The invisible trauma
Concussions in pro athletes are in the spotlight but thousands of B.C. kids, from playgrounds to playing fields, also suffer from these brain injuries and their long-lasting consequences
Colin Dierker was focused on the play. The 15-year-old centre midfielder was marking a player on defence when he was hit. The field was a touch icy that Saturday morning and Colin slipped, hitting his head on the pitch.
Dad Glen Dierker, who was watching from the bleachers that day, remembers the fall as clear as day in his nightmares.
“I still have a vivid memory of his head falling back, bouncing 12 inches and hitting the ground again. There are some things that don’t leave your mind.”
Immediately after the fall, Colin felt dizzy. His vision was blurry. His coach assisted him off the field. After 10 minutes, Colin felt better so he went back in and played the rest of the game. He felt normal on Sunday, and went to school on Monday.
But on Tuesday, as Colin got out of bed to go to school, he collapsed, lost consciousness and hit his head on the ground.
He was out for about three minutes before he came to. His parents took him to see a doctor. The diagnosis: a concussion.
“I’ve heard the word concussion thrown around before,” said Colin. “I have never taken any notice of it. I never thought you could get brain damage from just a typical fall.”
Concussions, a mild traumatic brain injury that can occur after a blow that causes a sudden jarring of the head, have been making headlines in recent years following highprofile cases among professional athletes and class-action lawsuits brought by former players against the National Football League and National Hockey League.
The issue was further thrust into the spotlight last December with the release of the movie Concussion, starring Will Smith as a physician who discovers the damage that repetitive and untreated concussions had on the brains of former NFL players.
But less reported are the concussions that strike an estimated 100,000 Canadian children and youth annually — not just on fields, trails or rinks, but also on playgrounds and sidewalks and in backyards and parks.
Statistics show concussions are more common in kids and youth than in adults, and they can have more long-lasting effects, which makes treatment and management more crucial for this age group.
In 2011, about 6,675 children and youth under the age of 19 were taken to emergency rooms in the Lower Mainland for concussions. Most were caused by falls, sports or recreation activities, or getting struck against an object. About 1,540 kids were admitted to B.C. Children’s Hospital for a concussion or mild brain injury in 2015, up from 1,400 the year prior.
The numbers are on the rise, said Dr. Shelina Babul, associate director of the B.C. Injury Research and Prevention Unit at B.C. Children’s — not because kids are getting clumsier or more violent in their play, but because of greater awareness.
“In my mind, it was Sidney Crosby who raised the bar on this,” she said.
When the Pittsburgh Penguins star captain and Olympian was sidelined with a concussion for more than a year after receiving two crushing hits in consecutive games in 2011, “that got people talking,” said Babul. “What is this thing called a concussion?”
under-reported injury
Even with increasing public awareness, experts believe concussions are under-reported. Statistics don’t capture patients who go to doctors’ offices, walk-in clinics, or those who simply don’t get their heads checked.
According to a 2013 report by the B.C. Injury Research and Prevention Unit that examined concussions among children and youth, many kids and teens may be falling between the cracks due to a lack of consensus as to what qualifies as a concussion and misconceptions surrounding the condition.
In 2011, after fielding numerous calls from parents who didn’t know what to do after their child banged his or her head, Babul and her team began working on the Concussion Awareness Training Tool (CATT), a free online resource to help adults recognize, diagnose and treat kids who may have suffered a concussion.
Last month, CATT released information and guidelines for teachers and school professionals to help kids who sustain a concussion while in school and kids who return to school after time off from a concussion.
CATT also has a section for doctors to keep them up to date with best practices and new developments in the concussion and brain injury field, as well as a section for parents.
The site gets updated monthly, a necessity in a field that’s constantly evolving, said Babul. To date, the website has been visited 60,000 times and there are plans to translate it into other languages.
Treated properly, 85 per cent of concussions resolve themselves. But research suggests that someone who fails to get a concussion treated is three times more likely to sustain a second concussion, while someone who experiences two concussions is nine times more likely to sustain a third, said Babul.
Research also suggests concussions, left untreated, have potential long-term effects, including an increased risk of suicide attempts, higher rates of harmful behaviour, and links to anxiety and depression.
“People have to acknowledge that a concussion is a brain injury and should be treated immediately,” said Babul, who played competitive soccer for many years and remembers a time when concussions were treated blithely as a mere “bonk to the head.”
“There was the belief you had to tough it out, get back out there and play,” she said.
Such attitudes still exist. According to a 2014 McCreary Centre Society survey, 18 per cent of youth who experienced a concussion in the last year did not seek medical care. Among those who did not go to a doctor, almost a fifth said it was because their parents wouldn’t take them to hospital.
An online poll conducted in late 2015 by the Angus Reid Institute also found that one in five Canadians have suffered a concussion playing sports, with the majority reporting they got the concussion before age 18.
There’s been a lot of research coming out in the recognition, treatment and diagnosis of concussions, noted Babul, but “we have a long way to go.”
difficult diagnosis
When Colin went to see a doctor after his concussion last November, he was told to give his brain a break for two weeks. Rest in a dim room: no school, no sports, no computer, no TV.
For the active, athletic and social Earl Marriott student, it wasn’t easy. Light homework was difficult; reading made him dizzy. LED lights at night triggered headaches that “literally feels like a balloon that’s getting blown up slowly and expanding your head.”
