Schoolboy rugby concussion: Causes and precautions

| June 24, 2014 | 0 Comments

By Shameemah Abrahams

As a science undergraduate student, I learnt animal laboratory skills to study brain diseases such as Parkinson’s disease. Ithen came across the MRC/UCT Exercise Science and Sports Medicine (ESSM) research unit, located at the Sports Science Institute of South Africa and part of the department of human biology within the faculty of health sciences at the University of Cape Town (UCT).

After completing a mini research project for my honours degree on performance in ultra-marathon runners at ESSM, my supervisors suggested a concussion project, combining the brain and sport, for my current Master’s project. On a personal level, my science journey has exposed me to the frailties and strengths of the human mind in confronting physical and mental pressures often unique to the elite sporting environment.

Young players at risk The issue of concussion or head injury in rugby is topical in the sports media and sports science literature.1, 2 Sports concussion is described as an indirect or direct ‘knock to the head’, resulting in changes in brain function that often include headaches, dizziness, confusion and balance problems, which usually clear in 24 hours to 10 days after the head knock.3

The highest occurrence of concussion during a season was reported as 14% in South African school rugby, while a greater incidence of 22.2% was reported in American high school football.4, 5 According to the recent International Rugby Board (IRB) concussion guidelines,3, 6 young athletes are more susceptible to sustaining a concussion, when compared to older athletes. Fatalities due to traumatic brain injury (including concussion), from 2002 to 2010, have occurred more often in South African high schools (six deaths) than in club rugby (three deaths).7

The exact cause of the increased vulnerability to concussion in school compared to professional athletes is as yet unconfirmed. However, some speculate that the developing cervical musculature, a greater head to neck ratio and poorer tackling technique in the growing youth athlete are possible explanations for increased concussion vulnerability.8, 9, 10

Recognise and remove and return to play critical protocols With regard to the resulting neurological impairments, children require special consideration due to their developing brain and cognitive function.11, 12 Concussed athletes younger than 13 years old are evaluated and managed differently to adults, as cognitive function differs from adults.3

A second head injury before complete recovery from an initial concussion, or ‘second impact syndrome’, can result in long-term neurological damage and death, which seems to occur more often in youth athletes.1 As a consequence of possible debilitating outcomes, the IRB has promoted the ‘Recognise & Remove’ initiative encouraging teammates, coaches and parents to monitor rugby players for any visible signs of concussion such as unsteadiness, convulsions, appearing dazed or confused, vomiting or being knocked out. However, concussion symptoms and signs sometimes only appear 24 to 48 hours after a head knock.

Therefore, suspected concussions should be referred to qualified clinicians or health professionals to confirm a concussion using a holistic combination of the symptom checklists, balance testing and neurocognitive testing.3 The step-by-step return to play (RTP) protocol involves physical and cognitive rest until symptoms clear, with gradual introduction of light exercise, and stopping any physical or mental exertion that exacerbates symptoms.

Furthermore, young athletes often take longer to recover from concussions than adults, with symptoms sometimes clearing only three months after a head knock.3, 13 The youth seem to have prolonged recovery and limited or no medical support, therefore prompting a more conservative management of concussion.3 The priority for youth athletes is to ‘return to learn/school’ before attempting any RTP. Although no guidelines currently exist for ‘return to school’, temporary absence from school or half-day attendance should be employed on an individualised basis depending on symptom exacerbation, academic schedule and clearance by a qualified medical doctor.14

The research on concussion in South African youth rugby is limited, with a few previous studies investigating cognitive ability and injury rates.4, 15, 16 As a consequence of the limited information on recovery and risk exposure in South African school rugby and the worryingly prolonged recovery, it is important to investigate the possible risk factors for delayed recovery from concussion in youth athletes.

ESSM seeks answers In an attempt to answer some of these pertinent issues, I am part of a group of researchers from UCT’s ESSM research unit conducting a concussion research study with several top South African rugby schools, clubs and professional teams, including Boland Landbou College, South African College High School (SACS), Rondebosch Boys’ High School, Bishops Diocesan College, Paarl Boys’ High School, Paarl Gimnasium High School and Stormers, Sharks, Villagers and UCT ‘Ikeys’ rugby clubs.

As part of this study, rugby players complete questionnaires that provide personality, medical, sport and concussion histories as well as computerised ImPACT© neurocognitive tests for baseline cognitive ability. In addition, a DNA cheek swab is donated for genetic analysis of specific genes involved in nerve cell death and behavioural traits. Thus far in our study, we have identified several potential risk factors for sports concussion, based on the scientific literature.17

Results indicate that definite risks for sustaining a concussion are at least one previous concussion and participating in matches (compared to practice sessions; as there is often more contact during matches than practices). The other potential risk factors include: playing a position that in rugby union is an uncertain risk (some researchers suggest forwards are at greater risk,18 possibly because they are involved in more tackles than backs), an indefinite risk for playing environment (based on the theory that the harder artificial turf potentially increases risk compared to natural grass), fitness level (based on the theory that better fitness means better technique and reduced risk), protective equipment (no conclusive evidence exists that headgear and mouth guards reduce concussions, although this equipment protects against fractures and cuts or bruises) and inherent genetic profile.

The number, duration and type of concussion symptoms as well as varying cognitive outcomes between individuals highlight the possibility of an inherited genetic ‘profile’ for concussion predisposition. Research suggests that certain genetic sequence changes within genes involved in nerve cell death may be linked to severe outcomes and longer recovery after a concussion.19, 20

Developing a genetic profile The focus of our study is to identify the differences in the genetic blueprint between young players who get concussed compared to those who do not. All the DNA and questionnaire data collected will be compared between players who sustain a concussion (injured) and those who do not (uninjured) during the rugby season. The comparison between injured and uninjured players is necessary to determine which risk factors predispose rugby players to sports concussion. We hope that the findings from this study build on the foundation for future research on the biology underpinning concussion injury.

This study is the beginning of a journey towards discovering a ‘genetic profile’, in conjunction with external environmental factors (e.g. dangerous playing style, poor fitness), to determine which athletes are at a greater potential risk of sustaining a concussion or suffering long-term negative neurological outcomes (e.g. impaired memory or learning difficulties). 

Shameemah Abrahams spoke on this topic and her love of science at the 2014 Scifest Africa, held in Grahamstown in the Eastern Cape on 12-18 March 2014. Scifest is the largest annual science festival on the sub-Saharan African continent. See http://www.scifest.org.za/.

Category: Winter 2014

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