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Concussion - what is it and do we as coaches take it seriously enough?

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England's Dylan Hartley is stretchered off during the match between France and England

England's Dylan Hartley is stretchered off during the match between France and England in this years Six Nations

What is concussion, and do we as coaches take it seriously enough? Tim Hartley investigates for ConnectedCoaches...

As the final whistle blew and England’s men’s rugby team claimed the Six Nations Grand Slam, their captain was off the field, being assessed for a head injury.

The collision that forced Dylan Hartley from the field of play had left him prostrate on the pitch surrounded by medical staff, with some no doubt fearing that he was the latest high profile player to suffer a concussion in a big match.

In fact, you’d be forgiven when reading the news for thinking concussion and head injury are the biggest sports story in town, especially in activities such as rugby union.

However, it’s not a new phenomenon. The examples of brain injury in a wide variety of sports are legion, stretch back decades and perhaps have been swept under the carpet, with any recent publicity merely shining a welcome and long overdue light on the subject.

This season’s RBS Six Nations was the opportunity for the subject to be aired again in the high octane, high impact world of rugby. In just a few weeks, it will also be the first anniversary of a charitable foundation set up in memory of one of England’s finest footballers, and whose plight in his later years shocked many supporters of the ‘beautiful game’, Jeff Astle.

Astle, the Nottingham-born centre forward who became a legend at West Bromwich Albion in the 1960s and early ‘70s, died aged just 59 in 2002.

After a long battle to uncover the truth, ‘King’ Jeff was confirmed in 2014 as the first British professional footballer to have died from chronic traumatic encephalopathy (CTE), a progressive and degenerative brain disease found in those with a history of head injury. In his case, the ‘multiple concussions’ were caused by the repeated, low level brain trauma believed to have been caused by the heading of footballs. (Anyone aged over 40 will remember the heavy footballs – which became ever heavier in the rain – that are a far cry from the lightweight equipment of the modern game.)

It was something that shocked many, as fans, players and coaches had never seriously considered such a thing could be associated with football. Concussion was for high impact sports such as boxing and rugby, surely?

Much-needed attention

Cases such as that of Wales and Northampton Saints star George North have come to the fore. The winger inadvertently and unwittingly became the ‘poster boy’ for head injury and concussion after a series of blows last season. But the man himself realises that his case may have actually done some good in bringing the issue to the public’s attention.

In one recent interview, North said: ‘It’s good my name has been in the mix because the game around the world needs to identify that concussion is a big thing. I’ve read reports in the NFL and ice hockey, and sometimes, the research can be quite scary.’

His first ‘episode’ came while on Wales duty for the autumn internationals. Then, just weeks later, he was knocked out in a clash of heads with Richard Hibbard versus England. And finally, a third injury came during a collision while playing for his club side, Northampton Saints. As a result, neurologists told him not to play for several months and give himself time to recover. In the meantime, concussion quickly became rugby’s central talking point, and spread to include other sports too.

Northampton Saints George North down injured and receiving treatment

Northampton Saints George North down injured and receiving treatment

But what is concussion, and do we as coaches take it seriously enough?

The NHS advice tells us that concussion is the ‘sudden but short-lived loss of mental function that occurs after a blow or other injury to the head’. It can change the way the brain normally works, and recovery times can vary greatly.

North had to undergo return-to-play protocols, which require players to pass a series of tests in order to be given the green light to play again. If at any point the player fails one of the tests, they go right back to the first step, rather than attempt a second go.

‘Time is the best healer with concussion,’ he said. ‘It was rubbish when it happened, and I didn’t like my name being thrown around, but I was always going to be attached to the concussion story. With concussion, you haven’t got a cast on, you’re not on crutches, and you’re not in a sling. People assume you’re fit to go. It’s frustrating because you’re trying to explain what’s going on.’ North, to use rugby terminology, was ‘onside’ with the protocols and treatment, but many believe there is a long way to go.

Warwick Cann, Head of Performance at British Basketball, believes concussion and head injury are ‘a huge issue in sport within the duty of care and welfare perspective’, and for him, the subject is not high enough up sports’ agenda.

‘I feel many organisations are not placing the athletes’ medical welfare as high as we think. The medicine agenda has come a long way, but in the tough combat sports, being brutal is a sign of mental toughness. Yet we are seeing mental depression in male athletes and the impact of collisions on the brain. It’s a high issue for all sports, notwithstanding the obvious risks associated with being a competitive athlete.’

Managing with the four Rs

Concussion puts a player at an increased risk of further injury so although the NHS says it is ‘the most common but least serious type of brain injury’, a second or follow-up concussion can be very serious and, on rare occasions, fatal, particularly in youth players, whose brains are still developing and are therefore more vulnerable. Consequently, there’s an emphasis on the need for such episodes to be avoided by managing concussion correctly.