The slow pace and uncertainty took a toll.
“Missing school wasn’t that bad. It was more being in the house by myself,” said Colin. “It was very depressing. It was not fun being by yourself for 10 weeks. It can get to you.”
His parents, Glen and Janice, felt frustrated and helpless.
“With a sprained ankle, you can see it. With a brain injury, you don’t see progress,” said Glen Dierker. “You have to ask.”
There is no clinical diagnostic tool to conclusively diagnose a concussion, said Babul. Doctors evaluate symptoms, do cognitive and physical tests, and examine balance and co-ordination. Concussions cannot be seen on imaging scans or X-rays. Diagnosing and treating teens and young children, who may have trouble describing how they feel, can be a challenge.
A new U.S. study found that youth football players aged five to 14 are more likely to return to the field less than a day after suffering a concussion than players in high school or college. The finding could indicate “younger kids may struggle to describe” their symptoms, underlining the need for more prevention efforts, study author Zachary Kerr told The Associated Press.
The brain is one of the few parts of the body where it takes a child longer to heal than an adult, noted Dr. Paul Korn, Colin’s doctor and a pediatric emergency physician.
Doctors use the term clinical recovery to indicate a patient is feeling better and can do sports and engage in a variety of activities without getting concussion symptoms. But it’s tricky to know when that recovery is complete.
“We know physiologically that the brain takes longer to recover than clinical recovery,” said Korn. “I still like to wait an extra few weeks to get them back to full activity because there is an increased risk of injury even with kids who feel well.”
But doctors don’t want kids sitting out longer than they have to. The prolonged exile from school, activities and social life can lead to frustration, anger and depression.
“It affects them in other ways,” Korn said. “It’s not an easy situation. There’s no cookie-cutter approach to the management of concussions.”
Legislation and education
Recognizing the seriousness of concussions throughout the sports system, Ottawa announced late last year that it is working on a national strategy on concussion treatment.
In Ontario, Rowan’s Law, a bill named after 17-year-old rugby player Rowan Stringer, who died after two concussions within a week, is awaiting its third reading.
“With a sprained ankle, you can see it. With a brain injury, you don’t see progress. You have to ask ... The key is for parents to be optimistic and not lose hope. It will get better. Recovery is possible.” — GLEN DIERKER DAD OF CONCUSSION PATIENT
It aims to provide education and create a framework on procedures to follow in the event of a suspected sports-related concussion. If passed, it would be the first concussion legislation in Canada.
In B.C., Vancouver MLA Moira Stilwell proposed a private member’s bill in 2011 that would make it mandatory to remove an athlete from the game if a concussion is suspected. It failed to get support in the house.
Last November, B.C. Health Minister Terry Lake said no to concussion legislation in B.C., opting instead for education.
In the absence of legislation, it is up to each sports organization to deal with the issue. In 2014, the Canadian Concussion Collaborative found only 41 per cent of 44 sports organizations polled had concussion management protocols in place.
Patrick Waslen, executive director of Football B.C., believes government should take a stronger stance to push sports organizations to implement concussion policies.
“That’s a cop-out,” he said of the provincial government’s decision to focus on education rather than legislation. “Legislation is the best tool to put it out there to make it front and centre.”
The purpose of the legislation wouldn’t be to prosecute, he added, but to educate organizations, school professionals, and parents as much as possible about concussions.
Football B.C. established a mandatory concussion policy for its young players in 2010 — the first in the country — fashioning it after Zackery’s Law, which was passed in Washington State in 2009. The law was named after 13-year-old Zackery Lystedt, who became permanently disabled after getting a concussion playing football and returning prematurely to the game.
The policy is simple: Any young athlete suspected of having a concussion is removed from play immediately and is not returned to the game until cleared by a physician. The organization also disseminates concussion information from CATT, including its Return To Play protocols, to teams, players and families. Coaches are required to take the free concussion training, and information on concussions is included in registration packages sent to parents.
Waslen says there’s no reason why B.C. can’t implement what 50 U.S. states already have.
“My question is: Whose name do you want to put on the B.C. legislation?” he asked. “Let’s step up and talk about it now. This is important.”
Long road to recovery
About 10 weeks after hitting his head, Colin returned to school. He’s able to do homework again, and has caught up with his peers. He is skipping soccer this spring but plans to start playing again in the fall.
In the meantime, he fulfils his passion for the game by coaching younger players.
“Years ago, we would never hear about this,” said his dad. “Now the long-term implications are really coming out, especially when it happens to a young person or a teenager.”
Dierker credits Colin’s teachers, doctors and classmates for helping his son recover and re-adjust back into the classroom.
“The key is for parents to be optimistic and not lose hope,” he said. “It will get better. Recovery is possible.”
Thinking back to that November morning when he saw Colin go down, Dierker says his son should have been taken off the field.
“Of course, it’s teenage bravado. It’s ‘I want to go back. I want to help my team out.’ It’s part of sportsmanship.
“But at the same time, you want your child to be wise, to enjoy the sport but also to be prudent about what could happen if they continue to play if they may have received a concussion.”
“Missing school wasn’t that bad. It was more being in the house by myself. It was very depressing. It was not fun being by yourself for 10 weeks. It can get to you.” ť COLIN DIERKER CONCUSSION PATIENT