Concussions: All In Your Head
When Dr Craig Roberts does his rounds, he watches 15 potential patients hurl barrages of their own body weight at one another for 80 minutes. Since 2008 he’s been the team doctor to the Springboks, tasked with repairing the battered bodies of the country’s top athletes and sending them back to their national duties, each time
a little more battle-hardened and educated in the school
of hard knocks.
Besides being an expert in reviving, strapping, nose-straightening, hydrating, icing and taping, Roberts’s pitchside manner includes being a firm negotiator. And it was this particular skill that was tested in the second Test of the 2009 British and Irish Lions Tour when he had to convince a dazed, 120kg Danie Rossouw that it was time to leave the field in front of his home crowd after he had just come on as a substitute.
A minute earlier, Rossouw and Brian O’Driscoll had both rushed at each other, in an attempt to get their hands on a ball that Fourie du Preez had popped up from the back of a ruck. Neither succeeded. Instead, the right shoulder of the determined Irishman slammed into Rossouw’s skull and the Newtonian laws that were entrusted with holding an upright Danie Rossouw firmly on Loftus Versfeld soil were temporarily deranged.
“He tried to stand up to carry on playing and was
dizzy and fell over again,” says Roberts. “It was a pure concussion.”
This was where the doc’s mediation skills came in. “The challenge for me was to get him off because he was adamant that he was going to stay on the field,” Roberts says. “Danie’s quite a big guy so it took a lot of persuasion to get him off the field, but it was non-negotiable – he had to come off.”
The brain cased inside the hardy shell that is Danie Rossouw’s skull, believe it or not, is just like yours – it weighs about 1.3kg and has a similar consistency to that of tofu. That’s right, beneath the tough exterior of the Tuilagis and Tysons of this world is a dollop of vegetarian snack that floats freely and snugly inside their skulls. The familiar grey folds are connected by networks of white matter – nerve cells with long, spindly tendrils called axons that relay signals from cell to cell in milliseconds. The connections among axons account for every function of your brain, including memory, concentration, movement, emotion and even maintaining consciousness – as long as a jarring hit doesn’t deprive you of it.
When that jarring hit shocks your brain – the average injury occurs in less than a second – it can’t absorb the acceleration so it’s briefly distorted. (Picture what happens if you shake a mould of jelly.)
“Your brain is suspended in your cerebrospinal fluid,” explains Roberts. “When your head gets knocked from one side to the other, you get acceleration and deceleration of your brain inside your head, and that’s what really causes a concussion.” This sudden stretch of axons can break the internal train tracks that nerve cells use to transport signal-carrying proteins along their length. There’s a limit to the elasticity of the transportation lines. It’s like pulling Prestik – yank it too fast, and it stiffens and breaks. After the impact, proteins that are normally ferried along the length of the axons are suddenly dumped, piling up like uncollected refuse bags. In the frantic rush to repair themselves, nerve cells can summon protection mechanisms that actually make the damage worse. The axons swell. Brain function is interrupted. All this can start instantly and go on for months.
YOU’VE SEEN PHYSIOS AND DOCTORS HUNCHED
over prone players on sports fields. Possibly, you’ve seen it first-hand from a worm’s eye perspective. If your memory serves you correctly – which it usually doesn’t in concussions – you will remember several questions being asked. These days, medical professionals will ask some, if not all,
of these questions:
What venue are we playing?
Which half is it?
Who scored last?
Which team did we play last week?
Did we win last week?
These are known as the Maddocks Questions, devised by Australian neuropsychologist David Maddocks. “This a little quick on-field test to determine if one should take a player out of the situation or not,” says Dr Jon Patricios, a lecturer in post-graduate sports medicine at the University of Pretoria, and founder and director of Sports Concussion South Africa and the Schools Sports Concussion Programme. “Maddocks compared them to the standard questions that they use in casualties in head injuries, like: who are you, where do you live and where are you now? He found that those questions weren’t searching enough; if you were still concussed you could still answer the questions. He devised these other questions and they’ve been shown to be more appropriate in sports concussion.”
Knowing the your team’s stats and finer details of the game is more challenging than, how many fingers am I holding up? “You’re asking questions that are easy, but a little bit searching in a way – they should be easily answered by somebody who is compos mentis but someone who has had their cognitive function compromised won’t answer them correctly.
“One has to make an on-field decision as to whether to remove the player or not,” he says. “Bearing in mind that when you remove a player from the field, you can conduct a more stringent assessment.”
