Concussion is an injury of force – to the head or body. It is an injury of signalling in the brain at a cellular level and is thought to be of greater significance in teenagers, as the teenage brain undergoes a growth spurt during adolescence (Baillargeon, Lassonde, Leclerc & Ellemberg, 2012).
The frontal lobe, paramount for working memory, is more fragile and susceptible to the effects of concussion in the teenage years. Multiple studies, including Baillargeon et al (2012), have identified that teens with a concussion have a worse working memory than children or adults.
Concussion is not always obvious, and symptoms may take up to 72hrs to manifest. Like all brain injuries, every concussion is different. However, they all do need to be identified and managed appropriately. Assessing brain function is subjective with current tools and assessing concussion requires evaluation and testing by qualified members of a multi-disciplinary team (MDT).
Once a person has had a concussion, it can easily occur again, and will take less of a blow to cause injury and longer time to recover (Gornall, Takagi, Morawakage, Liu & Anderson, 2021). If not managed well, morbidities result, which in turn increases the burden of health costs.
For several years, there has been collaboration with a large private boy’s school within the Northern Sydney Local Health District (NSLHD), regarding head injury assessment, treatment, prevention and school guideline development. It became apparent that there were many boys sustaining concussive head injuries at school, particularly in winter season sport, requiring monitoring in sick bay and several serious enough to be referred to hospital. It was decided that a collaborative approach to find out more about the boys’ concussions was needed, to see in what numbers concussion was affecting this population and then, what could be done to lessen the numbers affected.
A questionnaire (Table 1) was collaboratively developed with school approval and distributed in class to 727 boys in Years 7-12 (excluding Year 11 as they had exams at the time). From that survey, 217 boys identified as having had a concussive head injury. Those 217 boys were given a further survey asking more in-depth questions about their concussion experience.
Not surprisingly, most injuries occurred during the winter sport season – rugby union and soccer, but also from school playground injuries and summer sports. Pleasingly, most identified that they were wearing mouthguards for contact sports. The symptoms most complained about included headache, visual disturbances, neck pain, and fuzziness/forgetfulness. Other symptoms identified were hearing issues, nausea, one who had a seizure and another, a bleeding nose.
58% came off the field but 25% stayed on playing. 76% reported the injury (school, family), but 24% did not report it. It is these two points – ¼ stayed on playing and ¼ did not report the injury, that is concerning. Two days after the injury, almost half still had headache (46%) and complained of fuzziness (23%), neck pain, visual and hearing issues.
35% reported this being their first concussion and pleasingly, 86% reported the incident to their teachers. Most returned to school the next day or day after. However, 10% returned to sport the same day, which was alarming. It is mandatory at this school to follow FIFA’s guidelines (international governing body of football) of 19 days until returning to sport, and the majority were found to have complied. Unfortunately, there was a small number who were out for the season and one out for the rest of the year due to ongoing concussive symptoms.
It was found that under-reporting is a major concern. The students did not want to miss out on sport or let their team down. In larger studies, and not surprisingly in our smaller study, athletes often hide symptoms as the desire to play in the moment outweighs caution (Pengilly, 2021). Upon reflection, it was suggested that a survey at the end of the season possibly would capture more honest answers.
Although classed as a mild traumatic brain injury, concussion, unlike a fractured skull or extradural haemorrhage, cannot be identified on Xray, CT or MRI. This creates public confusion as a concussion is an invisible injury. It is through a detailed neurological assessment, noting the mechanism of injury that allows a proper diagnosis of concussion to be made. The issue to scan or not to scan, particularly in children, is a medical decision weighing up age, mechanism of injury, neurological assessment, and expertise. A detailed discussion with explanation to parents is required.
The questionnaire identified that there was an important need for further concussion education of the teachers, students, coaches, and parents. Education outlining what a concussion was, how to identify it had occurred, how to manage symptoms and importantly, the trajectory of returning to school and sport.
Whilst the Clinical Nurse Consultant undertook visits to many local schools, it was time consuming and not able to fulfil the need with so many requests. Therefore, it was decided that a video would reach more people and be more readily available.
This questionnaire is designed to obtain information on the effectiveness of concussion guidelines in the community and to obtain information on children who have had a concussion within the Local Health District, the actions taken to assist in their recovery and mechanisms in place to minimise any potential complications.
