Concussions have been a hot topic in the hockey community for the better part of 20+ years, never mind an active talking point for sports in general. While predominantly addressed through a medical lens, the field of psychology has played a significant role in researching and advocating for prevention and treatment in this domain for some time. While neuropsychology, the arm of my profession that has taken the lead in these efforts, is not my area of expertise, it has been an area that has held a great deal of intrigue for me throughout my education and career given its leanings to more concrete, measurable aspects of the human experience than my “soft science” clinical roots have held. As such, I've always tried to maintain a close link to the neurology side of psychology out of curiosity's sake, and have benefited over the years from exposure to topics that cross into my love of sports; hockey in particular. The hot button topic of concussions is one of the lightning rod topics in this respect. It has certainly seen an uptick in discussion given the events of Monday night which saw Sidney Crosby getting felled with yet another head shot that could see him out for the remainder of this series, never mind the playoffs, given his past concussion history.
Inspiration truly comes in strange forms at times. The unfortunate events of the other night got me to thinking about some of the more nuanced and interesting pieces of information I have learned on the topic, and I felt there was no time like the topically relevant now than to share a few of these. In the name of interest and learning, I've tried to stay away from more of the common knowledge aspects of concussions that people may be quite informed about, and attend to some of the more subtle, or less discussed, aspects. Some points are put forward in the name of clarity, others about dispelling myths. Even if you know some of this already, I hope something new and notable may jump out for you to make the read worthwhile.
Please note that I am coming to this discussion in my role as a writer with an interest in the topic, not as someone wearing their professional credentials. I am not a credentialed neuropsychologist or medical doctor, and present the information in the name of informing, not in the context of providing assessment or treatment advice. Any concerns for yourself or others with respect to potential concussion or other head injuries should be addressed by an appropriate medical personnel as quickly as possible. In the name of brevity, the information is presented in a condensed form, and as such will not tell the complete picture on the topic or the debates being held with respect to presentation or contributing factors. If you are interested in becoming more informed on these matters, I would encourage you to do some research as the topic is quite interesting and there are many sources available that discuss the topic in a very accessible manner!
1.The medical terminology for a concussion is a mild Traumatic Brain Injury (mTBI)
This is the biggest fact surrounding concussions that I wish people were hip to. Yes, knowledge has grown significantly in this arena over the past 25 years, and people do take concussions much more seriously than at any point in our lifetimes. At the same time, we are still not as far along as we should be given the breadth of research available, and perhaps increased use of the technical terminology would help to underscore the severity of what we’re dealing with: a form of brain injury. Ask yourself: Will people rally around preventing brain injuries more than concussions, or vice versa? Yes, it's a matter of linguistics, and yet it's one that could improve the quality and impact of discussion on the topic and the quality of life for many, so perhaps a simple transparency in terminology would be beneficial?
2. A direct head impact is not required for a concussion
While it is most certainly the case that prevention of blows to the head will go a long way toward reducing the incidence of concussions, it will not prevent them all. Concussions, in a very simplistic manner, occur as the result of the brain impacting the skull. While direct head trauma can most certainly cause this to occur, so can other types of impact to the body (i.e., body check or, in the case of football, a tackle) which suddenly stops the body from traveling in the direction it was going, resulting in an indirect acceleration/deceleration of the head. This is an oft overlooked causal factor which also may lead to brain trauma via brain to skull impact.
3. Force is not the only factor
We have become accustomed to equating the “big hit” with the more serious concussion, and while there is some logic to this, it is far from a perfect correlation. In many cases, rather than the force of the impact, studies have suggested that it is a complex combination of force, location of impact (i.e., sides, front, back or top of the head) and/or direction of force (i.e., linear [straight forward/backward or up/down] versus rotational). While there is a literature available that suggests particular scenarios are potentially more harmful than others (i.e., high impact, rotational force, top of head impact), there are also those suggesting that the picture is far from definitive given many observed exceptions to these benchmarks (i.e., repeated high impact events without concussion, while incidents of positive diagnosis are made resulting from far lower levels of impact force). In sum: while it seems a reasonable inference that force of impact is a part of the concussion scenery, it does not adequately represent the sum of the landscape when it comes to causal factors, in and of itself.
4. Concussions do not always involve a loss of consciousness
While stereotypic portrayals and/or descriptions of a concussed individual will often will often incorporate loss of consciousness (LOC) as a symptom, this does not represent the majority of cases one will see. Various statistics indicate that approximately 80% to 90% of concussions occur with no LOC. Furthermore, concussion grading scales utilized by medical professionals, such as the three grade scales developed by the Colorado Medical Society and American Academy of Neurology, indicate no LOC for either a grade I or II concussion, albeit observing such symptomology at the most severe grade III level. Further differentiation with respect to the significance of observed LOC is necessitated in light of emerging findings that LOC of a minute or under is not necessarily as strong a predictor as once thought (Concussion Guidelines for Physicians, Parachute Canada, 2017). This is not meant to diminish concerns surrounding LOC in the context of a head injury by any means, as it is certainly an event that signals a greater urgency for one's well-being than in its absence. At the same time, it is also fair to say that the presence of a LOC as a necessity for diagnosis of a concussion has been overstated, while also allowing for the fact that differences in the clinical significance of LOC may be present in relation to the length of the occurrence.
5. Concussions cannot be diagnosed via brain imaging techniques (i.e., CT scan; MRI)
This one requires some nuanced explanation. At its core, a concussion is an injury that impacts brain function, not structure, per se. If we want to get very technical, then yes, structural damage is likely present in the form of shearing of the neurons (the individual structures that form our brains communication system), but this is not the type of damage that would be captured in a scan such as an MRI or CT scan, as it occurs on a microscopic level. As such, if the individual is believed to have a concussion, these scans will, barring extenuating circumstances, probably not be ordered as they will likely indicate nothing amiss. But what of these “extenuating circumstances” you might ask? Well, there are times where concussion may be suspected, but the presence of other symptoms (e.g., severe headache, eye pressure, LOC over a minute, speech/language/motor impairment, lack of orientation to person, place or time) or pre-existing conditions (e.g., seizure history, various veinous malformations) warrants further investigation to rule out potential bleeding of the brain, structural brain damage or skull fractures. In the event any of these are present, a concussion profile is, in the vast majority of cases, extremely likely to be negated in favour of a diagnosis more indicative of another form of injury, including a moderate to severe TBI. So simplistically and generalized: if a CT or MRI can pick it up, the injury is likely beyond a concussion.
Hopefully there was something among this information that added to what you already knew about concussions, and it broadened some knowledge on the topic! If there are any other topics around psychology that people might be interested in hearing more about with respect to hockey, or sports in general, by all means let me know!
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