Today I'm going to take a sidetrack slightly from my usual posts and explore an area I would love to know more about.... concussion and head injuries, with particular focus on head injuries in snow sports. The National Alpine Committee Concussion Policy (2013) states that "Concussions account for 62 - 66 % of head injuries in winter sports admitted to a level 1 trauma centre."

As a passionate snowboarder I've experienced first hand the benefits of wearing a helmet and witnessed the growing number of helmets worn at ski resorts. I think this is brilliant. Most alpine resorts sources report an increase of helmet usages to 60-70%. While it has been reported that helmets can reduce the severity of injury such as protection from skull lacerations and fractures, it remains debated wether the increase in trend of wearing helmets has resulted in reduced risk of injury. But this may be more related to the increased risk-taking behaviours taken by skiiers and boarders. No matter what helmet is worn, each skiier and boarder has to make choices about their safety and the risks involved because helmets can't prevent serious brain injury from occurring. In saying that, there have been countless times when I have hit my head and immediately thought 'I am so grateful for my helmet'.

What are the symptoms of concussion?

Concussion is a transient brain injury sustained from a direct or indirect force to the head. Transient means that the neurological symptoms are reversible and therefore a concussion can only be truly diagnosed apart from a traumatic brain injury, once the full normal neurological function has returned. Therefore, all suspected concussions must be treated as a serious medical condition until it is clear that these symptoms are transient and not permanent.

It often doesn't always involved loss of consciousness (LOC).
Symptoms: headache, neck pain, pressure in the head, nausea, vomiting, dizziness, blurred vision, sensitivity to light and noise, and fatigue/drowsiness.
Physical signs: unsteadiness, restricted neck movement, and loss of balance,
Impaired brain function: confusion, impaired eye opening response, unusual verbal responses, disorientation to date, time and place, difficulty with concentration, difficulty with memory, drowsiness/alertness.
Abnormal breathing, changes in personality and emotional state.

So if you are the first person to see someone fall on the slopes and hit their head, at the very least ask them questions such as "Can you tell me your name? Do you know the day of the week and date? Do you know where you are? Do you have any pain? Are you feeling dizzy, nauseated or have a headache?" These are all signs that would alert you to seeking medical assistance. If you fall yourself and hit your head and notice any difference in your vision, thinking, strength, balance, then its highly possible you've had a concussion.

What do the sporting guidelines suggest about initial concussion management?

The first response for an injured athlete is to follow our first aid principles of DR ABC (Danger, response, airways, breathing, circulation).

Any athlete with suspected concussion should be removed from play, medically assessed, monitored for deterioration, should not drive a vehicle, should not consume alcohol, should not take aspirin or anti-inflammatory medications, and only return to sport once by a medical practitioner to be symptom free. NO ATHLETE SHOULD RETURN TO PLAY ON THE SAME DAY AS THE CONCUSSION.

After initial diagnosis until symptoms at rest have resolved.
1. Rest from strenuous physical activity and cognitive activity (school, homework, reading etc).
2. Increase sleep and rest time.
Gradual and monitored physical activity is allowed once symptoms have stopped at rest, but if any symptoms reoccur with cardiovascular exercise, then the exercise should be stopped.
Once no symptoms are present at rest and with exercise, physical exertion is increased to simulate playing and training demands and return to sport is allowed after full medical clearance. (momstream.com)

Image courtesy of Ski & Snowboard Australia

How do you know when it's safe to return to sport?

Most concussions will resolve within the first 7-10 days, during which time, return to sport and in particular contact-sport should not be allowed. All athletes need to be medically cleared before return to sport occurs.

Health professionals may choose to use the Sports Concussion Assessment Tool SCAT3, which is an assessment tool for evaluating athletes for concussion. This tool has 8 sections comprising of: potential signs of concussion, the Glasgow coma scale, Maddocks score, symptom evaluation, cognitive assessment, neck examination, balance examination, coordination examination and delayed recall test. Using the SCAT3 preseason will provide a baseline score to compare to post-injury testing.

Serious injury

If the athlete presents with these symptoms after initial assessment then immediate hospitalisation is recommended (www.momstream.com)

Has a headache that gets worse and does not go away.
Is very drowsy or can't be awakened (woken up).
Can't recognize people or places.
Is vomiting repeatedly.
Behaves unusually, becomes increasingly, restless or agitated.
Experiences convulsions or seizures (arms and legs jerk uncontrollably).
Has weak or numb arms or legs.
Is unsteady on his feet.
Has slurred speech.
One pupil larger than the other.
Loses consciousness (even briefly).
Will not stop crying/cannot be consoled.

On the initial assessment or if you're the first to respond to the incident the following are signs of serious injury requiring emergency management:

Glasgow Coma score less than 15.
Deteriorating mental status - recognition of self, place, date, communication, response to questioning, response to pain.
Potential spinal injury.
Progressive, worsening symptoms or new neurologic signs - loss of strength, sensation, inability to feel or move limbs.
Persistent vomiting.
Evidence of skull fracture - always be cautious to remove the helmet in the presence of suspected neck injury or spinal fracture.
Post traumatic seizures.
Coagulopathy.
History of neurosurgery (eg Shunt).
Multiple injuries.
For further information check out (Concussion Clinical Toolkit)

What are the risks of continuing to ski or board after a concussion?

"There is strong evidence indicating that a history of concussion/mild traumatic brain injury (mTBI) is a significant risk factor for additional concussions. There is moderate evidence indicating that a recurrent concussion is more likely to occur within 10 days after a prior concussion" (American Academy of Neurology, 2013).

Concussion should be taken seriously because there is a large risk associated with repetitive head trauma resulting in permanent neurological damage, progression from mild brain injury to severe brain injury and developed of chronic traumatic encephalopathy (cumulative cognitive deterioration).

New products are being developed to improve the shock absorption and impact force, with the goal to reduce the risk and severity of impact. One product in particular is a helmet insert, Unequal, which can used used for most sports in which helmets are worn.

Unequal is a helmet insert, which comes in many shapes and cuts and is easily inserted into the helmet without modification. It is comprised of Accelleron, Kevlar, and Impacshield which act to reduce the acceleration of force through the helmet and the severity index of impact. Head injury is caused by a large force of energy being applied to the head/skull. The composition of materials "confuses that energy and absorbs, disperses and dissipates much of it away from the body".

"With over 85 patents and patents pending, our UNEQUAL® military grade composite handles blunt force trauma and impact shock better than any padding on the market of equal weight and thinness. UNEQUAL® is ultra-thin, flexible and comfortable. Athletes in any sport in which collisions or wipe-outs occur can go all out and achieve a higher level of performance with less fear of injury." (Unequal, 2015)

In my opinion Unequal is a fairly inexpensive addition to a helmet which helps to reduce the impact on collision and anecdotally, many athletes will say that having the insert meant they didn't get a concussion when they fell or got hit. So if you're in a high risk position, its definitely something to consider.

There are policies which enforce helmet use for athletes and safety standards that need to be met. For recreational use however, most helmets on the market these days are well designed, just make sure it fits well and feels comfortable.

My goal for this blog was to improve my understanding of new helmet technologies, identifying symptoms of concussion, and initial management skills. Hopefully when you next fall and hit your head, or you witness a friend taking a tumble, you may be able to ask a few questions to determine if it safe to continuing smashing the slopes, or whether its best to call it a day. Stay safe and make good choices.

Sian

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