The BRAIN CONCUSSION Issue One
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The BRAIN THE BRAIN SERIES
IS BROUGHT TO YOU
BY THE QUEENSLAND
BRAIN INSTITUTE
Issue One
CONCUSSION
A SPECIAL REPORT ON THE
LATEST SCIENCE
Does concussion lead to
brain injury?
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P H OTO G R A P H Y N I C K VA L M A S
A M E S S AG E F R O M
Professor Pankaj Sah
Q U E E N S L A N D B R A I N I N ST I T U T E
D I R EC TO R
CONCUSSION IS EMERGING AS A MAJOR HEALTH ISSUE.
M
ore and more professional sportspeople are discussion about the wide-ranging and too-often tragic
speaking out about their experiences of head consequences of head injuries?
injury, including well-known former rugby It’s not just major head trauma that we need to worry about
league players such as Mario Fenech and Peter or the short-term consequences of head impacts. Research on
FitzSimons. Furthermore, concussions have forced a growing the brains of former athletes is raising awareness of the long-
number of current athletes to take time out from or cut short term neurological damage that can be caused by repeated,
their sporting careers, including rugby league professional apparently minor knocks to the head.
James McManus, who plays with the Newcastle Knights, At the Queensland Brain Institute, we have the expertise
former Australian tennis powerhouse Casey Dellacqua, former to be able to explain some of the confusion surrounding
Australian cricketer Chris Rogers and former Brisbane Lions concussion and to explore many of the unanswered questions.
player Justin Clarke. We have produced this booklet as the first part of a major
Outside of sport, but also garnering significant attention new public awareness campaign surrounding concussion and
is the spate of ‘one-punch’ attacks that has plagued young traumatic brain injury.
Australians since the turn of the century – responsible for Our intention is to inform and support a community response
almost 100 deaths since 2000. Where does concussion fit to what is emerging as a significant and confounding health
with this appalling phenomenon that has also ignited public condition affecting the lives of a growing number of us.
The BRAIN series Q B I .U Q. E D U. AU / C O N C U S S I O N
CONTENTS
CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4
WHAT IS TRAUMATIC CONCUSSION KIDS &
CONCUSSION? BRAIN INJURY & SPORT CONCUSSION
What causes concussion, The symptoms and major The changing attitudes of There is growing awareness
how is it defined and who is causes of traumatic brain our sporting codes to the of the potential long-term
most at risk? injury (TBI). dangers of concussion is a consequences of head injury
positive. in young people.
Detecting the signs and Helmets in sport. Do they
effects of concussion and help to protect the brain? Prominent sporting figures
post-concussion syndrome. share their experiences and
How concussion has Our fragile brain comes insights into the impact that
affected Australian tennis with its own protective concussion has had on their
player Casey Dellacqua. packaging. lives.
The long-term
consequences of concussion:
Dr Bennet Omalu and
the discovery of chronic
traumatic encephalopathy
(CTE).
CONTENTS
Publisher
Professor Pankaj Sah
Editor
Karen McGhee
Online Editor
Donna Lu
Clinical Editor
Assoc Prof Terry Coyne
Writers
Donna Lu,
Alan Woodruff
Bianca Nogrady
Additional Sub-editing
CHAPTER 5 CHAPTER 6 CHAPTER 7 Kirsten MacGregor
Additional Editorial Support
DIAGNOSING LONG-TERM TESTING FOR Carolyn Barry
Designer
CONCUSSION CONSEQUENCES CONCUSSION Ivan Chow
QBI Photography
Nick Valmas
Diagnosing concussion A protein called tau, Striving for better
Medical Illustrations
through changes in brain and its association with concussion diagnosis Dr Levent Efe
function. dementia and Alzheimer’s in realtime on the Marketing and Communications
disease. sporting fields. Mikaeli Costello
Kirsten MacGregor
Andrea Markey
Publishing Consultant
Kylie Ahern
On the cover
Tatafu Polota-Nau of the Wallabies, and
Jude Bolton, ex-Sydney Swans.
Photography
Mark Nolan/Getty Images
For any queries please contact
Mikaeli Costello at
mikaeli.costello@uq.edu.au
The Queensland Brain Institute
is located at The University of Queensland,
at St Lucia, QLD, 4072
The Queensland Brain Institute would like to thank the following people for their volunteer work around this important issue. The Brain Series: Concussion
Rebecca Appleton / Beatrice Bowen / Caroline Chalmers / Richard Chalmers / Brooke Connell / David Croft / Clare Fox was produced by the Queensland Brain
Sarah Grant / Lucy Gundelach / Amanda Haack / Lyndsey Henderson / Liza Jane Loch / Hamish Maclean / Marcus Maclean Institute in partnership with the Australian
Jeff Maclean / Stephanie Maynes / Terry McCoy / Marnie McLaren / Simon O'Brien / Jonathon Stewart / Zachary Tan Athletes’ Alliance (AAA), the peak body for
Alexis Wallace / Kelly Wilkes / Sally-Ann Williams / Jeremy Willink. Australia's elite professional athletes.
Chapter 1. WHAT IS CONCUSSION?
M E D I C A L I L LU ST R AT I O N L E V E N T E F E
WHAT CAUSES CONCUSSION?
T
he brain floats inside the skull, suspended within a brain can move so that it strikes the skull or twists upon itself. Just as
protective cushion of cerebrospinal fluid. A direct for any body part that is struck, bruising and cell damage can
blow to the head, face or neck, or from an impact occur. When those cells are neurons, however, concussion is the
to somewhere else on the body, can create a force outcome. Because the brain is so central to our lives, controlling
that shakes the brain. When that force is strong mood, perception and movement, the effects of concussion can be
enough, or comes from a particular direction, the far-reaching.
C H A P T E R 1 . W H AT I S C O N C U S S I O N ?
WHO IS MOST AT RISK FROM CONCUSSION?
T
he connection between contact sport and concussion has been widely publicised. In the
general population, however, concussion is in fact extremely common. Typically caused
by a fall or car accident, it can also be sustained by a wide variety of other activities.
The outcome of a blow to the head can be either mild or severe. While anyone who has
been ‘knocked out’ has usually suffered concussion, you can be concussed without losing
consciousness. When concussion occurs in sport, players in most cases remain conscious,
and the condition often goes undiagnosed. And while protective headgear prevents skull
damage during high-impact knocks, it doesn’t prevent the brain from moving inside the skull.
