| STUDENT-ATHLETES
ARE CALLING OUT FOR HELP IN THE TREATMENT OF CONCUSSIONS
 Candace
Larsen is a typical teenage girl who just wants to enjoy the
benefits of playing sports for her high school while she is
developing her academic skills in preparation for post-secondary
school. A concussion during a soccer game may have altered the
course of her life.
While Candace is from
Sudbury
and
she was playing soccer at the time of her injury, she represents
all student-athletes, male and female, who participate in any kind
of sport or activity in the secondary schools across
Ontario
and
indeed across
North
America
.
Whether it is a recognized high risk sport such as hockey,
football, basketball, rugby, or soccer, or other activities where
one might not think the risk is as great, such as competitive
cheerleading, gymnastics, or wrestling, there is always going to
be a risk of suffering an injury that may cause some degree of
brain trauma which will produce signs, symptoms and behaviours
consistent with concussion. When that happens, it is critical that
the key people in the life of the student-athlete be aware of how
to identify those signs, symptoms and behaviours, and then
understand what accommodations are necessary in all aspects of the
student’s life in order to allow the brain to heal and recover
from the injury.
During an interview that I had with Candace and her mother,
Dawn Larsen, Candace had one simple request, “I wish more people knew about concussions and knew how to treat it
and how to treat persons who have a concussion. It’s difficult
feeling helpless and not being able to explain to someone what
happened to you or how it happened because you don’t know, you
blacked out. You can’t explain how you got hit. No one
understands that this is the amount of pain I’m in and even if
you have headaches once in a while you are not going to be able to
compare it to mine. You don’t understand the pain. No one sits
back and does research on it. They all just assume that it’s a
“bonk” and you’re done in two weeks that you’re fine. But
really it’s more complex than that. No one takes the time to
research it and understand it.”
It's time for all
people in leadership positions to take significant steps to
protect the well being of all students like Candace. It's time for
us to do more than just direct coaches, students and parents to
web sites for information about concussions. It's time for
individual school boards and sport organizations to develop local
concussion management programs that include specific protocols and
procedures, arrangements with sports medicine specialists who will
see injured athletes the day after an injury, training for
teachers so that accommodations can be made in the classroom to
facilitate return to learn rehabilitation, counselling for injured
student-athletes and their parents so that they understand what is
happening to them, and a whole new approach to coaching which
emphasizes safe play in order to minimize the risk of concussions.
THE EPIDEMIC OF UNREPORTED CONCUSSIONS
A study that was published in the Journal of the American
Medical Association in June 2013 reported that in a survey of
9,000 students conducted during 2011 from Grades 7 to 12 in
publicly funded schools across Ontario, one in five adolescents
said they have suffered a traumatic brain injury that left them
unconscious for five minutes or required them to be hospitalized
overnight. A statistic researcher in
Toronto
says
this is much higher than previously thought. And further to that,
sports such as ice hockey and soccer accounted for more than half
the injuries, said Dr. Gabriela Ilie, lead author of the study and
a post-doctoral fellow at St. Michael's Hospital.
The Ontario School Boards Insurance Exchange,
which provides insurance to most of the school boards in
Ontario
requires that
incident reports be prepared for each injury that occurs among
students in those schools. During 2011, a total of 634 incident
reports were labelled as concussions or “possible
concussions”. Of this, only 60%, or approximately 400 were
sport-related. With approximately 1 million students enrolled in
Grades 7 through 12 alone, the age group where the incidence of
concussions is the highest, the fact that only 400 sport-related
injuries were labelled as concussions or possible concussions is
great cause for concern given the statistics that have been
reported in studies around the world.
Experts from the medical field tend to agree
that the annual rate of concussions for sports like hockey,
football and soccer typically range from 15 to 20%. With over 900
secondary schools in Ontario, many of which offer competitive
hockey, football and soccer programs for both boys and girls, to
see only 400 sport-related incident reports labelled concussions
or possible concussions is a clear indication that this type of
injury is being grossly under reported or unidentified.
