The world is watching athletes in Sochi compete in sports such as hockey and downhill skiing. Concussion poses a risk, not only to the highly trained individuals competing in the Olympics, but also to ordinary Canadians who play sports occasionally.
Concussions are the result of a blow to the head, and are the most common type of mild traumatic brain injury. In the past decade, there has been growing awareness and research about how often concussions occur and about their long-term effects. A 2006 study found that about 1 out of every thousand Canadians have a concussion each year. Concussions are especially common among young people and account for around 10% of all injuries in young athletes.
To learn more about concussions, view this video narrated by Mike Evans, a family physician at St. Michael’s Hospital, Toronto.
With increased awareness of concussions has come increased demand for treatment, especially from those suffering from prolonged symptoms related to their injury.
Increasing awareness of concussions
In the past, concussions were considered no more than a brief bout of ‘seeing stars’. Athletes with a knock to the head returned to play almost immediately, both in recreational and professional sports. However, a growing body of research evidence demonstrates that the effects of a concussion, especially multiple concussions, can be long lasting and result in permanent brain damage with a decline in cognitive and sensory and motor abilities.
“The seriousness with which the public considers concussions has been ratcheted up considerably,” says Charles Tator, a neurosurgeon at the Toronto Western Hospital. “People now know it’s not just a ding or a bell ringer – it’s a brain injury.”
In Canada, much of this awareness has been raised by the experience of hockey superstar Sidney Crosby. Crosby sustained two concussions in quick succession, and had lingering symptoms which kept him out of play as captain of the Pittsburgh Penguins for nearly an entire season.
Martin Mrazik, a professor in clinical neuropsychology at the University of Alberta points to Crosby’s high profile, and time off the ice, as helping to increase awareness of concussions. “Crosby’s experiences probably have done more for education than we could have ever hoped for,” says Mrazek. “He took it seriously, he didn’t come back to play before he was ready and that is the approach we want young athletes to take.”
Rumours flew about what treatment Crosby sought out for his concussion. However, the information publicly released by the National Hockey League stated only that he was taking time off the ice to rest and recover.
What are evidence-based treatments for concussion?
Current evidence points to physical and mental rest as the main treatment for concussion. Athletes are encouraged to stop playing sports until they are free of symptoms. Mental rest is more difficult to define, but has been described as refraining from any activities that can trigger symptoms such as headaches. This can include reading, looking at a computer screen or doing homework.
The vast majority of people with concussions, perhaps 80 to 90%, are symptom free about 10 days after the injury.
However, about 10 to 15% of people experience lingering symptoms for months, or even years after their injury. Those who have had more than one concussion in quick succession, like Crosby, are especially prone to have prolonged, complex symptoms – this is known as post-concussion syndrome.
Symptoms can include headaches, insomnia, dizziness, difficulty concentrating, fatigue and mood changes. All of these symptoms are subjective, however, which makes it difficult for clinicians to diagnose, assess and treat post-concussion syndrome.
Patients suffering from post-concussion syndrome are often referred to brain injury clinics, which would ideally offer an evidence-based approach to the assessment, diagnosis and management of concussions. However, there are anecdotal reports from patients and experts that growing numbers of health care providers are offering unproven and expensive treatments, including hyperbaric oxygen therapy, acupuncture and homeopathy.
Tator says “there is no evidence based treatment to accelerate recovery from concussion.” He acknowledges that “it’s distressing for parents to watch their kids who are still suffering from post-concussion syndrome.” While concerned parents are desperate for treatment, Tator emphasizes that “there just isn’t anything other than the passage of time.”
Allison Haggart knows firsthand how difficult it can be to wait for concussion-related symptoms to resolve. She was a competitive snowboarder when she suffered a concussion in January 2012. While on the slopes practicing with her high school team, Allison swerved to avoid a teammate, and slammed into the ground, falling backwards and hitting her head.
Even though Allison was wearing a helmet at the time, she began to feel symptoms immediately, including dizziness, fatigue and headaches. Following several assessments by physicians, she was diagnosed with a concussion. Unfortunately, Allison has had persistent symptoms, including trouble with her vision and headaches.
Allison had no clear indication of how long full recovery could take and felt frustrated with the absence of evidence-based treatments to alleviate her symptoms. “When I was going through the medical system, no one could give any assurance on the number of days it will take to feel better, or to tell me to take this pill and I’ll feel better.”
Allison tried a whole range of treatments – physiotherapy, massage therapy and acupuncture – to try to alleviate and reduce the lingering concussion symptoms. She says full recovery took 18 months.
Allison hasn’t snowboarded since her concussion, and she has no plans to return to the slopes. She says she’d rather “err on the side of caution” given the risks associated with a recurrent injury and “that there is so much that we do not know” about the long-term impact of concussions.
Motivated by her experiences, and the frustrations around absence of treatment options and a timeline for recovery, Allison’s family has partnered with the Toronto Western Hospital to establish a fellowship to support research in head trauma, with a focus on concussion diagnosis and treatment.
‘Buyer beware’ of quick fixes for concussions
Allison’s experiences underscore the challenges for health care providers struggling to manage expectations of patients suffering from concussions. Martin Mrazik cautions that “the reality is that concussions can be complex, require a multidisciplinary approach – and if someone offers a quick fix, it’s a concern.”
For athletes in particular, there is a desire to return to play as quickly as possible. Current guidelines for return to play follow a six step process, where after a period of rest, athletes can resume exercises within their sport, and avoid contact, and if symptoms return they drop back to the previous step.
However, there are many clinics across Canada that promise those suffering from post-concussion syndrome that they can hasten their return to play, and try to alleviate prolonged symptoms of a concussion. Clinics from coast to coast staffed by physicians, exercise therapists, physiotherapists, chiropractors and other health care providers, promise to improve and hasten recovery from post-concussion syndrome.
A 2013 research article reviewed all published clinical trial data available on such treatments, including acupuncture, acupressure, creatine, homeopathy, hyperbaric oxygen therapy, mindfulness practices, music therapy, neurotherapy, Tai Chi and yoga. This study found a high risk of bias in the published trials on these treatments, and the authors of the study concluded that the evidence for these treatments for traumatic brain injury was inadequate. These conclusions echo the findings of previously published studies on complementary and alternative treatments for concussions.
“The best evidence suggests that with cognitive and physical rest, people will get better” says Mrazik. He cautions Canadians that clinics offering a quick fix ought to come with a “buyer beware label – they charge a lot of money for non-proven treatments when people are desperate for some relief.”