Just 10 seconds after kickoff in a recent Springbok Test at home against Argentina, scrumhalf Grant Williams was knocked out in a dangerous charge by the Pumas’ fullback and fell flat on his face like a stone, before being stretchered off the field.
“Grant was out cold, so there is definitely concussion,” coach Jacques Nienaber said on the day.
Concussion strikes down elite and schoolboy rugby players alike, every weekend during season, but they are not the only ones to suffer this “mild traumatic brain injury”. Women slammed into the wall by abusive partners. Car crash victims. Cyclists knocked off bikes. Children tumbling off jungle gyms. Pensioners tripping down steps. All are among those at risk.
Naledi Kuali, legal manager at People Opposing Women Abuse, says: “Women have head injuries as a result of domestic violence. We had a client who had to get stitches on the head and another who lost an eye.”
Sports medicine doctor and Wit’s professor, Jon Patricios, says concussion is often missed — yet unrecognised, unmanaged and repeated concussions can compromise people’s cognitive, physical and emotional wellbeing.
We are treating concussion in very different ways. If we identify and manage concussions properly, they can be resolved with good outcomes. We are in a different era to even 10 years ago.
— Prof Jon Patriocios
Cape Town psychologist Mandy* discovered this after being concussed twice in 10 years. At 16 she was on an Orange River school trip, when she slipped on a rock and hit her head. “I was dizzy after that and I told the doctor I was not OK. She advised me not to paddle too much. When I got home, I spent two weeks in a dark room and was fine.”
Years later, monkeying around in a tree with her boyfriend, she fell. “I landed on my stomach and catapulted my head into the grass. I had a bit of a headache but didn’t think much of it and went to play a hockey match. We played terribly and I lost vision in my one eye,” she says.
“The doctor later told me I had mild concussion. I struggled to read because my eyes wouldn’t track and I was light sensitive. When I walked, I would bump into stuff and I got frustrated. I had to figure out much of my own treatment.
“I was doing a masters (degree) at the time and I had to suspend my course work for four months. After that I could study and run and paddle again, and I could have a glass of wine. I did not notice it any more in everyday life,” says Mandy, now 36 and fully recovered. “Concussion is not taken seriously enough.”
New ways of treating concussion
Patricios, head of Wits sport and health, has been working to change this. He jointly led the process of developing new world guidelines on how to prevent and reduce the risk of concussion in sport, diagnose it and treat it.
“SA has played a leading role in this,” says the first author of the updated consensus statement, published in the British Journal of Sports Medicine in June.
The new guidelines include changes to old practices, for example, replacing the practice of cocooning in a dark room after a concussion with light physical activity, like walking.
“We are treating concussion in a very different way,” says Patricios, calling for greater awareness and an end to scaremongering. “If we identify and manage concussions properly, they can be resolved with good outcomes. We are in a different era to even 10 years ago.”
The sport guidelines overlap with how to manage concussion from recreational or daily activities, like falling off a ladder or a horse, says Patricios. “Concussions in equestrian sports are very underestimated.”
Concussed patients typically underestimate the injury to their brain, says Dr Leigh Gordon, a director of the Cape Sports Medicine Clinic. “’They say, ‘I wasn’t knocked out, mine wasn’t a bad concussion.’ But 90% of the time people are not knocked out and after a blow to the head there is lot going on invisibly, at a cellular level in the brain.”
Common in school sports
Concussions in school rugby occur at the rate of about 16 per 1,000 player hours, says Gordon. “If there is a big school rugby derby with 1,000 players on a weekend, we can expect about 16 concussions.
“Schools often have a major issue pulling boys out of rugby for three weeks after a concussion, but we need to protect players,” says Gordon, who was the Springbok Sevens team doctor for seven years. “Concussion was their most common injury with ankles and shoulders.”
“After multiple concussions, very little force can (trigger) lots of symptoms. The more concussions you have, the more vulnerable you are.”
Dizziness, lack of balance, blurred vision, vomiting and feeling disoriented are warning signs which must be taken seriously after a blow to the head.
Most concussions occur in collision sports, like rugby, and they also happen in other sports such as hockey, soccer, netball and water polo. Surfing concussions were recently under the spotlight in Zigzag magazine.
