Concussion: an interview with Dr Rob Reid

Interview conducted by April Cashin-Garbutt, MA (Editor)Sep 10 2012

Please could you give a brief introduction to concussion? When does it occur?

Concussion happens when something produces a concussive force to the head, such as a blow to the head. The definition from the 2008 consensus, which was in Zurich, is, “concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”

Generally concussion occurs when a force is applied to the skull. It may be direct or indirect. You don’t actually have to have a hit on the head to induce it.

What are the symptoms of concussion?

The symptoms and signs of concussion cannot be split apart. Loss of consciousness happens in less than 10% of cases. Other signs/symptoms include:-

• a feeling that they are in a fog
• disorientation in time and place
• drowsiness
• unsteady on their feet
• nausea
• vomiting
• headache
• double-vision
• poor balance
• irritability

Do the symptoms and the severity of concussion vary depending on the age of the patient?

That is a very hard question and I don’t think we have the answer. We know that concussion has a greater effect on the younger brain, so the concussive force does not have to be as great. The severity of the concussion, however, depends on how hard the person has been hit.

Concussion is more significant in children and adolescents, as are the consequences of concussion in these groups.

Do the symptoms of concussion vary for males and females?

Males and females may present with symptoms in a very similar way. The next summit on concussion, which is to be held in Zurich in November this year, is going to look at whether there are any differences between men and women who present with concussion.

Why is it important to spot the signs of concussion?

It is important to spot the signs of concussion for a number of different reasons.

One is that if the concussion is bad enough, it can lead to long-term consequences and long-term brain problems. This seems to happen more with repeated blows.

Some of these consequences are significant things like memory loss, loss of sense of taste and smell, light sensitivity, inability to think properly.

There’s also the possibility of second-impact syndrome. This means that the person experiences a much more severe injury, if the person hasn’t fully recovered from the first one.

What should happen if someone is suspected of having concussion?

If someone is suspected of having a concussion, the first thing is to recognize it. The recognition of concussion is probably one of the biggest problems in some situations.

Once the concussion has been recognized, then the normal first aid procedures need to come into play first. In Australia we call it DRSABCD. This stands for:

• Danger
• Response
• Send for help
• Airways
• Breathing
• Compressions
• Defibrillator

This first aid comes before the treatment of concussion.

When there is a concussion and there are no other dangers around we refer to the 5 R’s. This means we need to:

• Recognize the concussion
• Remove the person from play and not let them return to play that day
• Referral to a medical doctor
• Rest – complete cognitive and physical rest until the symptoms have gone – this is the main treatment for concussion, as we have no other treatment
• Return to play – once the symptoms have gone completely. This needs to be gradual and it needs to be monitored. The player needs to gradually increase the amount of exercise they do without a return of symptoms, before they are ready to take to the field for return of play.

How is concussion diagnosed?

It is a clinical diagnosis. Concussion is defined as having no structural problem with the brain. This means MRI, CT scans and X-rays all appear normal.

Loss of consciousness is an easy diagnosis of concussion; however, this only happens in less than 10% of cases.

Other diagnoses must be based on the signs and symptoms of concussion that we see.

Is it ok for people with concussion to be allowed to fall asleep?

No and yes. For the first 4 hours they really shouldn’t be allowed to sleep, because other changes may occur in this time. When someone has a concussion and they go to hospital, they will be observed for 4 hours. This means that they will be roused every 15 minutes or so, to make sure they are arousable.

For the next 4 hours, after these initial 4, they need to be watched and they need to make sure they are arousable, at least every 30 minutes.

After that time it is probably safe for them to sleep, because most of the secondary consequences, such as bleeds inside the brain, will occur within that time.

Why is it important to take a conservative approach to concussion?

The conservative approach, i.e. removal from play and rest, is important as this allows the most rapid return to normal. Not everybody does make a rapid return to normal, but this is the time that they can.

Unfortunately, there is no active treatment for concussion, we can’t put a bandage on it, or have physiotherapy, or give a medication to treat it. It seems that time is what makes a difference to people with concussion.

The other thing is that there are potential long-term consequences of a single–blow or multiple-blows that are very significant. We would like to prevent those.

On average, how well-educated are people about concussion?

Poorly. Many “old-school” coaches and the public think that people just need to “toughen-up”, because they have just had a head knock.

This is very far from the truth as the head-knock is potentially a very serious problem.

What plans are in place to improve people’s knowledge about concussion?