People in certain sports have a higher risk of being concussed than the general
population – rugby players and boxers, for example. People in the military who
are exposed to explosions and victims of domestic abuse are also at particularly
high risk. These groups are also more likely to suffer repeated concussions.
HOW IS CONCUSSION MEDICALLY DEFINED?
CONCUSSION IS THE MILDEST FORM OF TRAUMATIC BRAIN INJURY (TBI).
THERE IS NO UNIVERSALLY ACCEPTED DEFINITION OF CONCUSSION, BUT IT RESULTS IN:
� Rapid
impairment in
brain function that is
� A variety of
symptoms, but
not necessarily loss
� Disturbance
to the brain’s
function rather
� Symptoms
that gradually
improve over time,
temporary and gets of consciousness than physical but which may be
better by itself structure, which prolonged in a small
means that standard percentage of people
neuroimaging tests
such as MRIs and CT
scans can’t detect
any changes
P H OTO G R A P H Y E U G E N E O N I S C H E N KO / S H U T T E R STO C K .C O M
C H A P T E R 1 . W H AT I S C O N C U S S I O N ?
SIGNS AND SYMPTOMS
WHAT ARE THE SIGNS OR SYMPTOMS OF POST-CONCUSSION
OF CONCUSSION? SYNDROME
Many people who sustain a concussion have no observable signs, which
can make diagnosis difficult. Recognising the condition often depends
on the affected person reporting the symptoms they are experiencing.
These can occur either immediately after the head injury or minutes to
hours later.
PROBLEMS WITH BALANCE & STABILITY
MEMORY & LEARNING PROBLEMS
DOCTORS LOOK FOR THE PEOPLE WHO HAVE SUSTAINED
FOLLOWING SIGNS IN SOMEONE A CONCUSSION MAY ALSO
SUSPECTED OF SUFFERING REPORT THE FOLLOWING
FROM CONCUSSION: SYMPTOMS:
Confusion and inability Headache or a feeling of
to speak coherently pressure in the head
DIFFICULTY SLEEPING DOUBLE OR BLURRY
Disorientation Confusion or difficulty OR STAYING ASLEEP VISION, SENSITIVITY
(e.g. unaware of time and place) concentrating TO LIGHT
Lack of co-ordination Dizziness
(e.g. stumbling, inability to walk in a
straight line) Changes in vision
(e.g. ‘seeing stars’)
Loss of memory
(e.g. about the causative event) Ringing in the ears
Nausea and vomiting FATIGUE & WEAKNESS DIFFICULTY
Slurred speech CONCENTRATING
Delayed response to questions Fatigue
Appearing dazed or with a Sensitivity to light
vacant stare
Loss of smell or taste
Inappropriate emotion
(e.g. crying for no reason)
DIZZINESS & DEPRESSION
Any temporary loss of HEADACHES
consciousness
C H A P T E R 1 . W H AT I S C O N C U S S I O N ?
“I WAS SO DESPERATE TO
JUST FEEL MYSELF AGAIN
BUT I STRUGGLED TO DO
EVEN DAILY ACTIVITIES
SUCH AS THE GROCERY
SHOPPING.”
RECOVERING FROM CONCUSSION
I
n terms of short-term recovery, the brain changes that
occur after a single concussion don’t appear to have
clear long-term cognitive effects. Return to contact
sport should be gradual: the ‘if in doubt, sit it out’ rule-
of-thumb is now adhered to by many sporting codes.
A very small percentage of people who sustain a concussion
go on to develop what is known as post-concussion syndrome.
Symptoms usually develop seven to 10 days after a concussion,
and can persist for weeks, months, and sometimes years.
Why the syndrome occurs remains unclear. This was the Left:
experience of Australian tennis player Casey Dellacqua. Concussion from
a freak accident
Dellacqua, who suffered a heavy on-court fall in October while competing in a
2015, wrote in a blog post that post-concussion syndrome doubles tournament
was “honestly some of the scariest stuff” she had experienced. in Beijing, in
October 2015,
Her symptoms included headaches, inability to sleep, memory forced Australian
problems and constant drowsiness. “I was so desperate tennis player Casey
Dellacqua out of the
to just feel myself again but I struggled to do even daily game indefinitely
activities such as the grocery shopping,” she wrote. in 2016.
P H OTO G R A P H Y M A R K N O L A N / G E T T Y I M AG E S
C H A P T E R 1 . W H AT I S C O N C U S S I O N ?
THE LONG-TERM Former
NFL player
CONSEQUENCES OF Mike Webster
(below)
CONCUSSION THE MESSAGE
W
hile the short-term symptoms of concussion WHEN SHOULD YOU SEEK
are reversible, research suggests that MEDICAL ADVICE?
even a single knock to the head can have
severe consequences later in life. For example,
figures from one study that analysed the records Because the symptoms usually
of more than 160,000 trauma patients identified resolve by themselves, a
that, in patients aged 65 and older, just one concussion is best managed
concussion was associated with a 22-26% increase with physical and cognitive
in dementia risk in the following five to seven years. rest. However, stories about the
Even clearer is research showing that neurological potentially tragic consequences
damage accumulates with multiple knocks of undetected brain injuries are
to the head, even when they are apparently difficult to ignore. Symptoms
symptomless, or ‘sub-concussive’. Repeated of severe TBI can develop
concussion has been linked to increased risk of over several hours. Therefore,
neurodegenerative conditions such as Alzheimer’s after a knock to the head, it’s
and Parkinson’s disease, as well as chronic traumatic important to be alert for the first
encephalopathy (CTE) – see page below about 24 hours. Some symptoms are
the medical identification of this condition. red flags for more severe brain
Data from studies of former American injury: if a head injury results
footballers is staggering. A survey of more than in a loss of consciousness,
2000 retired professional players found that increasing confusion, vomiting
those with a history of multiple concussions were or a worsening headache, the
three times more likely to have been diagnosed person should seek medical
with clinical depression. Another study of death advice. It’s important that a
certificates found that the death rate from doctor makes an assessment
neurodegenerative diseases was three times higher to rule out more severe TBI.
for pro-footballers than the general population.
P H OTO G R A P H Y G EO R G E G OJ KOV I C H / G E T T Y I M AG E SC H A P T E R 1 . W H AT I S C O N C U S S I O N ?
