Ireland needs to talk about head injuries among children playing school sports, insists Dr Michael Micky Collins, an internationally-renowned expert, who has treated US sports stars and elite athletes.
This weekend, Collins, who is based at the University of Pittsburgh Medical Centre (UPMC), will speak at a University College Dublin conference on the subject:
“There is a lot of misinformation about concussion,” he says.
“Yet it is a very prevalent injury. Concussion affects a lot of different systems in the brain, and it can affect kids’ academic functioning, their social functioning, their physical wellbeing. There are real consequences to this injury, particularly if it is not treated properly. That’s the case here in Ireland.”
The neuropsychologist and fourth-generation Irish-American, whose ancestors are from Co Cork, estimates about one in 10 schoolchildren playing contact sports in Ireland will suffer a concussion every year.
That is a lot of children. Most youngsters take part in school sports while up to three-quarters are also involved with at least one local sports club, according to a 2019 report by Sports Ireland.
That study found that soccer, Gaelic football, hurling, rugby and basketball are the most played among boys, while Gaelic football, camogie and soccer are among the five most popular sports for girls.
Each of the sports carries a significant risk of concussion, despite the popular misconception that head injuries are a rugby problem. In fact, it is not even a sporting problem. Children can be concussed from schoolyard horseplay, falls and accidents.
Collins is among leading figures in the field gathering at UCD on Saturday for a conference on treating the widespread head injury. His findings have helped overturn conventional wisdom about concussion over the past 10 years.
And his findings will surprise many. For example, girls are more likely to suffer concussion than boys, he says. Dizziness after a head collision is a worse predictor of a bad outcome than being knocked out unconscious. Children who suffer migraines, car sickness or anxiety are all more prone to concussion than those who do not. And lying down in a dark room is not the cure.
“A concussion occurs when the brain moves in the skull, like an egg yoke moves in an eggshell,” says Collins.
“If it moves violently enough, the membrane to the neuron will stretch, potassium leaks out the cell, calcium leaks into the cell. That all causes energy problems to the cell. It is called a metabolic crisis, where the cell is not getting enough energy. When that happens, different systems in the brain can compensate for that energy problem.”
Collins and his team at UPMC — which is developing a network of medics in Ireland who are trained at Pittsburgh — have broken down concussion into six types, all of which need to be treated differently.
One is cognitive concussion, which causes problems with thinking. Then there is vestibular concussion, dealing with that part of the brain that interprets motion and allows us to balance, and then there is ocular concussion, where eyesight is affected after a head injury “60 per cent of the cells in our brains work on eye movement”, he says. Children who have a history of “lazy eye” — where one, or both eyes are not properly aligned — are, say experts, more prone to this type of concussion.
And then there is a type of concussion that is suffered by people who are already prone to migraines. “That’s what it sounds like. Not fun.”
Meanwhile, where a concussion injury is sustained in the neck, this can cause nausea, dizziness and lack of concentration.
Anxiety levels and mood changes are regarded as a separate category of concussions.
“There can be a lot of mood problems after a head injury. There is a lot of emotional circuitry involved,” says Collins. “Patients can have one of these sub-types of concussion or all six. They are not mutually exclusive.”
Describing the prospect of a child incurring a concussion as a “realistic probability”, Collins says awareness of the injury is key and understanding the signs. Obvious signals are loss of consciousness, but it can also manifest itself through amnesia, dizziness, headache, nausea, difficulties in school, fatigue as well as noise and light sensitivity.
“Awareness with no solution is called hysteria,” he says. “Awareness with a solution is called clinical management. That is what we are trying to bring to Ireland. If this is recognised and treated, kids can play sports safely. Sports are wonderful. They allow kids to be actively engaged in competition and camaraderie. They have benefits for everyone. But coaches and parents need to be aware of the subtleties of this injury. When in doubt, send them out. If you see signs or symptoms they need to pull the kids out of play.”
While concussion is a “very treatable” injury, diagnosing it quickly — ideally within a week — and getting proper treatment is vital. Otherwise, it can lead to “chronic symptoms” down the line.
