Q&A on Concussion with Professor John Olver: Part 1
12 Apr 2019
Professor John Olver is one of the world’s leading doctors for the treatment of acquired brain injuries. He talks about concussion and issues relating to treatment.
Is there a concussion protocol that is commonly used by sports clubs and schools?
There are no protocols. Even though there’s a lot of literature around about concussion, there isn't a one-size-fits-all protocol and that’s been a problem.
Should schools and sporting clubs have a protocol?
On the SCAT 5 there is a symptoms checklist. I go through that checklist with any new patient when I first see them. I’m not saying a teacher at school should know any of that, but they should know the types of things that the child might complain about, and that may lead them to say “well you better go to a doctor because you’ve got a few of these sorts of warning symptoms...” It’s just the recognition that certain symptoms may be apparent some days or weeks later.
What should a concussion protocol look like?
It should have two parts:
- On-field and that would be based on the SCAT 5 and elements of that.
- The recognition of ongoing symptoms and a protocol that relates to how you deal with a child displaying some of those checklist symptoms that in the days after their concussion. It’s sort of monitoring by being aware that a child might act differently, might not be able to concentrate, might fall asleep at their desk, it’s seeing a change from what that child was like before. Teachers are often really aligned with that because they know the personalities of their students, they know what’s normal for that child, some kids may fall asleep at their desk anyway and the teacher will know that’s not unusual for those kids but for others it would be a sign of something else, a teacher would know if a child is unusually disinterested. It’s easier of course to recognise the physical symptoms of the headache and dizziness if the child complains of those. In the protocol, the sports teacher needs to tell the class teacher that a child was taken off field for a concussion and that should trigger the class teacher into looking at their protocol and being aware that they have to monitor the child for changes.
What should teachers know about concussion?
The first thing is that current perceptions of the impact of concussion often underestimate its effect partly due to its evolving nature, so the symptoms can come up worse during the first few days for a start, and given the information we have we know that the majority of patients can recover within a short period. About 85% recover within two weeks. This also means that people minimise it, and don’t take any notice because they think it’s going to get better. The 15% of people remaining; they are the ones we see that don’t get better and there’s a lot of complexity around their presentation because there are signs and symptoms such as dizziness and headache. These are symptoms that can be crippling and cause depression, anxiety, lack of sleep. Some of these are the direct result of the blow to the head, and some are the psychological reaction to having chronic dizziness or chronic pain, or just being taken out of one’s normal lifestyle and not being able to go back to it. There’s always a psychological and a symptom element to concussion, and you’ve got to work out which is which.
What can help teachers to recognise potential concussion symptoms?
I can show you videos we’ve got of a number of footballers that get concussed and there are some signs on the field that should tell you a person has had a significant head injury…the blank stare, the lack of purposeful movement, examples of where they try to move their arm and either nothing happens or it moves in an odd sort of direction. Obviously the head strike, it’s often a double impact from something like an elbow in the head and then the head strikes the ground. Talking to the person about what they remember is important so asking questions like What venue are we at today? Which half of the game is it now? This is on-field stuff.
There is the Maddox score. David Maddox was a psychologist that actually worked here, but he did a concussion study with AFL footballers 30 years ago and he’s about to look at the same footballers 30 years later and test them from a thinking point of view to see where they are. He developed a score that gives a trainer on the field some indication that a player needs to be taken off and then shouldn’t take any further part in playing. When you know someone at school has had a knock to the head, do you deal with it conservatively? If they show symptoms then you don’t allow them to go back on the field. Secondly, what do you do in the days after? Teachers need to be aware of a graded or paced return to school for a child who has had a concussion.
The SCAT 5 is an assessment tool put together by a whole group of people, and Paul MccRory in Melbourne is a neurologist who chairs that group. Teachers should have the latest one.
(With a post concussion protocol, we don’t want any teacher to go through pages of thinking testing…that’s not for the teacher at school, that’s for the doctor or medical therapist that sees them a little later on.)
How should teachers respond to a head knock during sports?
An incident response with the SCAT 5 is a good idea. Then there’s got to be a second response when that kid gets back to the classroom. A teacher has to have some understanding of the symptoms that the child may be experiencing once back at school. Asking about a few symptoms is worth it, and if they answer that they have a few of those symptoms then it’s straight off to the doctor for someone to check out.
Why is it important to recognise concussion symptoms?
The teacher needs to be able to tell the parents if the child is not quite right, and ask them to take him to the clinic or the emergency department to get checked out if they are seeing these symptoms in a student. It’s the recognition of those symptoms that persist. It’s the on-field stuff that gets the kid off the field, and off to a doctor. Knowing about the longer term symptoms when they return to school the next day or a few days later, a teacher can recognise if a child is not quite right and can determine they need more time out. Those are the two elements of a checklist or a school’s concussion protocol that need to be in place.