CTE was first discovered
by neuropathologist
THE NEED
Dr Bennet Omalu (left)
in the brain tissue of
FOR EARLY
former NFL player Mike DIAGNOSIS
R
Webster. Their story
has been depicted epeated head trauma
in the motion picture
Concussion. doesn’t always lead to
CTE and it is likely a
person’s genetic background
also plays a role. Currently,
the only way to diagnose CTE
is post-mortem, which means
it’s impossible to determine
how prevalent the condition
is in the general population or
catch the condition at an early
stage. The next challenge for
TBI researchers is to develop
techniques that can identify
CTE in living brains. QBI’s Dr
CHRONIC TRAUMATIC Fatima Nasrallah is using the
support of a Motor Accident
ENCEPHALOPATHY (CTE) Insurance Commission Senior
C
TE is a progressive disease with Alzheimer’s-like symptoms. It was first Research Fellowship to work
discovered by neuropathologist Dr Bennet Omalu in the early 2000s on TBI, specifically to try and
in the brain of Mike Webster, a former National Football League (NFL) develop an early diagnostic test
player. When Omalu looked at Webster’s brain tissue under the microscope he for concussion. She hopes to
observed concentrations of a material known as tau. This is one of two proteins use biomarkers and imaging
known to accumulate in the brain in Alzheimer’s disease. Since then, CTE has to develop a test that will be
been found in the brains of 76 out of 79 former NFL players who have donated able to detect even subtle
their brains to research. changes in brain function
following a head injury.
P H OTO G R A P H Y I DA M A E A ST U T E / A B C V I A G E T T Y I M AG E SChapter 2. TRAUMATIC BRAIN INJURY (TBI)
WHAT IS TRAUMATIC BRAIN INJURY? MAJOR CAUSES OF
TRAUMATIC BRAIN INJURIES*
T
raumatic brain injury (TBI) is an injury to the brain caused by an
external force. Common causes (see right) include falls, car accidents, as-
sault or being struck by objects such as might occur during sport. TBI
is classified according to its severity: mild, moderate or severe. From a medical
perspective this judgment is based on what’s known as the Glasgow Coma Scale
(GCS), which assesses motor, verbal and eye-opening responses. The scale runs
from 3 to 15, where 3 is assigned to someone who is dead or comatose and 15 is
normal. Someone with a mild TBI generally has a GCS of 13–15.
In the absence of clinical assessment, TBI is considered moderate-to-severe
if there is a loss of consciousness that is longer than 30 minutes and amnesia –
memory loss – lasts for more than 24 hours. It’s mild if those conditions are not
met. Concussion is classified as a mild TBI. *Based on
information from
the National
SYMPTOMS OF TBI Center for Injury
Prevention and
Control, CDC
MODERATE TO SEVERE TBI MILD TBI
Accounts for 10% of all cases Accounts for 90% of all cases
(based on WHO information) 1% SUICIDE
SYMPTOMS: SYMPTOMS: 11% ASSAULT
l slurred speech l headaches
19% STRUCK BY OBJECTS (INCL. SPORTS)
l profound confusion l dizziness & fatigue
l seizures l sleeping difficulties
20% MOTOR VEHICLE ACCIDENTS
l persistent headaches l memory & concentration problems 21% OTHER
l coma l blurred vision
28% FALLS
I L LU ST R AT I O N L I G H TS P R I N G / S H U T T E R STO C K .C O MC H A P T E R 2 . T R A U M AT I C B R A I N I N J U R Y ( T B I )
PROMINENT TBIs BRAIN HAEMATOMA
T
he tragic outcomes of a spate of one-punch
attacks – so-called ‘coward punches’ – in recent
years has drawn considerable attention and
resulted in harsher sentencing laws for perpetrators.
Many researchers in the TBI field argue the tough laws
are justified because even when a single punch isn’t lethal,
or doesn’t have any apparent immediate effects, the head
trauma can lead to irreversible consequences years or
decades later.
Recent highly publicised cases of severe TBI have
included Formula One driver Jules Bianchi who died as the
result of head injuries received when the car he was driving
crashed during the 2015 Japanese Grand Prix.
Retired Formula One driver Michael Schumacher
continues to receive intensive treatment for severe head
injuries that he suffered during a skiing accident in France,
in 2013. In both of these cases, a severe TBI resulted in an
immediate and prolonged loss of consciousness.
However, a loss of consciousness isn’t always necessary
for the consequences of TBI to be catastrophic. In 2009,
British actress Natasha Richardson knocked her head
while skiing. Thinking she was fine, she refused medical
care on multiple occasions before later experiencing
headaches that prompted her to go to hospital.
Richardson subsequently died due to an epidural Natasha
Richardson
haematoma, a build-up of blood between the skull and
the membrane that surrounds the brain (see illustration
right). Haematomas are considered secondary injuries, Michael
Schumacher
meaning that the damage done to the brain doesn’t
coincide directly with the blow to the head.
M E D I C A L I L LU ST R AT I O N L E V E N T E F E
P H OTO G R A P H Y K H A L E D D E S O U K I / A F P / G E T T Y I M AG E S ; P H OTO G R A P H Y E V E R E T T C O L L ECT I O N / S H U T T E R STO C K .C O MC H A P T E R 2 . T R A U M AT I C B R A I N I N J U R Y ( T B I )
C O N C U S S I O N B Y N U M B E R S (ESTIMATES ONLY)
The ratio The proportion THE MESSAGE
of men to of injuries
women that are head
who are injuries in rugby Most blows to the head are
likely to union, league
suffer and Australian minor and nothing to worry
concussion. rules football. about, producing no symptoms
other than pain and perhaps
a small tender lump. However,
Number of
concussions per the Natasha Richardson case
1000 hours of highlights the fact that even
playing rugby seemingly innocuous head
union, league or knocks can later produce
Australian rules Number of concussions per devastating effects. Warning
football. 1000 hours of playing soccer.
signs to watch for after any form
of head injury, no matter how
minor it might seem, include:
persistent headaches, balance
The number problems or cognitive changes.
of annual If a head injury results in
The percentage of traumatic brain concussions a loss of consciousness,
injuries that are concussions. worldwide. increasing confusion, vomiting
or a worsening headache, the
person should see a doctor.