The IRB recently experimented with the idea of a “brain bin” in the IRB Junior World Championship in Cape Town and Stellenbosch. “Here you’ve got five minutes to take a player off the field and do a brief but more thorough assessment on him to determine whether there’s a potential for concussion and either put him back on or take him off,” says Patricios. “That’s the type of rule change that might creep into sport because it may be in the players’ interest to have a little bit more time to do a proper assessment.”
THE INVISIBLE INJURY
Patricios, a former president of the South African Sports Medicine Association has worked with Bafana Bafana, the Gauteng cricket team, Kaizer Chiefs and the Lions rugby team, says one of the challenges with working with concussions is that they are injuries without any visible wounds. “Because you can’t necessarily see the injured brain, you rely a lot on what people feel and as a result it’s often not taken seriously enough.”
He explains that concussion goes under the banner of mild traumatic brain injury. “In other words it’s not in the more severe end of the spectrum like a bleed in the brain or a burst aneurysm or a stroke.”
There is a myth that you have to be out cold to be concussed. “Loss of consciousness doesn’t necessarily mean a more severe concussion,” says Roberts. One of the main indicators of a severe type of concussion, he says, is memory loss before the impact. “We look if they don’t remember the start of the game. That’s generally an indicator of a more severe type of concussion,” he says.
Patricios agrees with him. “Only about 25% of people who have concussion lose consciousness. Amnesia is something more common and probably more significant.”
Another myth is that it’s only the big hits that will concuss you; the location of the hit is as important as the power behind it. Roberts says there are several sweet spots on your head that can knock you out. “A lot of it is where you get hit. You can get hit on the bottom of the jaw and that impact can travel through your jaw straight into the base of your brain,” he says.
Recovery rates depend largely on the patient. “There used to be a three-week rule in age-group rugby but sometimes it needs to be longer than that, while at professional level it sometimes needs to be shorter,” Roberts says.
Research suggests that perhaps 10% of people have life-changing symptoms after a single concussion.
Patricios mentions that severe, continuous concussions can also affect emotions. “There are a lot of cases of long-term depression, particularly in American football, that have been described as a result of repeated concussions that haven’t been acknowledged.”
He describes post-concussion syndrome as a lingering complex of physical, cognitive and emotional symptoms, and sleep disturbances. “We divide them into those symptom complexes, and that can linger for weeks and months.”
When it carries on for this long, the mild aspect of “mild brain injuries” becomes something of a misnomer. “I’ve even seen them become permanent when concussions occur regularly and are not treated properly,” he says. “There are the rare but catastrophic consequences where patients die as a result of concussions not being treated properly, and possibly from suffering a second blow before they’ve recovered from the first.” This, he says, is known as Second Impact Syndrome and almost exclusively affects adolescents.
“You don’t want to return to play before the concussion can be resolved. And that’s the danger, that’s where there’s a risk of further injury,” says Roberts.
“Under these conditions the already vulnerable brain sustains a second injury and undergoes dramatic swelling and can cause death,” says Patricios. He says there have been several cases of schoolboy rugby players dying as a result of the severity of the concussion scenarios not being properly acknowledged.
Concussion occurs most commonly in those under 20 years of age, he says. “The brain is still developing; it has a higher fluid content and the neurons in the brain are not fully developed yet and require increased nutrition, bloodflow and glucose.”
“In a concussion, there’s a dramatic metabolic change affecting the blood supply and the metabolic requirements of the brain and the developing brain is increasingly vulnerable to those situations,” he says.
OFF THE FIELD
You don’t have to be on the receiving ends of Manny Pacquiao’s gloves, Butch James’s shoulder or Dale Steyn’s bouncer to injure your brain. You just have to be in a position where your balance is compromised. Or when you let testosterone levels surpass common sense (“Dude, hold my beer and check this out…”), or some texting driver rear-ends you on your way to work.
The fact that you’re a male already puts you at risk. “The number one genetic risk factor for traumatic brain injury is having a Y chromosome,” says Dr Douglas Smith, director of the centre for brain injury and repair at the University of Pennsylvania.
About 59% of TBIs occur in men and in boys. Among adult participants in sports and recreation, men account for 70% of TBIs, according to the US-based Centers for Disease Control.
In some ways, off-the-field injuries may actually be worse than the ones seen among the pros. Athletes risk concussion week after week. But with regular guys – trying their hands at DIY or cycling over wet surfaces or simply goofing around – injuries tend to occur when they’re not braced for impact. Plus, they don’t have the neck muscles of Tendai Mtawarira. There is a widespread theory that neck strength might lessen the g-forces inside the brain. While Roberts agrees that neck strength does indeed play a role in conditioning the body for big hits, it does not necessarily make one more tolerant to concussions.