In fact, St. Michael’s College in
Toronto
reported that
out of the 1000 students attending their school in 2011, a total
of 80 students were reported as receiving a concussion during the
year, amounting to 8% of the total student body. Projected across
the province, this means that we might expect as many as 80,000
concussions among the 1,000,000 adolescents attending Grades 7
through 12 per year. But only 400 sport-related incident reports
were submitted from across the province in 2011. Considering that
there are over 900 high schools alone in
Ontario
that means
that there would have been only 1 concussion for every two high
schools during the entire year of competition in 2011. We know
that this could not possibly reflect reality and something must be
done to improve the identification of concussions in our schools.
IMPACT ON LEARNING IS SIGNIFICANT
Researchers from the Medical College of
Wisconsin may have come up with an important discovery which will
help us understand the overall impact of a concussion on all
aspects of a student’s life, including the effect the injury has
on the ability of the student to meet his/her responsibilities in
the classroom. The findings of the study were published in the
September 2013 issue of the Journal of International
Neuropsychological Society.
The researchers were studying the natural
recovery from sports concussion, and they used 12 concussed high
school football athletes and 12 uninjured team mates. They
evaluated each injured player at 13 hours and again at seven weeks
following their concussion injury.
The injured athletes demonstrated usual post
concussive symptoms, but when the researchers performed an fMRI
(functional magnetic resonance imaging) on the athletes after 13
hours, they showed decreased activity in the right hemisphere of
the brain, which is the part of the brain that controls the
ability to be attentive. They concluded that this level of
activity in that part of the brain would explain the poor
cognitive performance which is typical of an athlete following a
concussion.
Seven weeks after the injury, the concussed
athletes reported that the signs, symptoms and behaviours
consistent with their concussion had resolved. However, the fMRI
testing showed that these athletes also had a higher level of
activation in their brain than the uninjured athletes. This lead
the researches to conclude that their findings may have shown how
the brain compensates in a way that facilitates recovery
immediately after an injury by “slowing down” activity in
order to reduce the stress on the injured part of the brain, and
then “increases” the energy level as the brain recovers and is
on the way back to normal functioning.
This study has serious implications for
doctors, coaches, teachers and parents who are responsible for the
well-being of student-athletes who have been identified with a
concussion. It could very well mean that long after the signs,
symptoms and behaviours consistent with concussion have appeared
to have resolved, the brain is still providing “extra” support
in the form of increased stimulation and activation in order to
help the injured part of the brain function normally. In actual
fact, the injury may not have completely healed, but the extra
energy level being supplied to the injured area may be making it
seem as if everything is back to normal.
The questions that remain to be answered from
this study will have a tremendous impact on the rehabilitation
procedures that are recommended in the future for student-athletes
who suffer from concussions. Does this increased level of activity
reflect the effort on the part of the brain or person to perform
tasks that pre-injury took less of an effort? If a student was a
straight ‘A’ student prior to an injury, and after seven weeks
seems to be back to normal, but this return to normal functioning
is in fact because of a more intense effort on the part of the
person/brain to accomplish tasks that usually took less of an
effort, then has the student-athlete really fully recovered from
the injury? Is the student even aware that it is taking his/her
brain more of an effort to perform cognitively? How long does this
increased activity level in the brain last? Does it ever return to
normal levels or will this now become the new level of activity
needed to perform certain tasks for the rest of the person’s
life?
It makes sense that there are limits to the
amount of energy and reserve that a person’s brain can draw
upon. If as the result of a concussion a student-athlete is forced
to use up more of that injury to compensate for the loss of
cognitive ability in one particular part of the brain there is
quite likely to be some cumulative consequence to that adjustment
and some other part of the brain may suffer. Whether those other
parts of the brain become more susceptible to injury remains to be
proven scientifically, but from a common sense point of view, it
does seem likely.