How do you manage concussion in children?
When school children come to see me they don’t like me, because I send them straight back to school. Now, I might write to the teacher to say I want him to only do half days for a week or something like that, but it’s the difference between staying at home and doing nothing or recovering (and a lot of them won’t do nothing, they’ll watch television which in itself is an activity but not a particularly useful one…). The worst thing you can do is take to your bed and hope that the symptoms get better. We believe in resting for one day or two, but then getting back into a normal activity is important.
Should children be allowed to use devices after a concussion?
It’s not that using ipads and devices after a concussion should be restricted, but restricted in time spent on them. If you get fatigued and therefore your concentration goes, you can’t battle through fatigue. You must stop the activity. So what we get people to do is time limit activities. You can pick it up, check emails or go online for a little bit, but you can’t sit on it for hours because then you will get a headache and as soon as symptoms come on then you know you’ve overdone it. We symptom-base the return to activity. Do something, if you don’t get the symptoms then the next day you can do a little bit more, and that’s the graded return to activity. If you do something that brings on symptoms, then ease back a bit but not doing anything at all is no good. Some symptoms do require medical intervention, particularly headache and neck pain, and perhaps physical intervention. A physiotherapist might give exercises to get rid of the neck pain.
What should teachers know before a child returns to school after a concussion?
For PE teachers, if they know they have a student returning to sport after a concussion they need to think about grading the return. They need to think about reducing the amount of impact potentially to the head. The difference between running and walking is that with running, the impact as the foot hits the ground does shake the whole body to some degree and including the brain. If you allow running too early, people will get a thumping headache and might feel dizzy. Again, it’s recognising that after a concussion people can get symptoms if they overdo exercise and it’s a matter of getting the balance right and not putting kids back into intense exercise too early. With sport, if you do drills and have body contact then don’t start with that. You make certain that the patient can walk first, then run and slowly they can start doing drills that are a little bit more energetic. It has to be a graded return to exercise.
Are there any sports you consider too rough for our kids?
That’s a controversial topic. How much do you protect children? If they play football later on, should they learn how to protect themselves earlier with proper tackling methods and know they shouldn’t get involved in that violent sort of behaviour on the field. There are some AFL players who constantly get concussed, and there’s something about the way they play the game that they need to alter in order to stop that from happening. Any contact sport has the potential for concussion.
In American football, one of the things that they changed was that in the early days you could actually grab someone’s helmet and jerk their head around, but now that’s completely banned. It’s about making the sport safer. The AFL is doing that to an extent. Some of the old players talk about how it’s sanitising the game too much but that’s just crazy stuff because they don’t understand that for these guys the rest of their career can be ruined, or they can’t function properly because they’ve got brain damage after multiple concussions.
It’s not really about going through a checklist but rather that there is a cluster of symptoms that you may be able to see in a child when they get back to school, and it’s recognising that it can be a concussion and then pushing the button. That’s all that teachers have to do really. Information about symptoms will make a difference now, whereas before they may not have related those symptoms to a concussion.
Are there increasing numbers of concussion cases among children playing sports?
I think there are more reported cases of concussion, and more awareness coming from the AFL with commentators talking about it.
About Professor John Olver AM MBBS MD (Melb) FAFRM (RACP)
John Olver is an internationally-renowned expert in Acquired Brain Injury rehabilitation, and was recognised in Australia Day Honours in 2014 for his many decades of service improving rehabilitation for people suffering from Traumatic Brain Injury. He supervises a team at Epworth’s Rehabilitation and Concussion facilities who treat patients and are involved in pioneering research. He advised on the clinical panel of Victoria’s Transport Accident Commission (TAC) for many years, and mentored and trained rehabilitation doctors across Australia over two decades. He is the Victor Smorgon Chair of Rehabilitation Medicine, Victoria’s only chair in rehabilitation medicine – a position that comprises dual relationships with the Epworth Rehabilitation division and Monash University’s Faculty of Medicine, Nursing and Health Sciences. In 2012, Professor Olver chaired the seventh World Congress for NeuroRehabilitation (WCNR) in Melbourne. He was selected to bring the Conference to Australia for the first time, following his presentations and involvement at others in Malaysia and Austria previously. More than 1800 rehabilitation personnel from 53 countries including the USA, Canada, Scandinavia, Europe, Malaysia and Australia, arrived at the Melbourne Conference to hear leading international experts and to discuss the latest clinical advances, patient treatment, and research in neuro-rehabilitation.