The movie Concussion, currently screening at your local picture palace, deals with NFL players’ catastrophic experience of the phenomenon. Actor Will Smith plays Bennet Omalu, the doctor who uncovers the truth about the damage to the brain concussions can cause. So if you play a vigorous contact sports and have ever seen the little birds and bells circling your head, pay closer attention…
What is concussion?
It’s sudden – but usually short-lived – loss of mental function that occurs after a blow or other injury to the head. Symptoms include headaches, dizziness, confusion, amnesia, balance problems, blurred vision, vomiting and nausea. According to the NHS it is the most common but least serious type of brain injury.
How is it different from having just “banged one’s head”?
Very different. Concussion is most often caused by being punched, kicked, whacked, smashed or crunched in the head. But it’s how the brain reacts that is the key – concussion occurs when the brain moves so much that it’s not protected by its cerebrospinal fluid, bruising the brain and/or damaging the brain’s pathways.
So you don’t have to be knocked out to get concussed?
No. In fact, as Dr Dominic Paviour, a consultant neurologist at St George’s University Hospital in London, tells Coach, “Concussion doesn’t necessarily correlate particularly well with the severity of a head injury. A minor bump on the head can cause it. A more significant clash of heads, with a loss of consciousness could cause it, but not always. And sometimes people with very severe head injuries, of the kind that leaves you unconscious for a longer period, don’t describe common concussion symptoms on recovery.”
But it’s always caused by a blow to the head, yes?
Not necessarily. As Dr Mike Loosemore from the English Institute of Sport (EIS) explains, “Sometimes when people jump off a high building and land on their feet they can get concussed because of the force impulse going through body and into their head gives them a concussion as well.”
So apart from parkour, which other sports may be more likely to lead to concussion?
Horse riding, rugby (union and league), skiing and snowboarding and American football. However, according to Loosemore, who also works with GB Boxing, says that boxing “comes quite a long way down the list”. “Boxing has about the same concussion rate as ice skating,” he says. “Because when you fall over in ice skating you hit a pretty solid floor.”
So should I stop my young sons playing rugby?
Not necessarily. But it is worth being aware of the risks. In 2013, for instance, the Auckland University of Technology examined every hit sustained by a single amateur rugby union team in New Zealand during a season by using a high-tech mouthguard, which measured the force of each hit and how much the brain moved afterwards. It found that over a 19-match season, the squad experienced 20,687 impacts to the head greater than 10g (roughly the impact of a light punch) – or an average of 77 impacts to the head per player-position per match.
And the take home from the study?
According to Doug King, one of the academics involved, “The research shows there are repetitive sub-concussive impacts to the head in rugby union. When compared with American football, in some cases these are higher in frequency.”
What do you mean by sub-concussive impacts?
These are the hits which aren’t severe enough to cause concussion but can still show up as bruising on a brain scan – and, researchers are finding, can possibly lead to lasting brain damage, if the brain is not allowed to heal through resting.
What about my weekly game of football?
The chances of getting a concussion playing football are very slim. But interestingly, recent research suggests that repeated heading of modern lightweight footballs could have a greater impact on the brain than previously thought. Researchers at Purdue University in the US found that some of the forces generated by heading back goal-kicks were as high as between 50g and 100g – similar to American football players crashing into each other.
But could that really cause concussion?
No. But the Purdue study did find something else: that MRI scans on players who headed the ball frequently showed evidence of sub-concussive damage. With rest these bruises healed, just like any other bruise. But without rest the risk of a more serious injury increased. So it might be wise not to spend every day practising heading goal-kicks.
But context and balance is key, right?
Exactly. As Paviour points out, the chances of having a significant injury from playing an amateur sport such as football, rugby or tennis are low. “That goes for horse riding and skiing too,” he adds. “There may be a small risk, but if it happens to you it is potentially catastrophic. Anecdotally, I have a neurologist friend who has two boys and he will let them play soccer but not rugby. He doesn’t think it is worth the risk.”
When should you see a doctor?
If you take a hit on the head and don’t feel right. As Paviour explains, the symptoms could include not liking light or loud noise, feeling an inner fogginess, headaches, nausea, feeling tearful or over-emotional or depressed. “Any one of those things could indicate concussion,” he says.