Unlike a pro athlete’s head injury, your own concussion isn’t likely to happen in front of a crew of trained medical professionals who can put you through a concussion protocol, whisk you to immediate medical attention as needed and enforce a Homer Simpson-type holiday until you’re healed. Your only witnesses are likely the ones who you asked to hold your beer.
So, you or your absent-minded friend got hit on the head. What now? Take it easy, the doctors order. “In terms of treatment for concussion, the best thing is to rest,” says Roberts. “We say no exercise and limited mental activity.”
“The scenario is exactly the same as a sporting situation,” says Patricios. “The first is to not harm yourself any further. Remove yourself from that situation, rest and know that most concussions improve with time.”
Symptoms should start getting better, he says, but you should look out for red flags. “These may be an indication that it’s more serious than a mild injury; if headaches are deteriorating, repeated vomiting, fits, loss of function of one side of the body, pupils dilate – that sort of thing.”
This is why people who’ve been hit should be supervised. “So if someone’s monitoring someone who falls and hurts himself in the house, the same thing applies. If anything gets worse, that person gets taken to hospital immediately; he needs a CAT scan and needs to see a neurosurgeon.”
If the flags aren’t red, rest, he advises. “The analogy I use is one of a hamstring injury. If you strain your hamstring, you don’t jog on it that day. So if you strain your brain, you need to rest your brain, this means that you need to not play computer games, read for long periods of time or study.”
There is a theory that one shouldn’t sleep after a concussion, which Patricios says is not entirely concrete. “Get monitored for a couple of hours and if things are settling down and the patient is not deteriorating, then sleep is actually a good idea because it allows the brain to recover.”
A female hormone may be one of the saviours emerging from research. A clinical trial now underway at 17 major
US medical centres aims to determine if the female hormone progesterone – which plays a role in maintaining pregnancy – might protect against neurological damage when it’s administered within the first few hours following impact. After animal studies suggested that progesterone might protect brain cells, scientists at Emory University in the USA conducted a randomised trial of 100 victims of moderate to severe concussions, each of whom had received an infusion of either
progesterone or a placebo within
11 hours of the injury. This study was primarily a test of safety and revealed no side effects. But the study participants who had received progesterone were half as likely to die, and if their concussions were moderate, then they were significantly less disabled.
The results were promising enough that Emory University is administering a clinical trial, which will test progesterone in more than 1 100 TBI patients. Athletes would not be the only beneficiaries; the military has a stake in the outcome. If the pregnancy hormone proves to be an effective aid in healing brain cells, it would be the first new treatment for severe brain injuries in three decades.
PROTECTION IS BETTER THAN CURE
None of these brain specialists is suggesting that we all cower at home on the couch. But they all do caution that you protect your head as if your life depends on it. Because it does.
“The one thing to have is a good-fitting mouth guard,” says Roberts. “Not only does it help prevent dental trauma but there is evidence that it prevents the shockwave travelling up into the brain when you get hit on the jaw. But it needs to be a proper mouth guard fitted by a dentist, not one of these boil-and-bite ones that you get at a pharmacy,” he adds.
No helmet, however, is concussion-proof. “The simple truth is that no current helmet, mouth guard, headband or other piece of equipment can significantly prevent concussions from actually occurring,” admits Dr Jeffrey Kutcher, chairman of the American Academy of Neurology’s chairman of sports neurology.
Helmets are designed to protect against high-impact collisions that could crack the skull, but they don’t have the design or technology to prevent the delicate, enfolded grey matter within from shifting.
“There’s no evidence that scrum caps protect from you a concussion in any way,” says Roberts. “They help with lacerations but at this stage the jury’s out on them helping with concussion.” He adds that sometimes headgear can have the opposite effect. “You can be a bit more gung-ho because you wear one,” he says.
“Even with a helmet, you’re still at extreme risk of having a traumatic brain injury in any type of sport,” says Smith. After all, the number of sports-related TBIs has not decreased, even though helmet use is now more prevalent than ever.
The bottom line is that it’s better to be careful than to be brain damaged, and the best course of action after an unwelcome knock is to follow the mantra in the SARFU guidelines: if in doubt, then sit out. If we can remove a player from a potentially serious situation, for me, that’s already a victory,” says Patricios.