The percentage
The percentage of concussions
of all sporting that may go
injuries that unassessed
concussion by medical
makes up. professionals.C H A P T E R 2 . T R A U M AT I C B R A I N I N J U R Y ( T B I )
Why is this the case? Helmets are designed mainly to dissipate
force. Most sports helmets consist of a hard outer shell and an
inner foam layer, normally of polystyrene. The hard shell spreads
or dissipates the impact force over a larger area. Meanwhile the
HELMETS: foam inner section also reduces the peak impact by extending the
WHAT ARE distance of head deceleration – meaning that it takes longer for
THEY GOOD the head to slow down, which makes the movement less abrupt.
FOR? The foam layer also crushes and deforms, which absorbs as much
of the remaining energy as possible. While these factors decrease
the level of the impact force, they do little to address rotational
forces caused by head movement and any concussion this might
cause. There is no evidence that the soft headgear players in some
B
efore describing how helmets work and what they’re Australian football codes wear protects against head injury.
capable of, it’s important to understand how injuries can Many current attempts to improve helmets still focus on
result from head impact. A blow to the head can cause the decreasing impact by using new materials, or on developing
brain to move back and forth (translational movements) or rotate different foam and shell arrangements. However, the growing
and twist on itself (rotational movements). concussion crisis has led some researchers to try to limit
In translational – back and forth – movements, the brain rotational forces as well, with helmet manufacturers now looking
crashes against the skull, potentially even rebounding in the other to incorporate elements that slide against each other upon
direction and receiving a second impact with the opposite side impact.
of the skull. The damage is done by direct impact and is much
like bruising. In rotational movements, as occurs when the head
is struck at an angle, the brain itself twists, causing damage as
neurons rub against each other in a shearing fashion. THE MESSAGE
Hard helmets protect reasonably well against translational
movements and the impact injuries they cause, significantly
reducing the risk of skull fractures and bleeding inside the Helmets, of course, are good for protecting against
skull – intracranial bleeding. They are far less effective against brain injuries. But they don’t do a good job against
rotational movements and it’s these that researchers believe are all types of head impact. Different impacts cause
responsible for most concussions. This means that a helmet may different head movements, and different head
protect the head better against severe TBI, which is caused by movements result in different injuries.
translational forces, than against concussion.
I L LU ST R AT I O N S P E N C E R S U T TO N / S H U T T E R STO C K .C O MC H A P T E R 2 . T R A U M AT I C B R A I N I N J U R Y ( T B I )
Several layers protect the fragile brain.
The meninges are membranes that lie
between the brain and the hard skull; the
dura is the toughest of these layers and
adheres to the skull, providing a sac that
limits brain movement. Cerebrospinal fluid
cushions the brain when the head moves
The FRAGILE BRAIN around, limiting contact with the skull.
I L L U S T R AT I O N B Y L E V E N T E F EC H A P T E R 2 . T R A U M AT I C B R A I N I N J U R Y ( T B I )
Despite this, Rushworth began a graded
Perspectives return to work as a journalist at the ABC
NICK RUSHWORTH in Sydney, and was back working full-time
EXECUTIVE OFFICER, six months following the accident. Initially,
BRAIN INJURY AUSTRALIA he found the noise of the busy newsroom
environment challenging, but feels
fortunate that his working life was able to
continue more or less unaffected.
N
ick Rushworth is more familiar than “I had a really easeful return to work,
most CEOs with the effects of given the severity of my injury,” he says,
traumatic brain injury (TBI). Twenty adding however that this isn’t the case
years ago, he was in a major bicycle for the vast majority of people who suffer
accident involving a head-on collision with a brain injury. “For a lot of people, the
a car. He was hit mid-leg, breaking both lack of public awareness about brain
his femur and the bicycle frame. injury means that, in a return-to-work
“I was catapulted over the bonnet context, their inability to concentrate, to
of the car and took the full force of the “THE LACK OF PUBLIC pay attention, and their fatigue — which is
impact near my right ear,” Rushworth AWARENESS ABOUT BRAIN a huge issue post–brain injury — is often
says. “I pretty much fractured my skull INJURY MEANS THAT, IN mistaken for laziness.”
right around.” A RETURN-TO-WORK Behavioural problems, Rushworth adds,
Motor vehicle accidents are the CONTEXT, THEIR INABILITY are sometimes perceived as simply being
second-most common cause of TBI in TO CONCENTRATE, TO PAY “who’ve they’ve always been as a person”,
Australia, after falls. Depending on its a misconception that he says is “re-
severity, TBI can cause a range of long-
ATTENTION, AND THEIR FATIGUE disabling” for the injured individual.
term disabilities and changes in feeling, IS OFTEN MISTAKEN FOR Rushworth is now the Executive Officer
thoughts and behaviour. LAZINESS.” of Brain Injury Australia, the peak body
Rushworth has no memory of his for more than 700,000 Australians living
accident — nor of the proceeding two cared to listen about the story of my with acquired brain injury. In this role, he
weeks he spent in hospital. “My almost- accident, and tell them repeatedly,” raises awareness about the causes, types,
continuous memory starts again when he says. and effects of brain injury, ranging from
I was discharged from hospital into A neuropsychological assessment concussion in sport to more severe brain
rehabilitation, but even then, it was very brought sombre news: it found “that injury resulting from assault or accidents.
fragmented,” he recalls now. my intellectual capacity, my ability to “The aim,” he says, “is to make
He also suffered short-term memory concentrate, to plan, to organise, was someone’s return to work or return to
impairment. “I used to tell anyone who going to be ‘radically impaired’.” community life as easeful as it was for me.”Chapter 3. CONCUSSION & SPORT
I
t’s not often a major Hollywood if a concussion diagnosis is made.