We are learning more and more about the brain
every year – indeed every month. In the meantime, we are not
able to determine which student-athletes will be able to live
through their concussion and continue to thrive in all areas of
their life with seemingly no impact from their injury. For some,
the injury may have indeed created a process in the brain that
will have altered the course of their life and which may be part
of an accumulation of damage that will produce symptoms at a much
older age that are consistent with premature aging of the brain,
depression, anxiety or dementia. Therefore, we must treat every
traumatic brain injury as if it will have serious long-lasting
affects on the student-athlete, and that means exercising caution
with respect to any form of activity that will produce stress on
the functioning of the brain during the recovery period, which
according to the study from the Medical College of Wisconsin may
be at least seven weeks following an injury. This does not mean
that the student-athlete should be prevented from participating in
athletics or from attending school, but it does mean that we
should be paying particular attention to accommodations that will
reduce the risk of causing further damage.
All of the above will put into perspective the
story you are about to hear about Candace Larsen, the young
adolescent girl from
Sudbury
who has a
story to tell about her traumatic brain injury and the subsequent
challenges she has endured.
CANDACE’S CONCUSSION STORY
Candace
Larsen is a 15 year old girl from
Sudbury
who should be excited about entering Grade 10 in September. But on
May 9, 2013, during the fifth and final game of a weekend high
school soccer tournament in Southern Ontario, Candace and an
opposing player bumped together while running for a loose ball and
when her head hit the ground her life instantly became anything
but normal. This is her story.
Candace
has always been a straight ‘A’ student and her first year of
high school in Grade 9 was turning out to be no different. Her
marks were in the 90’s and even though she was only in Grade 9,
she was thrilled during the second semester to have made the high
school Varsity Girls Soccer team. Candace had never played soccer
competitively before, but she had participated in the sport at a
recreational level since the age of seven and she loved the game.
She suddenly found herself playing in a competitive league which
included girls up to four years older than her, but she did not
find the size and age difference much of an issue while playing
local teams from the Sudbury Area. Her school team was also pretty
successful and even qualified for the Northern Ontario
Championships.
During
the weekend of
May
7 – 9, 2013
,
she travelled with her team to play in one final out of town
tournament in order to prepare for the Northern Ontario
Championships. This was intended to be a warm-up for the NOSSA
tournament and also give the girls a chance to see what their
competition would be like if they won the NOSSA and qualified for
the All Ontario Championships. Candace found the size difference
between the girls much more pronounced with the
Southern
Ontario
teams. The girls were larger and more aggressive, but her team was
still competitive.
Candace
was playing her usual position on defence late in the first half
of the final game of the tournament. All she can remember is that
she and a much larger girl from the opposing team were running for
the ball. Her teachers told her that all they saw was Candace
hitting her head on the ground. They didn’t see Candace actually
make contact with the girl. The teachers/coaches called it a
“bonk” on the head. Candace continued to play for another five
minutes after the incident. Even though she felt a headache coming
on and had a pain in her neck, she felt that she had to continue
to play because she was only in Grade 9 and didn’t want to pull
herself off. Besides that, half time was only a few minutes away.
During
the half time break she knew she couldn’t go on any more. The
pain in her head was excruciating. She was laying on the ground on
garbage bags, “holding my head, crying. I told my coaches that
everything was spinning. I couldn’t see good and parts of the
sky were blurry.”
Candace
remained on the sidelines and then spent the next four hours
travelling home on the team bus. She was very groggy and confused
and remembers that she was not well at all. Her team mates kept
waking her up from time to time to check on her and then they let
her sleep the rest of the way. When Dawn Larson, Candace’s
mother met the bus at
midnight
to pick up her daughter, the teacher told her that Candace had
received a little “bonk on the head but she seems to be ok.”
According
to Dawn, “Right away when I saw her I knew she wasn’t ok. She
was white. Her eyes had different colouring. Even though it was
night when she got in the car you could see her eyes were
different. She had a really upset stomach and she just wasn’t
herself. So I assumed she had a concussion.”
