Early referral and treatment can minimise impact of brain injuries

Concussion concerns keep some parents from allowing their children to play soccer or other contact sports. They fear their children will get knocked out and sustain serious brain injuries that will have long-term effects.

Concussions are brain injuries. They happen when a strong force causes the head and brain to move rapidly back and forth, creating chemical changes in the brain.

Contrary to popular thinking, you don't have to be knocked out to sustain a concussion. And it is not just a direct blow to the head that may cause it; a jolt to the body, if it is strong enough, can also lead to one.

The real danger comes when there are multiple concussions, which, in rare cases, may even lead to death. In 2011, Irish teenager Ben Robinson died from brain injuries sustained playing rugby for his school. Reports said he was treated three times for blows to the head and then sent back to the field. He collapsed afterwards and later died in hospital.

A study published in the Singapore Medical Journal in June suggested that emergency physicians here do not know enough about dealing with sports concussions.

It highlighted the need for further education and awareness, said the paper's lead author, Dr Dinesh Sirisena, who is a consultant at the sports medicine department at Khoo Teck Puat Hospital.

While concussion awareness and how to manage it is better known among sports physicians, it may not be so well known among others, said Dr Sirisena. A way to improve the situation is to start training programmes at the undergraduate and postgraduate levels, he said.

Many of the concussion patients that he has seen at the hospital's sports clinic are from contact sports such as soccer, rugby and martial arts. However, any sport can put one at risk of concussions, he said.

"Sports-related concussion is among the most complex sports injuries to diagnose, assess and manage," said Dr Ng Chung Sien, a senior registrar in the Changi Sports Medicine Centre at Changi General Hospital.

The symptoms are often subtle.

Being knocked out or losing consciousness, which many people associate with concussions, occurs in less than 10 per cent of the cases, Dr Ng said.

While it is crucial to diagnose concussion and immediately remove the athlete from the field, this can be challenging.

"Due to the fast-paced nature of sports such as rugby and football, athletes who suffer concussion on the field could be missed," said Dr Ng, who is also the national team physician for the Singapore Rugby Union and a member of Football Association Singapore Medical Committee.

Dr Ng added: "In some international rugby competitions, the match-day doctor may have only 15 minutes to perform an on-site assessment of any player with a suspected head injury during play."

The most common symptoms of concussion include headaches, dizziness, balance and memory disturbances.

It can take a few minutes to a few weeks to recover from one.

"During this time, it is important for the athlete to have both physical and cognitive rest," said Dr Ng. "Clearing athletes to return to normal activities, including sport participation, should commence after the symptoms and signs of concussion have resolved."

A premature return to sports will increase the risk of further injuries. Cumulative effects of multiple head injuries increase the risk of long-lasting and progressive cognitive function impairment, said Dr Ng.

"Second-impact syndrome, a rare but fatal condition, may occur if an athlete gets a second head injury before the first concussion has been fully resolved."

Dr Jeremy Wee, a senior consultant at the Department of Emergency Medicine at Singapore General Hospital, said the local study was done only in one centre and may not be a true representation of emergency physicians here.

In the emergency department, they usually see patients with head injuries sustained from a fall or a traffic accident.

Sports-related head injuries are more uncommon, though, anecdotally, they feel that there has been an increase in such cases here, he said.

Dr Wee said the hospital's emergency physicians do undergo training on the identification, diagnosis and management of traumatic brain injury as a whole.

"Our priorities are to identify and diagnose patients with severe head injuries which require lifesaving neurosurgical interventions."

They will have to decide if those patients require a CT (computerised tomography) scan or not.

"Even (for those) with mild traumatic brain injuries or patients with concussions who do not require a CT brain scan, we advise patients and their caregivers what symptoms to watch out for and when to seek further medical attention. For patients who have had a CT brain scan which was normal, they will be observed in hospital until they are deemed fit for discharge."

On discharge, they are given a medical certificate to rest at home for a few days and advised to do only light duties to prevent further injuries.

There is thus little difference in the initial management or assessment of a patient with traumatic brain injury versus sports concussion, said Dr Wee.

Knowledge about concussion is relatively new and evolving, said Dr Sirisena.

"Over the past 15 to 20 years, we have witnessed increased awareness of this as a condition and our understanding of how vulnerable the brain is, has grown with it," he said.

"Imaging does not really help in the diagnosis of concussion, other than to rule out a significant brain trauma or bleeding."

Hence, once a concussion is suspected, early referral is important.

"A sports physician who is experienced in concussion management will never be critical of a clinician who refers a suspected concussion and it turns out not to be the case. It's better to be safe than sorry," said Dr Sirisena.

Dr Ng added: "Although there are existing international clinical guidelines, there is no perfect diagnostic tool or method for an immediate diagnosis of concussion."

In order to better manage the immediate and long-term health of athletes with concussion, it is crucial for attending clinicians to have a good understanding of the subject matter, he said.

Apart from incorporating sport-related concussion programmes at medical school, doctors can go for such courses. "One such initiative is the online training resource on concussion management for doctors provided for free by World Rugby," said Dr Ng, referring to the world governing body for the sport.

If untreated, a concussion can lead to continued brain injury and can even cause "second-impact syndrome". This may lead to death, said Dr Sirisena.

"Those who belittle concussions as a minor brain injury might be putting athletes, friends, family or their children at significant risk," he said. "If managed correctly, athletes can return to sports safely and successfully."