As a neuro-vestibular physiotherapist who has been treating people with the knock-on effects of mild traumatic brain injury for many decades, my view is our society is taking two steps forward and one step back when it comes to understanding concussion and putting proper safeguards and treatment regimes into place.
And this is because our focus is drawn to high impact collisions in sport at the expense of falls, and it also concentrates on the head and brain without enough attention given to neck injury. After all, as the children’s song suggests, the neck bone’s connected to the head bone; something often forgotten when concussion raises its head, so to speak.
Since my recent article, Football codes are waking up to the danger of concussion in sport, I have noticed a continuing procession of research papers and news articles, partly pointing to inroads in our understanding of concussion and its treatment, but also bemoaning the fact that sporting codes seem to be “going through the motions” of addressing the issue rather than fully committing.
In this article, I will share some of the latest examples from the world of sport and also point to some interesting research out of Colorado. In a follow up article, I will advocate for older people in our population who are equally at risk of concussion due to falls but whose plight does not have the glaring headlights of publicity and coverage that sport-based injuries do.
Are our sporting codes in league, downplaying the seriousness of concussion?
In sport-obsessed Australia, our sportspeople attain hero status relatively quickly and easily, once they make it to the levels of televised sport, because they play an important role in organisations making big money from the sports machine.
Therefore, while our sporting codes should and do have a duty of care to injured players, these sporting empires are under pressure to keep the money pouring in by fast-tracking players’ returns to the field, court, or track, lest the punters and commentators lose interest.
With cricket season upon us, one such story doing the rounds involves batsman, Will Pucovski, whose “lingering concussion symptoms” has been keeping his return to the game under a cloud amid the pressure on selectors to field the strongest Australian team possible against England in the Ashes Series, which is just weeks away.
As the Age’s cricket writer, Daniel Brettig, noted, in the article, Pucovski’s Shield return uncertain due to lingering concussion symptoms, despite the player’s delays in getting back into action, “he remains firmly in the thoughts of the national selectors, who will be … interested in his progress.”
Such is the competing pressure at this level of the game; the body needs time, the codes need action. This has been captured eloquently by Alan Pearce, director of NeuroSports Labs and a neurophysiologist researching mild brain injury in sport, who tweeted in commentary about Brettig’s article:
This shouldn’t come as a surprise as the science tells us that each subsequent concussion generally requires greater time to recover. Let the athlete recover fully without implying its unusually extended. (This is the brain and not a hamstring injury).
This shouldn't come as a surprise as the science tells us that each subsequent concussion generally requires greater time to recover. Let the athlete recover fully without implying its unusually extended. (This is the brain and not a hamstring injury) https://t.co/GR9RutBE7t
— Alan Pearce (@alanpearcephd) November 1, 2021
But don’t take my word or Alan’s word alone, a thoughtful article by Andy Bull in The Guardian, New paper launches attack on ‘biased’ sport concussion consensus process, has highlighted the concerns of a group of academics, clinicians and carers, who are demanding an overhaul of position held by the Concussion In Sport Group, arguing the consensus arrived at by the group underplays the risks of concussive and sub-concussive impacts.
I encourage you to read Andy’s article because it also links to this paper, Toward Complete, Candid, and Unbiased International Consensus Statements on Concussion in Sport, which provides a framework for developing a better approach that is less likely to succumb to vested interests.
The new paper argues that the CISG consensus process is both “biased” and “unethical”. They say that CISG has “consistently failed to include experts with the diversity of training, experience, cultural competence, and affiliations it would be reasonable to expect” and that it has instead promoted a “sports-friendly” viewpoint which has “consistently downplayed the risks of concussion injury and sought to emphasise all that we do not yet know rather than all that we do know”.
I will keep watching this topic closely and I implore you to be mindful of the risks surrounding concussion if you play contact sports, or know somebody who does.