Is it easily misdiagnosed?
Not by a professional. But during a match a player might be told to “run it off” rather than sit out on the sidelines, which could be inviting trouble.
So is there a risk of more damage if you play on through a concussion?
“For me that’s the biggest worry,” says Loosemore. “If you go on concussed you are not thinking as clearly, you are not moving as clearly and you’re more likely to get hurt. And the next time you might get hurt a lot more. There’s certainly good evidence that when you get concussed again while concussed, it takes much longer to get over it a second time.”
How long does concussion take to recover from?
Usually 90% of people get better in a week, and 99% get better in a month – providing they physically and mentally rest until the symptoms disappear. “Mental rest is often the hardest thing because that means no watching TV, no playing Grand Theft Auto, and no reading books or newspapers,” warns Loosemore. “It’s actually very boring. It could go on for a few days. If it went for longer than a couple of weeks I’d start to look at other causes for the symptoms.”
Should we just wear a helmet for everything, then?
No, says Loosemore, who also founded the Centre for Health and Human Performance (CHHP).
“Clearly there are some sports in which should wear a helmet. If you are horse riding or motorcycling – where your head is in danger of forcefully hitting a very hard surface – then you want a hard outer shell to protect your skull from fracturing. But the crucial thing is this: a helmet isn’t effective in stopping a concussion. Because, as we know from decades of research, your brain is still going to move inside your skull regardless of whether you wear a helmet or not. Your helmet could be made of titanium and that wouldn’t change.
“Look at the NFL. The risk of concussion remains high even though they wear helmets. The same with rugby, even though more players wear skull caps these days. It’s also worth remembering that when doctors forced the authorities to put headguards on boxers in 1984 for the Los Angeles Olympics, the number of knockouts increased by three times. It actually increased injuries – the opposite of what they wanted to achieve. And since removing helmets from amateur boxing in the past couple of years, what has happened? The number of concussions have reduced by 20%.
“My view is that a helmet gives you a false sense of security and an increased sense of bravado. So players put their head where you shouldn’t be because they are less worried about taking a blow. Yet those impacts to the brain still cause damage. And that damage can lead to concussion.”
The expert view: Clinton McKenzie, Boxer
Clinton McKenzie is a former British and European light welterweight champion. He now runs McKenzie’s Boxing Fitness in East Dulwich, London.
Is boxing safe?
I don’t think you can ever regard it as safe. It’s well covered by medical and scientific evidence and boxers are given annual brain scans and eye tests to make sure everything’s OK. But it’s not a safe sport by a long shot. Punching someone’s not a joke.
Does headgear help? Should hitting the opponent’s head be banned?
Wearing headgear doesn’t help – you’re braver with it on, you take more punches. Not allowing boxers to hit the head would take away the excitement: it’s a gladiatorial sport, the goal is to hurt your opponent. A good referee is essential; your life is in his hands.
Is it possible to get concussion from boxing?
The symptoms are the same as what’s known as being “punch drunk” – dizzy, you can’t talk properly, you feel really lazy, and you can’t walk straight (hence the name) – so it’s very possible to get concussion. You’re in the ring not to get hit, which is impossible, but that’s where the skill is.
How do you know you’ve got it?
You don’t know at the time. In the ring adrenaline and your body take you through it. You feel pain, but nothing like the day after when you feel the cuts and bruises. It’s like being in a car crash. I probably did have concussion, and I brushed it off, and hoped it would go away with rest. It didn’t frighten me. If my head hurt, it never occurred to me that it could be serious.
What do you tell people about it who come to box with you?
I explain to them that one punch could damage you and there’s always that possibility, so try not to get hit. No-one’s ever been concussed at my gym. There’s no full contact and even the guys who spar do it in a very gentlemanly way. These days the gloves are bigger and they have less impact. If anyone took a hard punch, I wouldn’t let them continue. Pride makes them want to carry on; if they’re hit they don’t want to show they’re hurt.
What is the best way to prevent concussions?
There is no best way. You need to be tremendously fit and aware. Boxers don’t think about the dangers, it’s in our nature to take risks. Even if I’d known about concussion at the time, it wouldn’t have put me off. I loved being on that stage. Boxing without sparring is great exercise and the only way to prevent being concussed.
