‘Follow protocols and you’ll be fine’
Dealing with concussion is serious
NINE weeks ago today, Springbok flyhalf Patrick Lambie was pole-axed by a tackle from Ireland flanker CJ Stander in a Test match in Cape Town. Lambie has not played since because of concussion concerns, but his text-book following of the strict protocols governing this type of injury will ensure his safe return to play.
That is the view of Dr Glen Hagemann, past president of The South African Sports Medicine Association and the head of the SharkSmart programme that has its headquarters at The Sharks Medical Centre at Kings Park.
Concussion is topical because of the concern over the 25-year-old Lambie and the reports in the media of the tragic death of a Falcons rugby player a week before the recent Craven Week tournament held at Kearsney College. Two other local boys have ended up in ICU after severe concussion-related injuries this season.
But these are the extreme cases and Hagemann is quick to point out that while concussion should be taken with utmost seriousness, 80 percent of concussed players are playing again in three weeks having followed the consensus guidelines that have been laid out by the leading experts in the field from all over the world. Every four years these concussion gurus meet to debate the latest research in order to update the guidelines which are then adopted by most international sporting federations, including World Rugby.
But how at risk is a schoolboy? Hagemann says that about 17 percent of schoolboy players are concussed in a season, or about one in six – close to three in a team on average. Having said that, Hagemann highlights that the chance of sustaining a serious injury in rugby is less than getting knocked over crossing the street.
A risk study undertaken by the University of Nottingham in the UK analysed just about everything in life from playing rugby to driving a motor car and found that an “acceptable risk” is 0.1 to 2 catastrophic incidents per year per 100 000 participants in an activity. Where does rugby fit in to that? “If you look at catastrophic incidents, like neck injuries, in England rugby is acceptable in that it comes in at 0.8 incidents per 100 000 players,” Hagemann said. “But Fiji is 13, which is out of the bounds of ‘acceptable’. Pedestrians have a risk of 3.7 per 100 000.”
Rugby in SA rates around 2 catastrophic incidents per 100 000 players, which places it on the margin of acceptability, while gymnasts (8/100 000) have four times higher risk of suffering a catastrophic injury than rugby players. Incidentally, schoolboy rugby has less than half of the risk of senior rugby, probably because of younger, more resilient bodies and collisions that are not as heavy as in senior rugby where the players are bulkier and more explosive.
Lambie has stringently followed the guidelines and has taken no short cuts, but unfortunately at lower levels of rugby, recognition of the problem, management of it and strict adherence to the returnto-play protocols sometimes fall by the wayside.
One of the biggest concerns is that boys can return to the playing field while still concussed and thus opening them up to the very rare, but serious problem of “second-impact syndrome”. In short, a concussion on a concussion can have dire consequences.
“All school coaches need to be Boksmart accredited, and as part of this process are exposed to the concussion management guidelines. If a coach chooses not to follow these, it is clearly not in the interest of his players, and places his school at medico-legal risk. Believe it or not, pressure also comes from parents to bypass the process.”
Concussion is thus often easier to manage at a professional level but not in the amateur game.
“In 90 percent of concussion cases, there is no loss of consciousness. You also do not necessarily have to take a direct knock to the head. A heavy knock to the chest can give you whiplash (resulting in possible concussion),” he said.
There is an internationally recognised list of 21 possible symptoms of concussion compiled by experts. They vary from obvious signs such as immediate stumbling and confusion on the field to later problems such as memory loss, sleep disturbance, irritability and an inability to concentrate on school work.
If a child is correctly diagnosed and observes the return-to-play protocols, he will avoid the possible calamity of second-impact syndrome.
“This is when a brain (that has not yet recovered from a previous knock) goes into a metabolic frenzy and starts to swell, increasing the pressure within the skull,” Hagemann warns.
“Another issue is that a parent might feel that their child is okay if nothing shows up on a CT scan. But that is to be expected because a CT scan does not pick up concussion.”
If a player under the age of 19 is concussed, the guideline is that he does no physical activity until he is completely symptom free, with a minimum of 14 days rest. He then undergoes a five-day period of gradually increased physical activity, starting with light jogging and progressing to full-on workouts with contact.
If any of his symptoms recur during this process, he needs to rest for 24 hours and may not progress to the next level. In other words, after sustaining a concussion a schoolboy player is out for a minimum of 19 days but possibly a good while longer.