Understanding concussion and the “nocebo” effect from advising patients to rest
In the 5280 Magazine article, Concussion Treatment Is Suffering From the ‘Nocebo’ Effect, researchers from Colorado have argued that long-held treatments for concussion, such as time in quiet, dark spaces, and prescribed amounts of rest, might be promoting “physiological harmful outcomes by setting negative psychological expectations with treatment”.
A “nocebo” is the opposite of a placebo. A placebo is a medicine or treatment that benefits patients psychologically, rather than physiologically, whereas a “nocebo” is the condition where a treatment arouses negative expectation leading to detrimental psychological effects. The article cites sources that the mere action of doctors emphasising the negative side effects of a drug or treatment, can almost triple a patient’s chances of experiencing them.
In relation to treatment for concussion, Dr. David Howell, director of the Colorado Concussion Research Laboratory at the Anschutz Medical Campus, refers to his observations of a 15-year-old soccer player who was experiencing wave after wave of “relapses” after suffering a concussion in a game. His novel insight is that the boy’s ongoing fears and anxieties about long-term knock-on effects is making his condition and prognosis worse because it’s easy to ascribe on-going symptoms as related to concussion, creating an environment of despair and sowing seeds for depression.
Dr Howell and his colleague, Dr Julie Wilson, in the paper, The Nocebo Effect and Pediatric Concussion, summarise this insight, thus:
Concussion, a brain injury at the mild end of the TBI spectrum, is caused by a direct blow to the head, face, neck, or body with an impulsive force transmitted to the brain, which results in a range of clinical signs and symptoms. Many high-quality research studies indicate that the majority of youth who sustain a concussion make an excellent clinical recovery, typically within hours to weeks. In contrast, a relatively high proportion of individuals seen in specialty clinics present with more significant symptomatology and disruption to quality of life. Injury-related variables (eg, severity of the concussion) can contribute to these postconcussive symptoms. However, many noninjury factors are known to influence the postconcussive symptom report as well, such as premorbid anxiety and somatization, maladaptive coping, parental anxiety, and symptom exaggeration/feigning. While both injury and noninjury factors account for variance relatively soon after concussion, noninjury factors account for much more variance when symptoms persist for many weeks to months.
The researchers then argue, as quoted in the 5280 article, that early prescription of exercise might well be the best medicine, both physiologically and psychologically:
This year, Howell published a flurry of six papers on the effects of exercise and concussion. One revealed that teens who exercised more than 160 minutes per week had fewer post-concussive symptoms a month after the concussion versus those who exercised less. Another reported that young athletes who exercised more were able to return to sport activities faster than those who exercised less. Increasingly, Howell was finding that patients who exercised more ended up feeling less depressed, anxious, or dizzy, and had better balance. It countered much of the conventional wisdom about concussion recovery.
“Obviously, there are psychological benefits as well as physical benefits to exercise,” Howell says. “Aerobic exercise at a level below what will make you feel worse will help get blood to your brain.” That increased blood flow provides more oxygen and energy that brains need to heal.
This observation adds nuance to this topic of taking concussion seriously in sport, because it seems there is a delicate balance to get right between taking concussive events seriously with rest and treatment while counterintuitively prescribing exercise to help hasten recovery.
As a neuro-vestibular physiotherapist, I can appreciate the value of exercise, prescribed carefully, as Dr Howell is advocating, while noting that all practitioners involved in treatment of mild traumatic brain injury need to be mindful that whether or not the injury has been caused by a high impact collision in sport or a fall, the upper cervical spine will almost certainly have sustained damage and will need direct attention too.
I will write further on this aspect of understanding concussion soon. For now, my hope is that if we can start taking this more seriously on the domestic and workplace front, then we might help change the narrative within sporting circles where “invisible” injuries are often not taken as seriously as visible, physical ones. And with Dr Howell’s insights, our more serious treatment can be carried out judiciously, so as to avoid any potential nocebo effect from artificially inflating fears, anxiety, and distress.