Have you been concussed?
I’ve never been knocked out, but I’ve been put down. The worst was a 15-round title fight in Nigeria in 1980. I lost on points. Afterwards, I was totally dehydrated, shattered, I couldn’t get up, I didn’t know where I was, I was dizzy, I could hardly stand up, I couldn’t walk, I couldn’t think straight, I had short-term memory loss. I suppose you could put that down to concussion. It didn’t affect my behaviour, because I didn’t go out, I waited for my body to heal. It took about two weeks.
Do you think you’ve suffered any long-term effects?
I don’t know what will happen in 20 years but right now I feel my health is pretty good. I keep fit, my memory is OK and I’m not stuttering. You can understand what I’m saying, can’t you?!
The expert view: Mick Fitzgerald, Jockey
Mick Fitzgerald rode over 1,300 winners as a jump jockey before retiring in 2008. He is now a member of the Channel 4 Racing team that broadcasts every Saturday afternoon, as well as The Morning Line at 9am.
Can you remember your first concussion?
It was at Sandown in 1989. The horse went through a wing [the side of a fence] and I landed on my head. I thought I was fine. I came back to the steward’s room afterwards and they asked me to explain what happened. I said, “I can’t actually remember”. I had to sit down and I felt wobbly. It was a very strange experience. My head didn’t feel bad but I also couldn’t remember getting back to the weighing room. But I was fine after a couple of days. When you’re young, you can’t wait for your next ride, you don’t think of the damage or what the long-term effects could be. You need other people to think of that for you. I was lucky I didn’t have multiple concussions in a short period because that’s where the damage is done.
So you didn’t completely avoid it after that one?
I was concussed three or four times in my career. Concussion is caused by your brain hitting your skull, more often than not by your jaws coming together. Dr Michael Turner [former chief medical officer for the British Horseracing Authority] mentioned a gum shield to me and I pooh-poohed it, I thought I’d look like an ice hockey player riding a racehorse, but I started wearing one in 2001 and I didn’t have a single concussion till my last fall. It definitely saved me a few times and they should be mandatory.
My worst concussion was in the Grand National in 2008. I had a very high-impact fall, landed on my head and broke my neck. I blacked out, I’m not sure how long for, and when I came to I was paralysed. After 30 seconds the paramedics arrived and I was getting feeling back. I’d broken my neck before and I told them that something was seriously wrong, and not to move me. Had I not worn a gum shield, no doubt I’d have been knocked out for longer. Who knows what might have happened?
Did you know when you were concussed?
You don’t know if you’re concussed, apart from the fact that there are parts of the day you can’t remember. In the early days, I’d get home, but I didn’t know how. When someone asked how I got on, I couldn’t remember. I don’t think concussion affected my behaviour. There were probably times when I wasn’t 100% but – perhaps ironically – I can’t remember any times when I was concussed and not aware of it.
Concussion can seem very frustrating. You can’t see it, unlike other injuries, and you’re not aware you’re hurt. You can’t feel anything wrong, and you feel 100% even though clearly you’re not. Jockeys need to be protected from themselves; they’re so desperate to ride winners. If I had seen someone visibly impaired from a fall I wouldn’t have let them ride. You have a responsibility as a person.
Do you think you took your own concussions seriously enough?
Now everyone does risk assessments but who did that 20 years ago? The beauty of being a jockey is that you’re blissfully unaware of the dangers. The day you become aware of the ambulances that follow you is the day you need to hang up your boots. You wouldn’t do it if you thought your next ride would be your last. I had to retire – I have a lot of metal in my neck and I wouldn’t be passed fit. I’d have carried on. I never saw the red warning lights.
What were you told about concussion at the time?
When you apply for your licence, you’re advised about the damage you can do. In the old days, a doctor examined you physically, then passed you as fit. Now there’s an annual baseline concussion test; it judges people’s reaction times by a series of tests and establishes your “normal” level. Every single time you have a fall, they test you. Your reaction times relate to how your brain is affected. If the results don’t match your baseline, you’re not allowed to ride. At the time it was introduced, we [jockeys] thought “Why?” but you can see the sense of it. Jockeys are more aware of the potential risks now.