movie is devoted to a single Professor Davis says the AFL
medical condition. But in has been ahead of the game on
late 2015, the film Concussion concussion, working with concussion
was released, telling the story of experts for many years and convening
a forensic pathologist’s attempts a concussion working group in 2010,
to shine light on the American long before head knocks began
National Football League’s hidden grabbing headlines. That working
secret of chronic traumatic group has developed guidelines to
encephalopathy (CTE) – a long-term help doctors, coaches and players
complication of repeat concussions. diagnose and manage the estimated
The film’s release represented a peak 6–7 cases of concussion that occur per
in public attention on a condition team per season across all levels of
that had previously not been AFL competition. The key principles of
discussed much outside medical these guidelines are that concussion is
circles but suddenly seemed to be a complex and still poorly understood
worryingly common. The film is set in ‘IF IN DOUBT, SIT IT OUT’ condition that needs to be managed using
2009. In the years since then, attitudes Melbourne-based neurosurgeon and an individual-based approach with a
towards concussion in professional sport concussion expert Professor Gavin Davis number of steps, including:
have come a long way. Concussion is now says the general attitude to the condition l A period of rest
widely recognised as a medical issue for just 10 years ago was that players should l Monitoring for ongoing or changing signs
many sports. In many codes it’s team ‘get over it and get on with it’. Today it is no and symptoms
doctors who are being given final say longer seen as a sign of weakness to be l Neuropsychological tests to monitor
about if and when a player can return to ruled out of play because of concussion. In recovery
play after a head injury. Most importantly, the Australian Football League (AFL), there l A graduated return to activity in
they’re being given the authority to are specific rules around head knocks, conjunction with monitoring
apply medical reasoning to override the such as a mandated 20-minute period l A doctor’s OK before returning to play
wishes of coaches and even the players off the ground to complete a concussion These recommendations are now found
themselves. medical assessment, and no return-to-play in a similar form in many other sport
P H OTO G R A P H Y N E A L E C O U S L A N D / S H U T T E R STO C K .C O MCHAPTER 3. CONCUSSION & SPORT
concussion guidelines around the world.
The overarching mantra, however, is ‘if in
“Whatever sport you play
it’s a short stand career. TATAFU POLOTA-NAU
You want to make the
A
doubt, sit them out’. most of it but there’s life s a player with the NSW Waratahs and
to live afterwards,” says Australian Wallabies, Tatafu Polota-Nau
Tatafu Polota-Nau,
FROM NATIONAL LEAGUES (pictured below). has had his fair share of concussions and
TO SCHOOL COMPS knows how tough it can be to accept the doctor’s
The heightened awareness of concussion advice to take a break from play, even for a short
at the professional level has also time. “Straight away, your basic instinct as a rugby
player tells you that you need to get back on the field
filtered down to community sport, straight away,” he says. “But in hindsight, you look at
says Professor Caroline Finch, director the [television] footage and you see clearly you were
of the Australian Centre for Research in a dazed state.
into Injury in Sport and its Prevention “That tension is felt by player, coach and doctor
– a unit based at Victoria’s Federation because they’re looking after the game and the
University Australia. Unfortunately, the health of the player too. It’s a hard one to judge, and
messages about concussion are often especially in a final game – there is no bigger stage.”
mixed or misinterpreted. Some parents The changing attitudes to concussion have had a
are so concerned about the risks and big impact on players, and ultimately on the teams
and game. “It has been a big eye-opener, particularly
consequences that they keep their
for professional players because although you think
child off the sports field altogether. you’re doing the right thing by your team mates by
Others see professional players return playing on, you’re not because you’re not 100% in
to the field after a head knock during focus,” Polota-Nau says. “At the end of the day,
a game, and assume therefore that becoming more mature with it but also having a bit of
concussion isn’t that serious. Professor experience means you can definitely tell what’s better
Finch says concussion guidelines also for the team initially and also for your health as well.”
apply to community sport. But without There’s also the awareness now that repeat
the same level of medical support concussions could have longer term implications
that’s available to professionals, those for players; something that Polota-Nau says made
him more aware of proper tackle technique, so as
guidelines aren’t always implemented to reduce the chance of him suffering a concussion
with as much rigour. However, it’s an issue from, for example, a ‘flying superman’ tackle.
taken seriously by many codes, some “Whatever sport you play it’s a short stand career,”
of which issue guidelines specifically he says. “You want to make the most of it but there’s
targeted at the community level. life to live afterwards.”
P H OTO G R A P H Y M A R K N O L A N / G E T T Y I M AG E SCHAPTER 3. CONCUSSION & SPORT
Players’ Perspectives approach at the helm of the RLPA. “It’s
really our job to continue educating
IAN PRENDERGAST people about the respect they need to
CEO, RUGBY LEAGUE have for the measures that are being put
PLAYERS ASSOCIATION in place,” he says.
Another priority is limiting the number
of incidents that go unnoticed or aren’t
properly assessed. “From a health and
safety point of view, there’s a huge
F
ormer Australian Rules footballer amount of money generated from the
Ian Prendergast has seen a big performance of players, so equally
change in attitude to head injuries there needs to be a huge amount of
since he was playing professionally for investment in protecting their safety on
the Carlton Football Club in the early the field,” Prendergast says.
2000s. “Back in my day, there wasn’t as These days, players are being forced
much awareness around concussion,” he to take concussion much more seriously
says. “It was almost a badge of honour than they once did. “Now, I think there’s
for players to continue playing after a a greater acceptance of the need to
serious knock.” report any symptoms that may be
Now, educating coaches and players linked to concussion so that you can be
about concussion is an integral part properly assessed and removed from the
of his working life. After finishing his game if necessary,” Prendergast says,
career as a player, Prendergast went adding that there is more work to be
on to represent the interests of elite done. “We still need to be able to assess
footballers at state, national and in a more objective way the impact that
international levels, first as a general concussion is having, both immediately
manager for player relations at the AFL after the incident, but also with respect
Players’ Association (AFLPA) and now “BACK IN MY DAY, THERE to the recovery and treatment required
as Chief Executive Officer of the Rugby WASN’T AS MUCH AWARENESS to rehabilitate a player.”
League Players Association (RLPA). Prendergast believes that finding
AROUND CONCUSSION. IT WAS
During his time at the AFLPA, the answers to the unknowns about
association worked closely with the ALMOST A BADGE OF HONOUR concussion is crucial. “Research is key
sporting code to push for a conservative FOR PLAYERS TO CONTINUE because knowledge is power,” he says,
approach to concussion management PLAYING AFTER A SERIOUS “and the more information we discover,
and Prendergast is taking a similar KNOCK.” the better informed our approach can be.”
P H OTO G R A P H Y DY L A N R O B I N S O N / N E W S P I XCHAPTER 3. CONCUSSION & SPORT
Players’ Perspectives innocuous ones can be the worst.
“I know that having sustained
JUDE BOLTON multiple concussions puts me in a high-
RETIRED AFL PLAYER, risk category. I would hate to think
SYDNEY SWANS that the way I played may contribute
towards potentially having something
like dementia, CTE or depression later
in my life.”
D
uring more than a decade Bolton emphasises, however, that
playing first grade with the he doesn’t want the sport to change.