Two
days later Dawn brought Candace to see a doctor after the pain
kept getting worse. She explained why she waited to seek medical
attention, “Because the teachers said it was a “bonk” and
she had headaches, I thought it would go away. I had a two
concussions myself when I was younger. One I spent time in the
hospital and the other one didn’t affect me much.” Dawn also
recalled that when she did spend time in the hospital with her own
concussion the doctors didn’t do much to help her.
Dawn
explained that because she did not have a family doctor at the
time, everything seemed to go downhill from the first visit to the
emergency room at the hospital. Every time Candace got sick they
had to return to the hospital and they ended up seeing a different
doctor. But none of the doctors would put in writing that Candace
had a concussion. Dawn said, “They said that it was a privacy
issue and that they did not like to say that anyone had a
concussion in a note that was going to the school. But the school
needed a note from a doctor to say why she was not going to
school, so it was frustrating.”
Indeed,
because it is so difficult to diagnose a concussion, many doctors
are now refusing to make a definite diagnosis, instead, referring
the patient to a sports medical specialist. This is becoming a
huge problem that is being exacerbated by the shortage of doctors
through out the region. The first response in most concussion
management protocols is to see a doctor. But if you go to the
emergency room, and there is no apparent structural damage to the
skull and no sign of internal bleeding, you will be told to see
your own family doctor or a sports medicine specialist. Apparently
what is happening in many places around the province is that a
student-athlete is being brought to the emergency room where
he/she “is not” diagnosed with a concussion. That is often
enough of a confirmation for a parent to send their child back to
school or back to the coach with a clearance to play again. This
may be one of the reasons we have so few reported incidents of
concussion in
Ontario
.
It is a case of wilful blindness that is putting our children at
great risk, both in the game and in the classroom.
Therefore,
it wasn’t until Candace had an MRI about two to three weeks
after the injury that she was actually diagnosed with a
concussion. The MRI showed some swelling of the brain but there
was no bleeding.
When
asked what it was like during the first few days after the injury,
Candace explained, “It was painful. I don’t know. I wasn’t
myself. It was a weird feeling of pain. I wore sunglasses and had
ear plugs every day after because I couldn’t handle the light
and the sound or the smells. It was difficult after. Even loud
noises would hurt.”
Candace
had not at that time received any significant advice from doctors
or medical professionals on what she should be doing, so she
decided on her own to wear sunglasses and ear plugs, and avoid
light and noise just to try to control the pain. She didn’t know
that what she was doing was correct. It just allowed her to avoid
some of the pain.
What
was disconcerting to Dawn was that “Some of the doctors we saw
in the emergency room visits seemed to make fun of her for wearing
sunglasses and ear plugs. The medical staff in general were not
very receptive to the fact that she needed to wear sunglasses, and
one neurologist we went to see was surprised that Candace was
having problems with the lights. There was only one emergency room
doctor who was actually sensitive to the need to turn down the
lights because he could see that she was trying to look at him but
she couldn’t keep her eyes open.”
“The
whole thing about the fact that she couldn’t stand lights, and
sound and smells was a real problem when she went back to school
because no one seemed to understand why these things were
bothering her. They couldn’t understand why she would need to
wear sunglasses and some of the students made fun of her,” Dawn
recalled about the first couple of times that Candace tried to
return to school.
“She
tried to go back to school within days of the injury because she
is such a conscientious student and she was worried about her
marks. She even tried to go without the sunglasses, but the pain
was so great that she just couldn’t do it. From the outside she
looked like somebody who was very healthy, but on the inside she
was feeling awful.”
Candace
also felt a lot of pressure to return to playing soccer since the
team was preparing for the NOSSA championships. Some of this
pressure might have been self-imposed because of her desire to
play, but she also felt some real or perceived pressure from other
members of the team who encouraged her to come back out and to
just travel with the team to the tournament to show support.
