One day, seven-year-old Ettie was chasing her friends around at school, playing a game they called “Monster Monster”.
But then the little girl tripped and fell face down, and her eye socket took the brunt of the fall.
When Ettie’s mum Deidre went to pick her up, she was not prepared for what she saw.
“I almost vomited her injuries were so bad,” said Deidre, who still gets teary thinking about the sight of the damage to her daughter’s face, and her black eye and broken glasses.
But Deidre was also not prepared for the ongoing impact the playground accident has had on their lives.
It is now 18 months since Ettie was first diagnosed with concussion and she is still having symptoms.
She has trouble keeping her balance and is prone to dizziness, which means she can’t do fun things like cartwheels, and playing on swings, trampolines and monkey bars.
Ettie has fatigue, sensitivity to noise and problems with sleep and attention. She keeps losing things and finds her schoolwork is harder than it was before. She can only manage being at school part time.
“She knows she’s not the same as she was before,” Deidre said.
“It’s sad to see such a little person navigating this.”
Concussion can affect us all
Concussion is a form of traumatic brain injury that occurs when you hit your head or jolt your body in a way that causes the force to transmit to your head.
“When there’s a blow to the head or any part of the upper body, the brain actually slams into the inside of the skull,” Naznin Virji-Babul, a physical therapist and neuroscientist from the University of British Columbia in Vancouver, Canada, told ABC RN’s All in the Mind.
Scientists are still trying to work out exactly what happens as a result of this trauma, but Dr Virji-Babul said a key feature of concussion is the microscopic tearing of neural connections in the brain, which change the way the brain works.
Just like when an airport shuts down and planes have to reroute, when a part of the brain is damaged, messages try and find a new pathway, Dr Virji-Babul said. And, among other things, this rerouting saps a lot of energy.
“Some areas that are not normally supposed to be involved in … doing all this work now suddenly have to, and they need more energy to actually be able to lead those tasks.”
While there’s been a lot of talk about the consequences of repeated head knocks in sport, an estimated 80 per cent of concussion occurs elsewhere, such as at home (and there is particular concern about domestic violence), at work, on the roads or at school.
Such “community” cases of concussion are under-reported and under-recognised, with many of us unaware of the symptoms, experts say.
A single knock can have lasting effects
Concussion is regarded as a “mild” form of traumatic brain injury which is not usually life-threatening. But even a single and minor knock can diminish a person’s quality of life in a way that lasts for months or even years.
Although most people who have concussion are likely to recover within two weeks, others, like Ettie, are not so lucky.
“Even if a person has apparently recovered within the two-week period after concussion, you cannot guarantee that they will be well at one month,” said Rowena Mobbs, a neurologist at Macquarie University Hospital who specialises in concussion.
Evidence suggests children, adolescents and women take longer to recover from concussion and it is important to keep an eye out for ongoing symptoms, Dr Mobbs said.
It is not clear what proportion of people are affected by this “post-concussion syndrome” (also known as “persistent post-concussion symptoms”), although Dr Mobbs estimates it affects between 20 to 50 per cent of those having concussion.
How to detect possible concussion
Concussion can be hard to recognise. Symptoms can be non-specific, are sometimes delayed and vary widely between individuals.
Dr Mobbs says it’s best to focus on the so-called “Big Five” signs of concussion, which can observed at the time the head or body is impacted. These include someone lying motionless, being wobbly on their feet, appearing confused and being slow to move, speak and respond.
But there are many other indications of concussion, some of which can be comparatively subtle.
These include:
- Ongoing headache
- Brain fog
- Fatigue
- Memory problems
- Difficulty concentrating and solving problems
- Sleep disturbances
- Sensitivity to light or noise
- Anxiety, irritability and depression
There is no single objective test for concussion, but it can be diagnosed by a health practitioner assessing signs and symptoms and carrying out cognitive and neurological functioning tests.
When in doubt, get medical advice early. This can help pick up something critical like a brain bleed or skull fracture and help reduce the risk of long-term complications from concussion.
Concussion’s emotional toll
The emotional impacts of concussion can be among the hardest to describe, as Sydney-based doctor researching concussion Lewis Freeth knows from personal experience.
While in South Africa in 2016, Dr Freeth was thrown 50 metres from a car crash into a paddock, knocking him out.
In 2017, he had a second concussion playing football back in Australia, followed by challenging symptoms that lasted two months.
Not only did he have fatigue and problems concentrating, he lost his ability to tolerate stressful situations.
“My normal emotional processing wasn’t the same,” he told All in the Mind.
Dr Freeth wasn’t able to talk himself into feeling calm — even stubbing his toe felt like the end of the world.
He said his own research has changed the way he looks at the brain.
“It’s very vulnerable and it’s very complex and it’s also who you are,” he said.
“So if that’s damaged, then who you are changes.”
Deidre remembers soon after Ettie’s school accident, as well as having physical symptoms like a lack of balance, Ettie had anxiety and low mood, and she had difficulties regulating her emotions.
“She was barking at me, she couldn’t find her way around the house, dress herself or do basic self-care stuff.”
Deidre said Ettie complained of headache, feeling hot, tired, and like “a kid from prep because I can’t remember what I used to remember”.
Ettie also had to stay indoors in the dark through the summer holidays because she was so light sensitive, and she had trouble expressing how she felt.
Encouraged by her mother, Ettie drew a picture to help express her feelings.
“My brain feels like it’s on fire, so I think I need some cold water,” Ettie told Deidre.
Recovery and support
Up until fairly recently, experts thought the best thing to do for concussion was to rest until you felt better.
Now, the advice is to rest just for one to two days before gradually increasing activity and returning to normal. This will mean negotiating with places like school and work for a staged return.
Since damage to the brain can affect so many aspects of a person’s physical and mental health, it is no wonder there’s a move internationally towards multi-disciplinary concussion clinics — although there are not too many around.
Deidre said she had a very hard time getting support to help Ettie.
“People basically said ‘she’s a little kid, she’ll recover.'”
Deirdre spent months trying to coordinate input from different experts — in her case, paediatricians, physiotherapists and psychologists — and says she is still waiting for a neuropsychology assessment.
“It’s been exhausting and taken all my resources,” she said.
“It’s great people are talking about concussion in elite sport but there’s very little support for people like us.”
Dr Mobbs calls this “the abyss of head injury”, where patients suffering long term symptoms — or those that care for them — don’t know where to turn.
Such people need reassurance that they will get better one day, Dr Mobbs said, but they also need “validation, empathy and long-term care”.
Unfortunately, though, there are no consistent guidelines for doctors and the community when it comes to concussion, Dr Mobbs said.
If you do get concussed, she recommends asking your doctor to coordinate your care by referring you to those with relevant expertise, such as neurologists, neuropsychologists, physiotherapists and psychiatrists as needed.
Deidre found taking part in a Zoom support group organised by Concussion Australia helped reduce the isolation she felt, and empowered her with tips on where to find people who specialise in concussion.
“It was really great to connect to others. I had felt so alone … It helped share the load.”
Even though Ettie is still yet to fully recover, Deidre says she’s come a long way.
Ettie still can’t manage swimming lessons in a noisy pool, but earlier this year she had her first go at surfing thanks to the volunteer-run Disabled Surfers Association Tasmania.
“It was probably the happiest day we’d had since she had the head injury,” Deidre said.
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