Sydney Swans, retired Australian “AFL is a tough and sometimes brutal
Football League (AFL) star Jude sport that I love,” he says. “I never want
Bolton experienced several major head to see the physicality taken from the
collisions. game, nor do I ever want families to not
He concedes that throughout his allow their kids to play sport. There are
career he prided himself on resilience at so many health issues that kids and
the expense of his brain and once wore adults have just through not being as
concussion as a badge of honour. “That active as they should.”
meant taking any hits and just getting Bolton says better protocols and
up and getting on with it,” Bolton increased awareness are important
recalls. “I remember my grandfather steps forward and senior players
always saying, ‘It’s better to wake up sitting out of the game for a week,
in an ambulance than to duck out of a or not returning to the game after a
contest.’” concussion, are wonderful examples for
But concern about the long-term young players to look up to.
consequences has since made him an He believes science is the key to
advocate for player welfare. “It was improving player safety: “I would love
actually my same grandfather who to see the research be to a point where
then said to me after I sustained two “A BRAIN INJURY IS NOT LIKE we have absolute certainty on the
concussions in one game – and played protocols and that kids, families and
ANY OTHER INJURY. EACH
the following week – ‘You don’t want to all sporting clubs know what to do if a
be a dribbling mess when you’re an old HEAD KNOCK IS DIFFERENT concussion is sustained, and have an
man’,” Bolton explains. “A brain injury AND SOMETIMES THE ability to limit any long-term effects.
is not like any other injury. Each head INNOCUOUS ONES CAN BE “In the end it is just a game. You only
knock is different and sometimes the THE WORST.” get one brain.”CHAPTER 3. CONCUSSION & SPORT
Players’ Perspectives that advice,” Clarke says.
But calmly taking medical advice can be
JUSTIN CLARKE a different story when a player sustains a
RETIRED AFL PLAYER, head knock during a game. Clarke agrees
BRISBANE LIONS that concussions are common in sport,
particularly football, and believes that
managing how they are diagnosed and
J
ustin Clarke has no memory of treated is crucial. An objective field-side
the head knock that ended his test would be ideal, he says, as it would
promising Australian Football override a player’s often-skewed self-
League (AFL) career at the age of just assessment. “A player in that moment—
22. Nor can the former Brisbane Lions whether it’s for the best or not—they’ll
defender recall the three weeks following want to be back out there. I wanted to
that concussion. be back out there,” Clarke explains. “It’s
“That period was a tough time because about being able to control how much
I wasn’t able to do much,” Clarke says, say that player has in that moment, and
explaining that he had a severe headache, being able to ensure their safety first and
and spent most of that time in the dark, foremost.”
because his symptoms became worse in Clarke says increased awareness of the
light. “Every little thing sort of set me off, symptoms of concussion is also important.
and I struggled to get outside much.” “Amateurs experience concussions just
Clarke sustained the concussion during as much as professionals do,” he says,
a routine training session, and footage adding that his message to young players
of the collision appears innocuous. “I is, “there’s no need to be a hero and go
just got a little shove in the back and He was assessed separately by back out into the field if they’ve been
that propelled me into a bloke who was three doctors and each urged that he concussed or have concussion symptoms.”
running in the opposite direction, into avoid future contact sport – a heavy But Clarke doesn’t hesitate in his praise
his knee,” he says. The impact knocked recommendation for a young athlete with of AFL. “I would be really encouraging of
Clarke unconscious. He had sustained his entire football career ahead. Although my kids to play contact sports because
head knocks in the past, but soon realised his decision to retire, in March 2016 after it’s such a wonderful environment to
this concussion was different. One month four years playing with the Lions, has been grow up around,” he says. “It’s such an
later, his symptoms still hadn’t improved. heartbreaking, it wasn’t difficult. “When important thing that we can increase
His brother had gone through a similar you have three specialists all tell you that concussion awareness, and increase
experience and Clarke “had an inkling that you’d be pretty silly to play footy again, research into it, so that people can keep
things might not turn out for the best.” then you’d be a stupid man to go against on playing the sports that they love.”
P H OTO G R A P H Y TA R A C R O S E R / N E W S P I XCHAPTER 3. CONCUSSION & SPORT
“My first experiences with concussion prevalent,” she says. “I would love the
Players’ Perspectives and hockey came at an U21 Nationals opportunity to educate a wider audience
JOCELYN BARTRAM when a teammate missed six consecutive about the importance of looking after your
HOCKEY PLAYER, games due to a concussion and at an brain whilst playing contact and non-
international level when I witnessed a contact sport at all levels.”
HOCKEYROOS Great Britain team member escorted In hockey, players are at risk of colliding
away in an ambulance after she fell and during play when they go in to contest the
her head collided with an ball, during a low defensive
J
ocelyn Bartram was destined for a opponent’s knee resulting tackling situation.
career in sport. She was an active, in a major concussion,” Goalkeepers are at even
outgoing child who always wanted Bartram says. “Personally, higher risk due to the
to be involved in any sporting activity just a few months ago I nature of the position.
that was going and eventually followed missed a training session “Although, I feel I have
in the footsteps of her mum and brother after I collided with a team a good understanding of
who played hockey. mate in a contest for the the range of effects that
“Despite playing soccer, water polo, ball, where my helmet was concussion can result in,
basketball and tennis during my childhood knocked off, and I suffered I think some sportspeople
and adolescence,” Bartram recalls, a reasonable headache. are not aware but also
“hockey has always been my most loved I was monitored for the feel ‘that it won’t happen
sport and passion.” remainder of the day and to me’, especially in non-
Through years of perseverance and concussion-tested to contact sports, where
hard work, she finally caught the attention make sure I hadn’t suffered concussions aren’t as
of national selectors and has been part of any further damage.” regular as other more
the development squad for the Australia Bartram was attracted visible injuries,” Bartram
women’s national field hockey team – the to QBI’s concussion says. She believes that
Hockeyroos – for the past 18 months. Now campaign because growing just because concussion
she’s set her sights up as a hockey goalkeeper, isn’t a visible injury, it
firmly on this year’s Olympics in Rio. with a parent in the shouldn’t be taken lightly.
Despite its sticks, hard balls and the medical profession, she was always very “It’s important to have a strict concussion
furious pace at which it’s played, hockey aware of both the short- and long-term protocol in place and, although it may
is not a contact sport and so it’s not potential effects of concussion. feel like a bit of overkill at the time of your
normally an activity that springs to mind “As I’ve grown older and started concussion, it will make all the difference in
when concussion is mentioned. And yet studying exercise and sport science, the the future when you have moved on from
Bartram has experienced concussion importance of concussion awareness elite sport and are living the next chapter
regularly on the hockey field. and treatment has only become more of your life.”CHAPTER 3. CONCUSSION & SPORT
F
or netballer Gabi Simpson, at all. It probably took a week-and-a-
Players’ Perspectives who plays mid-court with the half for me to be fully symptom free.”