Failure to detect
One of the major risks with concussions is that they are easily overlooked in busy hospital casualty wards, says Patricios. “Emergency rooms are concerned with gross damage and (not all) doctors have the skills or the tools to evaluate concussion. Unless there is bleeding or a fracture, standard imaging is almost useless in detecting concussions.”
Mountain guide Justin Lawson had a normal CAT scan but severe concussion after falling about 10 metres on a steep trail in the Cape, while hiking with friends.
“After assisting them on a scramble, a foot grip broke off, so I fell backwards and smacked my head on the way down. After the fall my head had some light bleeding and I became aware of my surrounds. A while later I realised I could not recall events from the previous day.”
Due to his symptoms and the remote location, a mountain rescue helicopter flew him to Cape Town, where he was admitted to hospital. “After my scans came back clear the emergency room doctor said I could go home, but when I stood up out of the wheelchair I was not able to walk properly.
“When I woke up the following morning, if I moved my eyeballs sideways towards the ground I got nauseous and threw up,” says Lawson, who spent two nights in hospital. “For the next two weeks I did nothing. I avoided looking at my phone and screens, did not read and rested in a dimly lit room,” says Lawson, who recovered 100%.
Get more sleep, light
That advice “to go home and rest” has been updated by the “return-to-learn and return-to-sport” strategies noted in the Amsterdam International Consensus Statement on Concussion in Sport.
Gordon says: “We want people to exercise, lightly but not to the extent that they aggravate their symptoms. We want people to use their brain, but not to overuse it.”
This is a problem for matric students who try to study or write exams too soon after a concussion. “The majority are desperate to write exams, but they can do harm and prolong their recovery if they try before they are ready,” she says.
In the past, people with concussion were woken every two hours to check on them. This has changed and, once thoroughly assessed, they are encouraged to sleep without interruptions particularly since the concussion itself can cause sleep disturbances.
“Sleep is an important part of the strategy to recover,” says Patricios, adding that screen exposure should be limited after the injury to support recovery.
Patricios says: “Many people may be affected by emotional symptoms, feeling anxious and depressed, aggressive or irritable after concussion. People who suffer from underlying anxiety or depression may have worse outcomes.”
Smart tools to test cognitive brain function
Concussion can be diagnosed “purely on symptoms”, says Gordon, who also does detailed evaluations at the Cape Sports Medicine Clinic, based at the Sports Science Institute of SA in Cape Town.
These include visual tracking and balance tests, which she demonstrated on biokineticist Alex Collins in her rooms and the corridor. She says: “These give us a snapshot of cognitive brain function, and once symptoms have settled, we can check it again.”
Detailed questionnaires — CRT, SCAT and SCOAT — used for assessing concussions are freely available online (sportconcussion.co.za) to the public.
The centre also has computerised tests, useful for athletes to establish their baseline function before being exposed to concussion.
“We now have better clinical tools to identify concussion, though the technology is not quite at the threshold we need,” says Patricios, of the imaging and blood and saliva tests. Another priority is making them more accessible to South Africans as the technology is expensive.
Prevention is key, says Patricios, lead author on a paper about later-in-life health risks associated with sport-related concussions and repetitive head impacts. The team reviewed 28 studies for this, but most were not designed to provide the right information.
“Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS (which former Springbok Joost van der Merwe had) and dementia,” they concluded, noting, however, that higher quality studies were needed.
Embracing safety
SA is a front-runner in concussion research though most of it happens in North America. “SA has been a key player in implementing protocols in the field, not just at a professional level but in schools with the BokSmart programme,” says Patricios.
SA was the co-chair in developing the Amsterdam consensus statement, based on 10 systematic reviews of 1,600 scientific papers.
“The take home message is this,” says Patricios. “To recognise and remove — recognise the concussion and remove the player. In collision sports, any abnormal change of behaviour must be treated as suspicious.
“Sport is overwhelmingly positive and I’m not chasing people away from collision and contact sports but putting safety first,” he says.
A banner at the last Scotland vs France rugby test match sums it up: “If in doubt, sit it out.”
*Pseudonyms have been used to protect the privacy of individuals
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