Earlier this month, a peer-reviewed study published in the medical journal Injury Prevention found adolescents who incur a concussion could be 25 per cent more likely to suffer academically.
A team of researchers at the University of Washington in Seattle found, if untreated, it could lead to “lasting physical, cognitive and emotional changes” and noted the lack of “clear, standard guidance” on rehabilitating children back into school work.
Of more than 10,000 high school students analysed in the study, almost 15 per cent reported at least one sports and activity-related concussion over the past year.
“History of concussion was significantly associated with poor academic standing and experiencing multiple concussions could be particularly harmful on student outcomes,” the report authors found. Their conclusion was that “school-based injury prevention efforts” including helmet use, screening for concussions and “return-to-play and return-to-learn guidelines” should be standard protocol.
We have to take a realistic view in terms of resources, but we have to give some level of guidance to improve safety outcomes— Dr Enda Devitt
Collins has worked with the GAA, the IRFU and other sporting bodies to put in place protocols — he says Ireland is “far ahead of the game compared to other countries” — but Dr Enda Devitt, concussion expert for Galway GAA and Connacht Rugby, says there are “gaps in this trickling down to underage sports. Things have improved here from where we were 10 years ago. Physicians are learning a lot more about it. But we need to share that information, not just among ourselves, but with the general public. In the vast majority of cases, this is a treatable injury.”
Parents, coaches as well as players “right down to the youngest” need to be educated “rather than just targeting senior level sports”, says Devitt. GPs also need to be trained in spotting the “red flags” for concussion so they can quickly refer youngsters to an expert.
“That will take a lot of expertise, and we have to take a realistic view in terms of resources, but we have to give some level of guidance to improve safety outcomes,” he says.
“We need to reeducate the medical community about the myths around concussion. Rugby gets all the attention, and very unfairly so. It has done a huge amount of work in educating coaches and players and it is continually being done. At my clinic, I see far more concussions from GAA or road traffic accidents.”
Devitt says concussion happens in all contact sports but also “even in horseplay in the schoolyard. I would see plenty of patients in relation to schoolyard injuries. We need to change that conversation in Ireland.”
Devitt’s worry is that children are not being quickly diagnosed with concussion and “we are going to miss the stuff that we can rehabilitate.”
He adds: “It is hard to put a figure on it, but there are plenty of cases that come before me, where if we saw them earlier there would have been a good outcome. Instead, they have struggled for months with headaches, poor academic performance, with their mental health.
“The earlier we see cases that aren’t responding quickly, the better the outcome. Rather than a wait-and-see policy, if someone is not recovering in the first week or two, you really need to be acting on it.”
Collins’s concussion clinic in Pittsburg sees 20,000 patients a year. About 60 per cent are girls or young women
On the long-term impacts, Collins insists the “jury is out. There is no good science at this point to really delineate what the potential effects are on this. In the short run, we know what the effects are but we are not as clear on the long term. I don’t want to raise alarm on that, because a lot of people get better spontaneously with this injury too. It is not going to cause long-term problems in every person. The research that does exist tells you we can treat this injury effectively.”
Collins’s concussion clinic in Pittsburg sees 20,000 patients a year. About 60 per cent are girls or young women. He believes the prevalence of migraine, car sickness, as well as hormonal issues and neck strength among females, make them more predisposed to the injury.
“The great, great majority of kids we see go back to normal, with no ill-effects,” he stresses.
“Are there some who are going to have problems, even with proper treatment? Sure. But we have a good success rate. The biggest fear I have is that parents or patients having problems don’t realise that the treatment exists. That’s where I get nervous. Even where symptoms are chronic, we can get them better.”
A father of four daughters, Collins says they all play contact sports, including soccer and basketball. Three of them have had concussion and he has treated them all “successfully”.
“I think the value of sports is tremendous,” he says. “In my opinion, it’s a really good thing for kids to play sports. Parents have to make their own decision on that, but I would be fairly confident in telling them it is a great thing. The advances we have made in treating concussion are very significant. It has never been safer to have a concussion than right now.”