Activity, not rest - Reframing the narratives on the treatment of concussion

Shane O’Donnell posed and answered his own question. “Everyone knows what concussion is but do they know what it entails? I definitely don’t think that they do.”

O’Donnell had just finished a nightmare personal account of the consequences of a seemingly innocuous impact with the ground during hurling training and how initial failure to treat the head injury sent him spiralling into a world of deep anxiety and fear.

Eventually falling under the guidance of Connacht Rugby and Galway GAA team doctor Enda Devitt, the Clare hurler and All Star nominee underwent treatment that at first seemed counterintuitive to everything he and others around him had previously understood.

When the rest orientated recommendations gave no relief, O’Donnell fell under Dr Devitt at the UPMC Concussion Network. The change involved no rest, no darkened rooms, no denial of using computers or halting physical activity.

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“Having gone to the hospital they’d given it as mild concussion and you just have to rest a for a few weeks and you’d be fine basically,” said O’Donnell. “My brother and his wife, also doctors, they also gave me the same kind of advice, just rest for a couple weeks and you’ll start to come out of it.

“I was trying to minimise the amount of work I was doing, trying to minimise the amount of screen time and got through the day okay. The next day it was worse. I started getting pressure in my head and feeling nauseous.

“Wednesday I woke up and it was just catastrophic. I couldn’t process any thoughts. I couldn’t hold a thought in my head. I was eight or nine or 10 in nausea. There was pressure in my head that I just couldn’t … there was this very severe pressure in my head.”

Dr Michael Collins, a renowned concussion expert and one of many speakers at UCD’s seminar, Concussion in Sport – A National Conversation, is at the cutting edge of understanding the injury and talks of a paradigm shift in the way it is treated.

“Active treatments are recommended, not rest,” says Dr Collins. “We need patients to exercise. It needs to be prescriptive, a nuanced approach. There are no dark rooms in our clinic.

“At least some exercise, walk twice a day, or put them on a stationary bike. Tell them not to turn down lights and noises. Tell them to use their phones. Keep them in school. The system needs to be reframed. It is not rest.”

The advanced methods are far from what most Irish people have understood as the way to deal with concussion and challenge the orthodoxies that had taken O’Donnell away from work, his electronic devices and exercise.

“I’d been told for four weeks by every person that knew what they were talking about, not look at the computer, don’t look at screens,” he says.

Dr Collins, whose Pittsburgh clinic sees 20,000 concussion cases a year, draws the analogy between brain injuries and other physical injuries to the body, where active treatment is encouraged.

Much of the therapy, which has caused some controversy, is ‘symptom provocation’ which is having patients engage in activity that may induce symptoms but result in better long-term outcomes.

Importantly, Dr Collins also asserts that concussion is a non-cumulative injury if it is treated correctly, with recovery often faster in a second concussion suffered by patients than in the first.

“The conversation on the cumulative effect is so important,” says O’Donnell. “If you talk to anyone when they talk about [Johnny] Sexton playing after the number of concussions they think: ‘Why is he doing that? Why are they letting him out there?’

“It’s only when you realise that if you treat them one at a time as they come that you can go out there and if you get another one, we can treat that as well.

“But the media would have you believe – and this is the general consensus out there – that if you have two or three or four then, regardless of how you are treated, you should stop playing.”

Last year, Johnny Sexton said he was “saddened and shocked” by what he described as the inaccurate reports emanating from the French media concerning the state of his health and questioning whether he should be permitted to play for Ireland against France in a Six Nations game at the Aviva Stadium.

[ Johnny Sexton: ‘You go off for HIA and don’t come back, everyone presumes that’s a concussion, it’s not’ ]

Weary of what he once described as “the stigma of concussion” which has followed him around for a number of years and which was not helped by comments from Eddie Jones before an England-Ireland game, Sexton has come to feel he is a target for the misinformed.

The reality of the injury, maintains Dr Collins’s team, is that concussion is treatable and in their research (300 published papers since 2016) they are not seeing cumulative effects.

“My girlfriend is actually a clinical psychologist and she said that I was presenting as someone with a mild PTSD after the entire event, that this was traumatic in the psychological sense and I think that was how I was processing it in my mind,” says O’Donnell.

“To this day, if I think about it or if I hear people talk about it I am very hyper aware of what it was like. It is a very vivid experience that is evoked. I’m okay talking about it now. But I still get emotional hearing that it is not cumulative and it is treatable.”

– UPMC Clinics are located in Mayo, Belfast, Cork, Kilkenny, Tipperary, Limerick, Galway, Waterford and Kildare.