GABI SIMPSON Queensland Firebirds, the most Since the incident, Simpson has gained
a greater awareness about head injury
NETBALLER, eye-opening aspect of sustaining a
concussion was that it initially went and its lasting impacts. “The thing that
QUEENSLAND FIREBIRDS scares me the most is that we didn’t
unrecognised. Netball at the elite level is
intensely physical but is not classified as know I had concussion,” she says.
a contact sport. Although concussions Simpson agrees that loyalty to a
do occur, they are rare. team often factors into a sportsperson’s
During a game, decision to play on after
23-year-old Simpson “I ENDED UP sustaining an injury. “As
was accidentally hit by an athlete, you’re there
HAVING TO BE IN A
a teammate. “She was for your team. Your culture
running backwards and I DARK ROOM FOR is that you’d do anything
got an elbow to the jaw,” THREE DAYS — for the team, anything for
Simpson recalls, explaining NO SCREENS, NO the win,” she says. “So if
that the impact threw her LIGHT AT ALL. you do get a knock, you
head backwards, resulting IT PROBABLY TOOK think, no, I’m going to
in whiplash. “I felt my eyes A WEEK-AND-A- stay on for my team.”
go a bit blurry, but I didn’t HALF FOR ME TO Now her own concussion
think anything of it. I did get experience has shown
some migraine symptoms
BE FULLY SYMPTOM Simpson the importance
pretty soon after, but we FREE.” of recognising, and not
thought that was because ignoring, the symptoms.
of the whiplash effect on my neck.” Athletes put their minds and bodies
Unaware that she had just sustained on the line, but it’s about “knowing
a concussion, Simpson continued to when it’s time to stop,” she says.
play. It wasn’t until three days later, on Simpson believes that research is
her way to a university class, that her the key to more accurate concussion
symptoms worsened and she sought diagnosis. “The more information we
medical attention. Simpson experienced know, the stricter we can be on our
a severe headache, sensitivity to light, reaction to concussion,” she says. “I
and vomiting. “It was pretty horrific,” she think that’s extremely important.
says. “I ended up having to be in a dark “I value my brain, and I study, and I
room for three days — no screens, no light need to think about the long term.”Chapter 4. KIDS & CONCUSSION
M
ost parents would lobes of the brain – regions
say childhood is a responsible for executive
concussion waiting functions and processing
to happen. Whether it’s sensory input – continue
toddlers with a fascination for maturing into the early 20s.
staircases, children who love Damage to still-developing
riding bikes, or adolescents areas has the potential to result
playing sports with reckless in detrimental long-term effects.
enthusiasm, at some point However, most children
many young people will thump recover fully from concussion.
their head hard enough to For children who have
make a parent’s heart stop. suffered a concussion – or
Just as with concussion other mild traumatic brain
in adults, there is growing injury – studies have found
awareness of the potential no significant differences
long-term consequences of the THE DEVELOPING BRAIN There is still only a limited in learning performance in
injury in young people. Where Because children have weaker understanding of the effects of school-aged students compared
once a child or adolescent necks and torsos than adults, concussion on the developing to their peers. However, in
might have been sent back less force is needed to cause a brain, partly because studying another study of students
to the playground or back to brain injury. Most concussion these is difficult. The developing aged five to 18, the presence of
school after a head impact, cases occur in young people brain responds to trauma more severe post-concussion
now parents, teachers and aged 5 to 14. In children and differently to the adult brain, syndrome symptoms was
doctors are taking a much adolescents, the two most and is in some respects more associated with more school-
more conservative approach to common causes are sporting vulnerable to damage. related problems and poorer
managing concussion. and cycling accidents. The frontal and temporal academic performance.
In 2016, the Australian Medical Association (AMA) and Australian Institute of Sport (AIS) released a joint position statement on concussion.
They recommended that parents, coaches and sports administrators should “err on the side of caution” and not allow any child or teenager
with a potential concussion to return to the sporting field until at least two weeks after being cleared of symptoms.
See ama.com.au/position-statement/concussion-sport-2016
P H OTO G R A P H Y S E R G E Y N OV I KOV / S H U T T E R STO C K .C O MCHAPTER 4. KIDS & CONCUSSION
CLEAR COMMUNICATION or whether they are having GRADUAL RECOVERY plan tailored to their recovery.
IS KEY trouble concentrating. Another recommendation This recovery can take a
Children often play sport in One challenge with made by the guidelines was long time. A recent US study
an informal setting with little diagnosis, particularly in a gradual return to activity, found that while the more
supervision. As a result, many adolescents, is that many with both physical and well-known and immediate
concussions in children and of the typical symptoms cognitive rest. For example, symptoms of concussion, such
adolescents go undiagnosed of concussion are also the an adolescent who has as headache and dizziness, can
and unmanaged, which can typical ‘symptoms’ of being a experienced a concussion ease, emotional disturbances
lead to repeat concussion normal teenager. One US study might be prescribed a period of can linger. The study of
and is best avoided. No child found a remarkably high more than 200 young
with a suspected concussion prevalence of concussion- people presenting with
should be allowed to return to like symptoms, such concussion showed that
play until medically cleared, as fatigue, headaches, irritability and sleep
as the risk for subsequent sadness, difficulty disturbances lasted 16
concussion is increased. concentrating and trouble days on average, while
Diagnosis in children is also sleeping, in a group of frustration and poor
complicated by difficulties high-school athletes concentration lasted an
with communication. who had not actually average of 14 days. Young
While adults may be able experienced a concussion. people who have sustained
to recognise and articulate The authors of multiple concussions
their symptoms, younger Canadian guidelines on are more likely to
children can struggle, which concussion in children experience prolonged
means parents and doctors and adolescents, released symptoms.
have to be a little more in 2014, recommended that 24 to 48 hours of complete rest, Professor Kaye stresses that
direct in their questioning. one way to address this followed by a guided return while it’s important to be aware
Professor Andrew Kaye, a could be to conduct baseline to school but not physical of the risk of concussion, and to
neurosurgeon at the Royal neurocognitive testing in activity, and finally, when the manage it appropriately when
Melbourne Hospital, says the children and adolescents concussion is judged by a it does happen, the low risk
best approach is to ask simple who play sports with a doctor to have resolved, a full of a concussion in children’s
questions, like asking the child significant risk of concussion, return to activity. Throughout sport is far outweighed by the
if they have a headache, feel such as football, soccer, this process, their symptoms benefits of physical activity
dizzy, nauseated or unwell, basketball and hockey. should be monitored, and their that come with playing sport.
