BE rider information: Concussion explained
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BE 2011 strapline logo 26 Sep 14

BE rider information: Concussion explained

Dr Judith Johnson, BE chief medical officer explains the effects of Concussion on the brain and performance.

Concussion is a term used to describe the effects of a biomechanical insult to the brain. It is the manifestation of complex molecular processes resulting from physical trauma. This can be as a result of a direct blow to the head or as a result of a deceleration injury affecting the whole body where the jelly-like brain moves inside the rigid skull.

Sometimes the effects can be seen immediately with loss of consciousness, confusion, disorientation, balance and speech problems; sometimes the effects can be delayed.

Neither is a guide to the severity of the concussive episode and all symptoms suggesting impairment of brain function must be taken seriously.

So what sort of symptoms should alert us to the possibility of a person being concussed? Most of us would think of being orientated in time, person and place and this is a valuable initial assessment. More subtle details such as knowing the fence they fell at, name of horse and other details may be helpful too. People with concussion may display problems with balance, walking and coordination. Or simply appear a little out of sorts – more emotionally labile or irritable.

Physical symptoms of headache, drowsiness, nausea and vomiting may also be manifestations of brain injury. There are many people who behave a little irrationally from time to time but such behaviour taken in the context of any fall, has to be considered evidence of concussion until medical advice has been sought and the rider evaluated. Concussion is an ill-defined collection of symptoms which can often be subtle but should not be ignored.

Various tools have been developed in sports medicine for the assessment of concussion. Whilst these are an invaluable framework of objective tests, input from people who know the rider is invaluable. 

Rehabilitation from a concussive episode is vital to ensure optimum recovery. We are all familiar in the care of physical injuries – of our horses if not ourselves! And the adage of POLICE (Protect, offload, ice, compress, elevate) are familiar guidelines to injury rehabilitation. We are less good at resting or offloading our brains, so what constitutes brain rest?

The old advice of ‘lying in a darkened room’ is, in fact good advice for initial brain recovery. Most of our idea of ‘rest’ is sitting in front of a TV/video game or computer and not exerting ourselves. Unfortunately whilst this is body and limb rest, it certainly isn’t brain rest! So rest is important and ‘screen time’ should be limited to < 2 hours a day. Boring maybe, but important. Rehabilitation time and speed varies enormously from individual to individual and bears little correlation to the perceived severity of initial symptoms. Whilst we may feel intuitively that a period of unconsciousness is likely to represent severe concussion and a bit of confusion and balance problems a minor form, this is not necessarily true.

Gradual Return to Play (GRTP) is part of an athlete’s rehabilitation from injury and represents a supervised increase in physical and mental activity in a progressive way WITHOUT the return of symptoms to ensure the safe resumption of competition. Slowly increasing activity to light day to day activities and some gentle changes in posture, avoiding anything sudden or at extremes of movement would be a sensible start. Gradually increasing levels of activity are allowed as long as symptoms (fatigue, nausea, dizziness, headache etc) do not return.  If symptoms do return, revert to prior levels of activity. Most people will make a good recovery in 7-10 days but younger riders and people with successive injuries may take longer. Concussion is, by definition a reversible condition but there is emerging evidence that failure to allow full recovery and successive brain insults can lead to more sustained dysfunction.

The vast majority of individuals recover from a concussive episode without any persisting symptoms. Some people suffer from post-concussion symptoms and may benefit from the input of specialist physiotherapists who will help with exercises to re-educate the balance mechanisms and proprioception.

Concussion is a common sequelae of eventing-related injuries. Many falls are high velocity and all involve falling from a height; the forces involved can be huge. It is very easy to think that because we are overtly uninjured, then we are undamaged in any way. Our evolving understanding of the biomechanics involved in brain injury and subsequent molecular changes leading to symptoms of concussion suggest that we should consider brain damage – even in a minor form - to be more common than is formally diagnosed. Raising awareness of this common but complex condition will hopefully lead to better understanding of the spectrum of symptoms, encouraging riders and their support team to seek help when they have concerns.