“They wanted me to go to the game to support the team, but I
couldn’t take the ride to the hospital let alone a three hour
car ride to the tournament.”
Dawn
explained to the school staff that her daughter was feeling
pressure to return to school, but until they found a family
doctor, she wouldn’t be able to bring a note explaining that she
had a concussion. The emergency room doctors refused to write such
a note. She was told that the school hadn’t experienced this
kind of situation in a long time. Even Candace got the impression
that hers was the first concussion injury of this nature that the
school had experienced in years.
Yet,
statistics in both Canada and the United States show that anywhere
from 10 to 15% of student-athletes attending secondary school will
experience a concussion in any given year, so it did not make
sense to Dawn that her daughter’s injury was so unusual. Dawn
felt that through no fault of their own, the teachers were not
properly prepared to deal with the aftermath of a concussion with
their students. She wasn’t placing blame on the teachers, but
Dawn felt that no one seemed to know what was going on or how to
help Candace recover from her injury.
At
the time that this article is being written, it has been 90 days
after the injury occurred. Candace still has severe headaches,
difficulty concentrating and low energy levels. Additionally, Dawn
indicated that her “personality totally changed and is just now
starting to come back. She was always a happy person, but after
the concussion she has become very negative, edgy and depressed
all the time. She is starting to get better but she is still a
totally changed person from the girl she was before.”
Candace
even lost touch with most of her friends because she couldn’t
sit up to communicate with them by phone or by sending text
messages. It was almost two months before she could turn on a
computer and she now has contact with only a few of her closest
friends. She has basically removed herself from society while
dealing with her recovery process.
Between
May 9 and June 14, the end of the school year, Candace was able to
spend only two full days at school and about two half days per
week on top of that. Her marks were high enough that she did not
have to complete any of the year end exams and she was only
required to do a couple of small projects to finish off the term
work for some of her classes. Nevertheless, Candace felt a lot of
anxiety over her inability to participate in school since she has
always been a high achiever. This anxiety and stress further
exacerbated the situation and obviously produced a higher than
desired activity level in her brain, thus possibly delaying
recovery. On top of that many of the students teased her about
faking her injury and just trying to get out of school and exams.
She looked fine to everyone else. They couldn’t see anything
wrong.
Another
problem that Candace has encountered as a result of not having a
family doctor, is that she has seen no less than eight different
doctors since she was injured, and according to Dawn, “No one
could tell us anything about what to expect or how to deal with
the concussion. The neuro psychiatrist was the only one who could
explain the mechanics of what was happening in the brain to cause
these problems, but we didn’t get much help from anyone on what
to expect or how to deal with the symptoms. A couple of doctors
told Candace to stay off the computer and phone, but not much
else.”
Candace
is admittedly “terrified” about going back to school. She is
still only able to read two pages before she has to stop. She
loses the ability to focus and concentrate after two pages and she
is finding this to be extremely frustrating and stressful, which
is not helping the situation. She is also worried about what the
teachers and other students are going to say if she has not
recovered to the point where she can attend school full time and
do the regular assignments and tests. Dawn confirmed that she is
afraid that everyone at school will expect that the summer months
will have been long enough for Candace to recover and they will
find it hard to believe that she is still experiencing so many
problems that she will not be able to do much in September. It is
also going to be hard for her friends and class mates to
understand that even though she looks healthy, she has not
recovered and she is still in pain.
Candace
has started doing lower body workouts with soccer specific skills,
but she is still only able to walk about two blocks before she
gets tired and must stop to rest. After 90 days, Candace finds it
exasperating that she is no where near the physical fitness level
she was at before her injury and until she gets her strength back,
she is unable to get back into shape. Her energy and the headaches
are preventing her from doing anything that requires even a
minimal amount of physical effort.
Dawn
wonders how things might have been if Candace was not in excellent
physical shape at the time of the injury and if she was not such a
high academic achiever. “If Candace is having so many problems
recovering, what about young people who are not in shape and who
have cognitive difficulties to begin with. The slow recovery is
causing a lot of frustration but it could have been much worse.”