What have you learnt about it?
The new research [Concussion in Sport from the International Concussion and Head Injury Research Foundation], led by Dr Michael Turner, is invaluable. It includes testing whether people who have concussions or multiple concussions in their early career then run risk of getting diseases like Parkinson’s, or if multiple concussions quicken the process. They hope to find out if certain people are more susceptible than others, whether concussion plays an active part or if it’s the luck of the draw. You’ve only got one brain. You’ve got to look after it.
The expert view: Jeanne Marie Laskas, Author
Jeanne Marie Laskas is a writer and professor at the University of Pittsburgh. She wrote the book Concussion, which grew out of her article “Game Brain”, written for American GQ in 2009.
Were you interested in concussion before you found this story?
No, I became interested when I was researching an article about it, and I stumbled upon the missing link to the story, Dr Bennet Omalu, and found out what had happened to this guy who kicked off the science and why he had disappeared.
What is concussion and how is it diagnosed?
It’s a description of symptoms: they’re all grades of traumatic brain injury. In American football players specifically these are sub-concussive, small, constant hits where they don’t know they’ve been concussed. A lot of them with a CTE [chronic traumatic encephalopathy] diagnosis after they died would’ve said they never had concussion when they were alive.
You can only diagnose it by symptoms, such as memory lapses, when you can look into the brain, and you can’t take someone’s brain out, so you can’t diagnose it until death.
What are some of the more alarming things you learned about concussion as a result of researching your piece?
The most alarming thing from a science perspective was how the science has moved in fits and starts over centuries. We’re so young in our understanding of what goes in a brain trauma. Outside of that, it’s the wilful ignorance of professional sports organisations, like the NFL, in squashing it. It reminds me of the tobacco industry when we started understanding that cigarettes were dangerous and the industry tried its hardest to say it’s not that bad.
The film deals with the injury in professional sport. How worried should people playing, say, rugby for fun be worried about it?
I would expect more to come out about rugby. You don’t wear actual helmets to protect against impact, so the head isn’t padded. In football, you don’t feel the hits, it doesn’t hurt. So the helmet works against you, and you use your head as a weapon. People take more head blows in sports with helmets.
How can people protect themselves?
The medical profession says don’t do sports that are high-impact on the head, especially repetitive impacts. In some American youth soccer leagues, they’ve banned heading the ball. Anyone can fall and get a concussion, it’s not limited to sports, but repetitive head trauma is the key. It’s cumulative. And it’s a matter of opinion if one concussion is one too many.
What treatment is there?
There’s no treatment – you can treat symptoms with medication for some stalling, perhaps. There’s no prevention, as they don’t understand enough about it yet and the assumption is the damage can’t be reversed. They don’t know if some are predisposed genetically – scores of players don’t get the disease. The trick is to diagnose this in a living person and develop treatment.
Won’t certain types of risk-takers always want to play dangerous sports? And won’t fans always want to watch?
Any teenage boy is a risk-taker who thinks he’s immortal, and until now there’s been no pressure from coaches to say that this is dangerous. So when people say they’ll do it anyway, I don’t think the players or parents have understood what the risks are. This is a conversation America keeps almost having, then backing out. People want to watch and nobody wants this to be true.
What’s the future for dangerous sports?
In American football, so much profit is to be made, the league is peddling the idea of building protective gear, via technology, but it’s not true – you can make a helmet a foot thick, it won’t protect the brain flushing around inside the skull. Or there’s talk of taking the head out of the game but how? People can’t solve this and they love football, so we start forgetting again until another dramatic suicide. That’s the progress.
What has been the players’ reaction?
The director invited NFL players to a screening. Most were concerned about their own heads. One current NFL player was really upset, and said, “If I had known that I was causing people brain damage I wouldn’t be hitting so hard”. He felt guilty. It’s rattling people. I’ve had no direct contact from the NFL.
Has this put you off watching or playing sport?
I love the game, the Pittsburgh Steelers [the death of Steelers player Mike Webster led to Omalu’s discovery of CTE], and the players, and I don’t want them to be committing suicide in ten years. My push is to advance the science, fund independent research, and start coming up with treatments and an eventual cure.