P H OTO G R A P H Y PAO LO B O N A / S H U T T E R STO C K .C O MChapter 5. DIAGNOSING CONCUSSION
V
isualising concussion- the white matter. White
related changes in the matter is like the ‘skeleton’
brain is particularly of the brain; it’s a framework
challenging. Unlike the made up of the main parts
bleeding inside the brain that of nerve cells – the long
might occur with a severe sections known as axons –
head impact, no obvious and glial cells, which are
structural changes accompany the most common type
concussion. This lack of of cells throughout the
obvious damage means that central nervous system.
much of the imaging research These disruptions to the
in concussion focuses on white matter are microscopic
changes in brain function breaks that, Professor
rather than brain structure. Reutens explains, may affect
connectivity and impair brain
LOOKING FOR PATTERNS function. Instead of neurons
IN THE BRAIN firing together in coordinated
networks, they are out of
MRI sync. It’s like, he says, a bunch
Although techniques such as of loudspeakers playing the
magnetic resonance imaging same thing but slightly out of
(MRI) are usually unable to brain. One imaging technique Director of the Centre for time with each other, giving
detect structural changes that can currently detect Advanced Imaging at The the sound a fuzzy quality.
in the brain following structural changes in the University of Queensland,
a concussion, specific concussed brain is diffusion says that diffusion imaging MR SPECTROSCOPY
specialised MRI scans can. imaging, which looks at is revealing some of the A second approach to
MRI uses a strong magnetic patterns of water movement subtle damage of concussion. studying concussion using
field and radio waves to through brain tissues. This includes, for example, imaging technology involves
build up a picture of the Professor David Reutens, evidence of disruptions in a technique called magnetic
P H OTO G R A P H Y FOTO I N FOT / S H U T T E R STO C K .C O MCHAPTER 5. DIAGNOSING CONCUSSION
A 3D diffusion
spectral imaging
In Profile
scan shows white
matter nerve tracts
in the brain.
DR FATIMA
NASRALLAH
D
r Fatima Nasrallah has a very personal reason
for dedicating her professional life to the study of
brain trauma. Her grandmother had dementia and
Parkinson’s disease, which worsened dramatically after a
fall. Since then, Dr Nasrallah has applied the full spectrum of
resonance (MR) spectroscopy, fMRI imaging technologies to advance our understanding of what
which looks at changes Researchers can look at is going on inside the brain during and after a traumatic brain
in brain chemistry. MR changes in brain function injury. She began her research career studying biochemical
spectroscopy is revealing that by using another type of brain changes using imaging, then shifted her focus to use
certain substances produced MRI known as a functional MRI to study physical brain changes in animals.
A move to a clinical research facility in Singapore
by brain cells as part of their MRI (fMRI). This imaging P H OTO G R A P H Y N I C K VA L M A S
brought Dr Nasrallah into contact with military personnel
usual activity are altered by allows us to see regions in who had been exposed to blast injuries. It allowed her to
concussion. This is the case the brain that are active. Dr begin exploring how these injuries could be visualised using
even in people who don’t show Fatima Nasrallah from the imaging technologies. Dr Nasrallah is now leading a large
outward signs of concussion. Queensland Brain Institute QBI study that will follow people with concussion over a long
This suggests that in even the has been using fMRI and other period of time. She’s using imaging technologies to study
mildest concussion, the energy imaging techniques to study brain changes and the effects of different treatments and
processes going on in brain what happens to the brain in interventions to reduce long-term damage from concussion.
cells are altered by the impact. the immediate aftermath of a
I M AG E A L F R E D PA S I E K A / S C I E N C E P H OTO L I B R A RYCHAPTER 5. DIAGNOSING CONCUSSION concussion, as well as in the For her work on brain A US study of former NFL first in the midbrain region, following weeks and months. networks she’s been using players suspected of having then moved to subcortical Specifically, she has been laboratory mice, which CTE used PET to generate areas and the part of the examining brain networks, provide good clues to what’s maps of how tau tangles brain that controls anxiety which are the different going on in our brains because were distributed through the and stress, and finally showed patterns of activity associated like us they’re mammals. brain. Firstly, these tangles up in the cortex. This was in with different brain functions. Dr Nasrallah has also been were confirmed to be absent contrast to what is seen in There are networks in the gathering information about from the brains of people Alzheimer’s patients, where brain that are engaged what happens inside the who hadn’t played football. In tau tangles appear first in during different activities, for heads of military personnel the ex-footballers the tangles two areas: the hippocampus example, during movement exposed to blast injuries, when were present and appeared and the entorhinal cortex, or emotional responses. they’re not close enough to to follow a particular pattern which are both important in The symptoms in diseases be knocked over but close of formation. They appeared memory and navigation. such as Alzheimer’s and enough to feel shock waves, schizophrenia result from which may shake the brain disruption to these networks. about inside the skull. For concussion, research is showing a similar brain PET THE MESSAGE network disruption, but Positron emission tomography one network in particular is (PET) is a form of imaging Brain imaging studies are helping us understand what affected. It’s known as the that uses a radioactive is going on in the brain during concussion. It’s also ‘default mode’ network and tracer to highlight certain hoped they might show characteristic changes with it’s the one that’s most active types of material in the concussion or CTE that can be used to diagnose these when our brain is in what brain. For concussion, it’s conditions and monitor recovery. The reality is that what could be called ‘idling mode’. being used to study the researchers are likely to find are a series of indicators We don’t yet understand why development of abnormal that can be used by doctors in combination with clinical this network is so important, tau tangles. These are known assessments to make a diagnosis of concussion and or why it is particularly badly to be a feature of chronic assess the recovery time required. That will enable affected by concussion. But, traumatic encephalopathy doctors to predict who is more likely to suffer long- says Dr Nasrallah, changes (CTE), which is a form of term consequences from concussion and allow them to to this network are apparent dementia associated with intervene early to prevent or limit the damage. soon after concussion. repeated concussions.
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