteadiness/loss of balance
- Feeling stunned or dazed
- Seeing stars or flashing lights
- Ringing in the ears
- Loss of field of vision
- Double vision
- Sleepiness, sleep disturbance
- Feeling slowed down
- Loss of consciousness/impaired conscious states
- Poor co-ordination and balance
- Slowness in processing information – e.g. answering questions or following directions
- Easily distracted or poor concentration
- Inappropriate emotions – such as laughing or crying
- Nausea or vomiting
- Vacant stare/glassy-eyed
- Slurred speech
- Personality changes
- Inappropriate behaviour – e.g. running in the wrong direction
- Significantly decreased playing ability
Pienaar added that since symptoms of concussion cannot always be distinguished from serious head injury, grading systems are used to evaluate patients at the scene and to help decide on treatment.
He said “there are almost 16 different grading systems in use currently and unfortunately there is no consensus on which one is the most accurate. Local neurosurgeons prefer to use either the Colorado Medical Society Guidelines (CMSG) or the American Academy of Neurology’s Score. The CMSG is more restrictive than other scoring systems and is in use by the National College Athletic Association.”
Concussion is classified into five grades:
- The mildest, Grade I, involves only confusion.
- Grade II involves anterograde amnesia which lasts less than five minutes. These patients are also confused.
- Grade III involves the symptoms above, as well as retrograde amnesia and unconsciousness for less than five minutes.
- Grade IV involves all of the above symptoms, as well as unconsciousness that lasts between five and 10 minutes.
- Grade V is the same as grade IV, with unconsciousness lasting longer than 10 minutes.
Pienaar said, “The American Academy of Neurology (AAN) guidelines make it clear that permanent brain injury can occur with either Grade II or Grade III concussion. Thus, it is clear that subtle brain injury can have permanent consequences if the acute symptoms of the concussion continue for more than 15 minutes.”
Concussion in schoolboy rugby
Pienaar said that attempting to estimate the incidence of concussion in sport is difficult for many reasons, the largest being a history of the under-recognition and under-reporting of mild injuries. The injury rates vary tremendously with the choice of activity, which is by far the number one risk factor for concussion”.
However, based on the most sensitive tests for injury and recent experience with university sports, some ballpark estimates include:
- Approximately 20 mild concussions per 1 000 athlete exposures (practices or games) in the highest risk sports like football, rugby and full-contact ice hockey.
- Approximately five mild concussions per 1 000 athlete exposures in moderate risk sports like basketball.
- Approximately one mild concussion per 1 000 athlete exposures in lower risk sports like volleyball.
Management of a player with concussion
“If any of the above symptoms or problems are present, a head injury should be suspected and appropriate management provided. If a head injury is suspected, the patient management must include a neck injury precaution unless evidence points to the contrary. The key here is to always err on the side of caution - if in doubt, sit it out!” stated Jakoet.
Jaoket stated that in addition to a symptom history and clinical evaluation, neuropsychological testing is best for assessing the functional deficits arising from concussion.
“Neuropsychological testing is done because it’s an objective test which prevents a player underrating his symptoms in order to return to play as sometimes the symptoms are inconsistent and may resolve before cognitive deficits have been determined.”
Pienaar added that initial treatment should start with basic life support principles and cervical spine protection, which involves ensuring an open, maintainable airway and confirming proper breathing attempts with no life-threatening haemorrhage. All these points should be attended to before moving onto the next step. The level of consciousness is then assessed.
Momentary loss of consciousness is difficult to determine and usually dependent on information gathered from the referee, team-mates or the doctor at the field.
Returning to play
Jakoet confirmed the IRB recommends that a player who has suffered concussion should not play rugby for a period of three weeks and this should be strictly enforced in Age Grade Rugby.
“More recent recommendations employ objective findings in determining return to play; the more severe the concussion, the greater the symptomatic period and thus a player would return to play later than a mild concussion,” he said.
The problem with returning to play while still symptomatic has many consequences, Jakoet pointed out, such as “second impact syndrome”, which can be fatal.
“It’s a rare condition because a seemingly mild blow to the previously concussed head may result in massive brain swelling.”
In the long run
“It has been recommended that, should a player suffer two concussions in a season, he should not play for the rest of the season. It has also been recommended that a player who suffers three concussions should be excluded from contact or collision sport permanently,” warned Jakoet.
Do and don’ts while awaiting medical assistance
Mark Stokoe of Netcare 911 said there are a few things which should be taken into consideration while one is waiting for medical assistance after a sport injury:
Neck injuries: In the case of neck injuries, rather be overcautious. If it’s a suspected neck injury, assuming the person is on the floor, he/she must not be moved.
Someone should kneel at the person’s head and place both hands so that they cover the side of the person’s face, temple and ear region, thus ensuring no movement of the head. A mishandled neck fracture could lead to permanent paralysis or even death.
Any swelling, numbness, intense pain or tenderness should be taken seriously. Be especially aware if the person is lying in such a manner that their head, neck or back is in an awkward position, and if there is any sign of tingling, weakness or loss of sensation below the injury point, unable to move arms or legs.
Head injury or traumatic brain injury:To be dealt with the same as with a neck injury because an associated neck injury cannot be ruled out after major trauma or impact to the head. Remember in sports such as rugby, impact can be extremely high so it should go without saying that helmets must be used where applicable.
A sudden, blunt force to the head could lead to blood vessel damage which could lead to bleeding into or around the brain.
The effects of a head injury could range from mild concussion to coma, or even death. Ensure medical assistance is on the way, while trying to keep the person still and calm. (They may be uncooperative.) Look out for headache, nausea, confusion/disorientation, change in personality, and even aggression or seizures.
Fractures or dislocation:Do your best to keep the person still and calm as long as you know assistance is on the way. There is very little you can do as almost anything will cause extreme pain. Once help arrives, if applicable, analgesic will be administered before the limb is moved or a splint applied. In the case of bleeding, direct hard pressure with a wad of gauze will do much to stop the bleeding. Remember always to wear gloves and don't remove the wad of gauze for the whole duration that you are waiting for help to arrive.
- (Amy Henderson, Health24.com, August 2007)
Crippled by school rugby
Take concussions seriously