Dawn
admits she, as a mother, is “tentative about school starting.
Candace wants to do well in her classes and get the marks back up
high again and she also wants to play soccer in the second
semester, so she is going to be putting a lot of pressure on
herself during the next school year. I don’t know how that is
going to affect her recovery.”
RECOMMENDATIONS
School
Boards are obligated to “promote student achievement and
well-being”. This means that every school board must pay
particular attention to helping students cope with concussions,
especially those that are experienced by student-athletes
participating in extracurricular, intramural or physical education
activities and competitions. The statistics show that as many as
80,000 student-athletes in Grades 7 through 12 are receiving
concussions each year, but only 400 incident reports are being
submitted to the Ontario School Boards Insurance Exchange. This is
not acceptable and something must be done to improve the ability
to identify and track possible concussions.
At
the very least, school boards should address the following
recommendations:
1.
Every
school board should develop its own comprehensive concussion
management program that clearly outlines the roles and
responsibilities of school administrators; coaches; teachers;
parents; and student-athletes.
2.
Each
concussion management program should include a mandatory protocol
that must be followed for every student-athlete who is identified
as being involved in an incident which may have caused a
concussion or who actually displays signs, symptoms or behaviours
consistent with concussion.
3.
A
formal report must be filled out at the office for each
student-athlete who may have been involved in an incident that may
have caused a concussion. This
includes incidents that may have occurred in community
recreational activities or from accidents that happened in
non-sporting events. It must be recognized that no matter where or
how a student received a concussion, the injury is going to have a
direct affect on his/her functioning in the classroom and at home.
4.
Each
concussion management program should include a provision that a
suspected concussion is to be considered to be an “identified”
concussion until a doctor, the parents, the teachers and the
coaches all declare that they no longer are aware of any signs,
symptoms or behaviours that may indicate recovery is not complete.
Further, the student-athlete must also self-report the absence of
any post-concussion effects.
5.
Every
school board should make arrangements with one or more sports
medicine specialists who are familiar with sport-related
concussions, to make time to examine on the day following an
injury any student-athlete who is suspected of having a
concussion. The sports medicine specialist must be in a position
to order an immediate MRI for the student-athlete if deemed
necessary.
6.
All
student-athletes who are suspected of receiving a concussion
should be required to attend, with their parents, a session with a
concussion management consultant from the Board Office, who will
provide the student-athlete and his/her parents with an
explanation of the recommended accommodations to be followed
during the recovery period and help them develop a rehabilitation
plan that will facilitate a full recovery. This plan should be
provided to all of the student-athlete’s classroom teachers and
to the athletic coach responsible for the student-athlete.
7.
A
concussion management unit should be mandatory as part of the
physical and health curriculum at all grade levels from Grade 7
and above and should be one of the first units taught during the
school year or semester.
8.
All
student-athletes must be required to attend a concussion
management workshop presentation before participating in any
inter-school or intramural sports activity.
A full concussion management program would certainly be much more
comprehensive, but the above recommendations would go a long way
to protecting the students in our schools across
Ontario
,
and indeed across
North
America
.
About
the author, Robert Kirwan
 Robert
Kirwan is a member of the Ontario College of Teachers who has a
Masters Degree in Education Administration. He retired in
2001 from a 28 year teaching career and was elected in 2010 as a
School Board Trustee with the Rainbow District School Board in
Sudbury
,
Ontario
. Robert Kirwan
provides independent consultation services with respect to the
academic implications of sport-related concussions among
student-athletes, including accommodation guidelines for classroom
teachers, home care guidelines for parents/guardians, and
lifestyle adjustments student-athletes must consider in dealing
with the effects of a concussion. He is currently taking on the
role of President & CEO of CMP Concussion Management Partners
Inc., a company in which he is also a Principal Partner.
www.concussionmanagementpartners.com
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