Age: ________________
What sport were you playing at the time of injury? _________________________________________
Were you wearing a mouthguard / helmet at the time of injury? (Circle)
Yes – mouthguard
Yes – helmet
Yes both
No
What symptoms were you experiencing? (Circle all that apply)
Headache
Visual problems –double vision, sore eyes, blurry vision
Hearing problems
Neck pain
Feeling sick / nausea
Vomiting
Forgetful
Fuzziness
Confusion
Other_______________________________________________________________________
Did you come off the field / court following your injury? (Circle)
Yes
No
Did you go back onto play the rest of the game? (Circle)
Yes
No
What treatment were you given on the sidelines: (Circle all that apply)
Told to sit down
Asked questions about your memory, pain, how it happened
Ice
Analgesics (name of the medication) ______________________________________________
Given head injury advice information – verbally
Given head injury advice information – written
Parents / caregiver spoken to on sidelines or shortly thereafter
No treatment given
At home after the game, did you experience any of the following: (Circle all that apply)
Headache
Visual problems –double vision, sore eyes, blurry vision
Hearing problems
Neck pain
Feeling sick / nausea
Vomiting
Forgetful / Fuzziness
Confusion
Other ______________________________________________________________________
At home after the game, did you take any medications? (Circle)
Yes (which medications?) ____________________________
No
Did you go to the: (Circle)
Hospital
General Practitioner / Medical Centre
Didn’t go to either (go to question 13)
IF you went to the hospital or GP, did you have a: (Circle)
CT scan
Xray
No scanning
IF you went to the hospital or GP, were you prescribed any medications?
Yes (they were) __________________________
No
IF you went to the hospital or GP, were you given any further information on concussion? (Circle)
Verbal
Written
Both verbal and written
The following day, did you experience any of the following: (Circle all that apply)
Headache
visual problems
hearing problems
neck pain
fuzziness
confusion
other ______________________________________________________________________
When did you go back to
The next day
2 days later
A week later
Other_______________________________________________________________________
Did you go back to school for: (Circle)
The whole day
Half day
Few hours
Did your school teachers know that you had a concussion?
Yes – who told them?________________________
No
When you came home from school did any of those symptoms come back?
Yes – which ones?: __________________________________________________________
No
When did you go back to playing
The same day
The next day
2 days later
A week later
Other_______________________________________________________________________
When you went back to playing sport, did you have any of the symptoms come back?
Yes – Describe them:___________________________________________________________
No
Did you report your injury to the: (Circle all that apply)
School
Coach
Parents
Have you been given any information regarding concussion management and head knocks at:
School
Club
Parents at home
Did you spend any time in the school sick bay or infirmary?
Yes – sick bay (how long for? _____________________________)
Yes – infirmary (how long for? ____________________________)
No
Other comments: ____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
To produce an educational video for use in schools, to educate teachers, coaches, students and parents on the importance of recognising a concussion, its treatment, management, and trajectory of symptoms in order to return to school and return to sport.
To produce one 5-minute video that could be broken into shorter 1-minute versions for social media bursts.
A Concussion Group was established, consisting of Neuroscience Clinical Nurse Consultant, Neuropsychologist, Emergency Department Specialists and Paediatric Specialists. The concept from the group was presented at the NSLHD Youth Forum (students 13-22-yrs). A wider presentation to First Nations and consumer representatives was also achieved.
The video was pitched at a 12-year-old level and combines animation and realistic scenes. The scenes were kept short to keep students engaged and the focus was placed on the learning aim, being conscious to dispel students’ misconceptions as well. Misconceptions such as “It only happens to footy players” and “I didn’t even bump my head” were highlighted.
After pitching the concept to the Chief Executive and team, the NSLHD provided the funding for the video, which was greatly appreciated.
The videographer’s briefing included the “words on paper”/ script, as well as concepts for the video footage :
A montage of pictures
Cartoon drawings and real-life pictures
Emphasis on Speech, Vision, Memory, Balance
Does just happen in sport!
Facts vs Fiction
Male: Female
The word Concussion to stand out throughout.
From the initial draft script (Figure 1), script version 6 was accepted. Devising and parenting the video took approximately eleven months from “words on paper” to fruition.
The video can be accessed via
From the 5-minute video, there were several shorter 1-minute segments for social media bursts e.g. Facebook and Instagram (Figures 2 & 3).
Many schools have written with positive comments, outlining how the video has been integrated into class learning and discussion. The Concussion Video has been included in the resources section of two of the NSW Education Department’s ‘Recognising and Responding to Concussion’ e-learning courses as a resource that teachers are encouraged to share with their students (School Sport Unit, 2022). It has also been taken up by the New Zealand Public Health Unit for inclusion in school education.
There is much discussion surrounding the risk of neurodegenerative diseases and complications associated with concussion and repetitive head knocks in sport, with rotational head motion as the primary contributor to brain injury (Tierney, 2021). Media saturation regarding Chronic Traumatic Encephalopathy (CTE) needs to be considered and properly understood. Public education needs to ensure that the threat of CTE does not overtake common sense. Already schools are seeing a move away from rugby to soccer, yet evidence shows that soccer is not necessarily ‘safer’, as concussions occur frequently in this sport as well.