There are two parts to this. The first part is the need for education. We need to educate the sports trainers, players, coaches, administrators and the general public about what concussion is and its consequences.

The other way to change people’s knowledge about concussion is to change the sports. There are a number of sports that are taking concussion very seriously. They are making rule changes to make the sports safer.

In rugby union and rugby league you are not allowed to tackle around the head. In ice hockey, they have banned head high hits – they have been outlawed by the International Ice Hockey Federation.

These changes filter down into what the public think about concussion. It makes them aware of concussion and it increases their knowledge in a secondary way that concussion is very serious.

How do you think the future of people’s knowledge of concussion will develop?

I hope it will continue to improve, especially with public awareness. I think for public awareness, the public need to want to have that education. I think it is extremely important to make the public aware of concussion and what it is.

There are also community education programs that are starting up. I know we have a couple in Australia.

Another thing we need to do is educate the media about concussion. I think this may be a little more difficult. This is because often when the media report on concussion, they are as uninformed and as uneducated as the public. Also, a lot of the media personalities tend to be a bit “old-school” in the way they view things. In other words, if somebody has had a bit of a head knock they tend to think they should just “toughen-up”.

How did your interest in concussion originate?

My interest in concussion originated through various different things. Originally, I did a Surf Life-Saving Australia bronze medallion in 1973 before I started my medical degree. So, I have always been interested in first aid.

I was also on a panel in Australia about injuries in boxing, these included head injuries. So I learnt more about concussion there. In 1994, I was on a panel about head and neck injuries in football.

My interest in concussion has also been peaked as my daughter had concussion a few years ago. She had a fairly significant concussion. She was a figure skater and she was knocked out on the ice. It took her about 16 months to get back to where she was before she had the concussion. It took her 3 weeks to get back to school. It also took her about 10 weeks before she could do one turn on the ice. She had been doing triple rotations before-hand. It took her 10 weeks to do a single turn, because she became so dizzy when she attempted one.

Would you like to make any further comments?

A lot of sports are taking this extremely seriously and they are working very hard to make their particular sport safer. A lot more helmets are now being worn. There have also been a lot of rule changes, such as making the head not a target.

The other point I would like to make is that a lot of people think that putting a helmet on, especially one of those rugby scrum-caps, protects them from concussion. This is not the case. The helmets do not change the concussive force enough to make a difference to the number of concussions.

There is a concern that people that use that sort of head-gear think they are more protected than they should.

The only helmets that really make enough of a difference to concussion are the motorsports helmets and American NFL helmets. Anything short of that doesn’t decrease the concussive force enough to make a difference to the number of concussions.

Where can readers find more information?

They can find more information at:

www.sma.org.au

www.braininjuryaustralia.org.au

About Dr Rob Reid, MBBS, FACSP, FASMF (Sports Physician)

Prior to taking up medicine, Rob was interested in Engineering and Architecture. He completed his SLSA Bronze Medallion in 1973.

Following his medical course at Monash University (1973-78), and a two year postgraduate internship at Geelong Hospital, Rob spent 1 year in Switzerland as a ski instructor, carpenter, painter plumber, electrician, tour guide, hotel manager, etc.

He then moved to (then) West Germany to work with the Canadian Armed Forces (as a civilian). During this time, he worked with the Canadian Ski Patrol System (eventually Schwarzwald Zone President) and German mountain patrol prior to going to London to complete a post-graduate Diploma in Sports Medicine.

This was followed by three years of sports medicine, corporate health and exercise physiology, while fulfilling a position as Chief Medical Officer for the Hockey Association in England.

He returned to Australia, and moved to Canberra to spend two years at the Australian Institute of Sport. He has since been in full-time private practice for 21 years.

He was one of the inaugural Fellows of the Australian College of Sports Physicians. He is a Founding Fellow of the Faculty of Sports and Exercise Medicine (UK). He has worked with hockey, basketball, rugby union, netball, rowing, ice hockey, figure skating, and running (among others).

He currently is Chief Medical Officer for Ice Hockey Australia, and Tuggeranong Rugby Union Football Club. He was the CMO of the Rally of Canberra for 17 years.

He is also one of the doctors for ACT Academy of Sport, and sits on the Faculty Advisory Committee of the Health and Wellbeing School at the Canberra Institute of Technology.

He is on the National Board of Sports Medicine Australia and also sits on the Board of Sports Medicine Australia, ACT branch. He has a lovely wife, and two children.