In the second of a series of posts about concussion, Dr Sam Barke – Medical Director of Return2Play and tournament Chief Medical Officer since 2018 – looks at some common misconceptions around recovery from concussion and how to handle them. Return2Play is the Official Medical Partner of the 2020 Rosslyn Park HSBC National Schools 7s.
As you’d imagine, Return2Play’s doctors see quite a few concussions. In fact, a quick check tells me that in 2019 we undertook over 1000 “concussion assessments”. A benefit of seeing so many in a relatively short period of time is that you start to see trends – not trends in how the injuries are occurring, that’s a blog post in itself – but trends in the common misunderstandings around recovery from concussion and the areas that most often need explaining to players.
1. “I don’t think I really had a concussion”
The standard opening sentence of the player desperate to get back to play. Not uncommonly it has been suggested by a friend or family member that everyone is being “over-cautious”. Or, even more difficult to deal with, a doctor with out-of-date knowledge has given the wrong advice.
I get the player to talk me through what happened. How did they feel immediately after the impact? How did they feel over the next few minutes? The next hour? Into that evening? And what about the following days? I explain the difficulties of concussion and talk about what we look at to try and diagnose it (see: Concussion: Back to Basics) and then the risks of getting it wrong. 99 times out of 100 the player sees how they fit the criteria and accept that they need to be treated as if they have had a concussion.
2. “I feel fine now; why can’t I play?”
If you broke your arm you’d be put in a cast. Pain, the main symptom of the injury, would settle within a week or so. At that point you wouldn’t rip off the cast and demand to play (at least, I hope you wouldn’t!), because you know that the bone is still healing and playing would risk further and probably more serious injury.
Concussion is no different. The symptoms may have settled but we know that this doesn’t necessarily mean the brain has recovered. Just like your broken arm, there are risks associated with getting further injuries when healing hasn’t fully taken place and it is those risks we are trying to avoid.
What are the risks of getting a second injury?
During recovery the brain is more vulnerable to further injury. Repeat concussions during this time can result in:
- Prolonged concussion symptoms
- Possible increased risk of developing long term health problems e.g. mild cognitive impairment or degenerative brain disorders in later life
- Second impact syndrome – sudden brain swelling causing death (extremely rare)
While it is difficult to quantify the likelihood of these occurring, I think we can all accept they are risks well worth avoiding. A few extra days rest, or a couple of missed games, isn’t much to ask.
3. “What difference does a couple of days make?”
For children the earliest possible return to sport after a concussion is 23 days. The majority of injuries happen at the weekend so sustaining a concussion usually means a minimum of three weekends off sport. It is often the case that day 23 falls on the Monday or Tuesday and players, understandably, question whether they can play in the day or two before then.
I’m honest with players. The chances are that if they went and played they would be absolutely fine. But, what if they’re not? What if they do take a knock and something nasty happens? People will start to ask “should he have been playing at all?”. I’m asked to justify why, as a doctor, I didn’t follow the guidelines. Your teachers and coaches are accused of putting you in harm’s way. Is it worth it? No, of course it’s not.
The player is still frustrated – I’d be surprised if they weren’t – but they understand the reasoning.
In my experience, once the reasoning behind the guidelines has been explained to players, they understand why we enforce them – which is ultimately, of course, to protect them.
It’s worth you taking the time to explain the injury and the guidelines early. Get the player’s (and parents’) buy-in to the process – it’s likely to significantly improve compliance and will hopefully make your job of monitoring your players’ return far easier.