In rugby union, the governing body in England advocates the four Rs:

  • Recognise the signs and symptoms.
  • Remove the player from play.
  • Recoverfully before returning to sport.
  • Return only after following a graduated return to play

Ian Gatt, Lead Physiotherapist for GB Boxing, is one man who has to focus on the issue every day, and for him, ‘education is paramount’.

‘As medical professionals, we aim to maintain the best training availability status in order for coaches to be able to maximise performance. This, however, cannot be made at the detriment of the athlete. Yes, there is now more awareness, and with the litigations that have occurred in the States around American football, it has made a lot of sports consider what is best practice.

‘Beyond that, a concussed athlete will not provide their best performance so using them for a competition is counterproductive anyway. We obviously need to be cautious not to over-diagnose, but that is why appropriate regular training and good knowledge of the sport we work in are important.

‘In my opinion, coaches just need to understand concussion’s relation to the sport they work in, the guidelines around recovery timescales, and ultimately trust and be guided by the medical professionals they work with. At more junior and school levels, appropriate education becomes even more important as access to trained medical staff may be limited.’

For Level 2 under-13s rugby coach Darren Slack, the awareness needs to be spread even further as, for him, communication with parents is also paramount. His interaction with his team is only on a Sunday and then a midweek training session so events at home, at school, in other sports or even subsequent to his side’s training sessions can only really be put into perspective by the parent.

‘Should we be educating parents to a certain degree for signs and symptoms occurring later at home as concussion symptoms don't necessarily show at the point of injury?

‘We need to understand the injury and how to prevent it occurring, ie understand that 80% of head injuries do not cause concussion, and it is not always a direct bang to the head that causes concussion. So perhaps, sometimes, it could be said we “overreact” to a knock to the head and probably overlook a whiplash-type injury.

‘My awareness of the subject changed a number of years ago when I suffered a prolonged concussion myself. At that time, coaches didn't really understand the potential damage that could occur – it was generally treated with a cold sponge and “get on with it, boy” attitude.

‘For three weeks running, after playing and training, I suffered headaches, dizzy spells and nausea. I was then diagnosed with prolonged concussion or an aggravated brain injury and had six weeks off playing.

‘In my experience, there has now been a massive swing from the RFU to change attitudes, and rightly so. As a coach, I have received online training for recognition of the subject and the facts about concussion. My knowledge has been massively improved.’

And on this subject, knowledge is king – perhaps an apt phrase a year on from the launch of the ‘King’ Jeff Astle Foundation.

Concussion – what to do, how to recognise it*

If you suspect concussion in a player, you must remove them from play right away.

Continuing to play increases their risk of more severe, longer-lasting concussion symptoms, as well as increasing their risk of other injury. You should:

  • not let them return to play that day
  • not allow them to be left alone
  • make sure they are seen by a health care practitioner as soon as possible that day
  • not let them drive.

How is a concussion treated?

Concussion symptoms are made worse by exertion, both physical and mental. The most important aspects of treatment for a concussion include the following:

  • The player should not exercise or do any activities that may make them worse, like driving a car, reading, working on a computer or playing video games.
  • If mental activities (eg reading, concentrating, using a computer) worsen their symptoms, they may have to stay home from work, college or school.
  • If they return to activities before they are completely better, they are more likely to get worse, and to have their symptoms last longer.

Once they are recovered, and cleared to do so by a health care practitioner, they can start a step-wise increase in activity. If possible, they should be seen by a doctor with experience in treating concussions.

Can it be anything more serious?

Anyone with a suspected concussion should be seen by a health care professional as soon as possible. They will usually give instructions to the injured person to return to them or go to hospital immediately if they have a worsening of symptoms such as:

  • drowsiness when normally awake or cannot be awoken
  • a headache that is getting worse
  • weakness, numbness or decreases in coordination and balance
  • repeated vomiting or prolonged nausea
  • slurred speech, or difficulty speaking or understanding
  • increasing confusion, restlessness or agitation
  • loss of consciousness
  • convulsions
  • clear fluid coming out of ears or nose
  • deafness in one or both ears.

*This guidance has been taken from multiple sources, including the RFU, World Rugby, Headway and the Jeff Astle Foundation.

Next Steps

The RFU has an informative ‘Concussion Headcase’ section on its website that is a great place to learn more about concussion. It includes various tools and resources, such as a number of interactive web courses for coaches, match officials, players and teachers, and parents and guardians of youth players.

What are your thoughts on concussion? Let us know by leaving a comment below.

Why not also share your views in the Simon Browning conversation 'Combating the stigma of concussion' where he asks "if there is anything else that you think we could do /or should be doing to help promote and develop the awareness of the dangers of concussion? To help alleviate this sense that the player is weak."

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