Sport is synonymous with being Australian. It should be encouraged. However, so should the rules of the game, sportsmanlike behaviour, and in particular, neck strengthening exercises. Mouthguards and helmets (in rugby) should be mandatory. Although they will not wholly prevent a concussion, they will absorb some of the mechanical force, as well as protecting the teeth, skull, and jaw (Allison & Tamimi, 2020). Encouragement to ‘look after your mate’ should also be emphasised in schools – if your mate is injured, report it.
Similarly, concussion needs a higher educational presence in schools. Early injury identification, assessment and treatment produces better outcomes (Cassimatis, Orr, Fyffe & Browne, 2021). This video will assist in highlighting identification and management of concussion. As a video, it can be played whenever and wherever required.
With the rise of public concern regarding concussion, particularly in children and young adults, and the many presentations to school infirmaries and Emergency Departments, the need for concussion education was apparent. The NSLHD’s Concussion Video is an ideal way to provide education and information to local schools and sporting groups whenever required.
21st January | YR 7 | Head Injury |
27th Febrnary | YR 10 | Head knock |
27th March | YR 8 | Head knock |
27th March | YR 8 | Head knock |
27th March | YR 8 | Head knock |
3rd April | YR 8 | Head injury |
4th April | YR 10 | Head knock |
6th April | YR 10 | Concussion |
7th April | YR 8 | Head knock |
7th April | YR 11 | Head knock |
7th April | YR 9 | Head knock |
7th April | YR 11 | Head knock |
9th April | YR 8 | Head Injury |
11th April | YR 10 | Concussion - Hospital |
7th May | YR 10 | Head injury |
7th May | YR12 | Head injury |
7th May | YR 10 | Head injury |
7th May | YR 12 | Head injury |
7th May | YR 8 | Head Injury |
9th May | YR 9 | Head Injury |
13th May | YR 7 | Head knock |
13th May | YR10 | Head knock |
13th May | YR 10 | Head knock |
13th May | YR 10 | Head knock |
13th May | YR 10 | Head knock |
15th May | YR 8 | Head knock |
16th May | YR 8 | Concussion - Hospital |
20th May | YR11 | Head Injury |
20th May | YR 8 | Head Injury |
20th May | YR 8 | Head injury |
21st May | YR 8 | Head Injury |
21st May | YR 8 | Head injury |
21st May | YR 8 | Head injury |
21st May | YR 8 | Head injury |
21st May | YR 10 | Head injury |
21st May | YR 12 | Head injury |
21st May | YR 8 | Concussion - Hospital |
21st May | YR 7 | Head injury |
21st May | YR 8 | Head injury |
22nd May | YR 11 | Head injury |
23rd May | YR 7 | Head injury - Hospital |
29th May | YR 7 | Head injury |
29th May | YR 10 | Head knock |
29th May | YR 7 | Head knock |
29th May | YR 10 | Head knock |
29th May | YR 10 | Concussion - Hospital |
5th June | YR 7 | Head injury |
5th June | YR 9 | Head injury |
5th June | YR 8 | Head injury |
5th June | YR 12 | Head knock |
17th June | YR 8 | Concussion - Hospital |
17th June | YR 9 | Concussion - Hospital |
17th June | YR 8 | Concussion - Hospital |
17th June | YR 7 | Concussion - Hospital |
17th June | YR 12 | Concussion - Hospital |
20th June | YR 8 | Head injury |
22nd June | YR 7 | Head injury |
25th June | YR 7 | Head injury |
28th June | YR 10 | Head injury |
28th June | YR 8 | Head injury |
28th June | YR 10 | Head injury |
28th June | YR 12 | Head injury |
28th June | YR 7 | Head injury |
30th June | YR 10 | Head knock |
4th August | YR 8 | Head injury |
4th August | YR 7 | Head injury |
4th August | YR 10 | Head knock |
6th August | YR 12 | Concussion - Hospital |
6th August | YR 10 | Head injury |
6th August | YR 8 | Head knock |
7th August | YR 8 | Head injury |
7th August | YR 8 | Head injury |
18th August | YR 10 | Head knock |
18th August | YR 11 | Head knock |
18th August | YR 12 | Head knock - Hospital |
18th August | YR 8 | Head knock |
18th August | YR 10 | Head knock |
18th August | YR 9 | Head knock |
18th August | YR 7 | Head knock |
18th August | YR 8 | Head knock |
18th August | YR 7 | Head knock |
18th August | YR 7 | Head knock |
18th August | YR 9 | Head knock |
20th August | YR 12 | Head injury |
20th August | YR 12 | Head injury |
20th August | YR 8 | Head injury |
20th August | YR 12 | Head injury |
20th August | YR 12 | Head injury |
20th August | YR 12 | Head injury |
20th August | YR 12 | Head injury |
21st August | YR 8 | Head injury |