Concussion in dance and aesthetic sports

Concussion, also referred to as minor traumatic brain injury (mTBI), is an injury more commonly associated with contact sports than with dancing. There has however been an increase in recent years in the number of reported concussions in dancers, and it is necessary for the dance teacher, director, choreographer and dancers themselves to be able to recognise and react to a concussion when it occurs.

In aesthetic sports such as gymnastics and cheerleading, and in dance related genres such as physical theatre, the reported instances of concussion are significantly higher than in dance, largely due to moves performed while elevated and in performing tricks and stunts. In cheerleading, stunts are responsible for 90% of the concussions suffered by athletes, with the majority of these affecting the bases, rather than the athlete in the air. Across various genres of dance, from street to ballroom to contemporary to lindy-hop, numerous aspects of choreography can pose a risk to dancers if not executed properly. With dance choreography constantly pushing new limits of dancers' physical abilities, and increasingly incorporating tricks and stunts in pieces, it is useful to now consider dance alongside gymnastics and cheerleading as an activity carrying the potential for concussion. 

In a wide variety of sports, it has been found that concussion is under-reported, and that athletes go on to perform or compete after sustaining a head injury. It is imperative for the safety of the dancer or athlete that all concussions are recognised and appropriately addressed. Self-reporting of symptoms has been proven to be ineffective at identifying concussion, and so standardised testing procedures should be in place to ensure concussions are identified and appropriately addressed.

What is concussion?

Concussion is when a blow to the head causes the brain to 'shake' inside the skull. A concussion causes temporary disturbance to normal brain function, and most do not cause permanent damage.

Symptoms may include a brief period of unconsciousness, dizziness, nausea, headache, loss of memory, confusion, increased pupil size, feeling dazed, loss of balance and vision disturbances.

Any persistent symptoms should be checked by a doctor.

Headway recommend that anyone experiencing any of the following symptoms following a concussion should go to A&E immediately:

Loss of consciousness	Increasing disorientation
New deafness in one or both ears	Problems understanding or speaking
Loss of balance or problems walking	Blurred or double vision
Any weakness in one or both arms or legs	Inability to be woken
Any vomiting	Bleeding from one or both ears
Clear fluid coming out of your ears or nose	Any fits (collapsing or passing out suddenly)
Drowsiness when you would normally be wide awake	Severe headache not relieved by painkillers such as paracetamol

Concussion rates are elevated for athletes with a history of concussion, therefore meaning it is more likely that after sustaining a concussion the individual may be more suseptible to sustaining another.

Concussion Management

Many sporting authorities, particularly in contact sports such as rugby and american football, insist on concussion managament plans being in place. While it is unlikely this will become mandatory for dance companies or schools in the near future, it is good practice for dance professionals to have an understanding of concussion management in order to safe guard their dancers.

There are numerous methods of assessing concussive injury on the sport-field or in the dance studio. If an athlete or dancer has received a blow to the head and claims to feel fine, it is worth assessing them regardless, as self-reporting of symptoms has been proven to be ineffective. If concussion is suspected, medical advice should be sought.

The Sports Concussion Assessment Tool (SCAT) is one of the most commonly used assessments, and can be found here

Another method that has recently come into use is a simple measurement of reaction time, used to identify impaired cognition. The test requires the athlete to grasp a falling measuring stick, with the reaction time to this being recorded. This is an inexpensive piece of equipment for the coach or teacher to use to assist them in making a in-studio assessment. A measuring stick with marking incremental markings down it is dropped from a fixed point next to the athlete. The athlete grasps the stick as quickly as possible, and the marking they grasp it on is recorded. For this to be effective, a baseline (non-concussed) reading must be taken initially. Although a new testing procedure, this has proven effective in identifying impaired cognition following a suspected concussion or blow to the head.

Post Concussion Syndrome/Post Concussion Trauma

There is some controversy around Post-Concussion Syndrome, regarding the length of time after a concussion is sustained that the symptoms are then classed as "post-concussive". Some medical practitioners will diagnose PCS at 48 hours after a concussion, whereas others diagnose from 7 days onwards. The symptoms of PCS are similar to those of concussion - headaches, dizziness, nausea, restlessness, insomnia, fatigue and drowsiness, heightened emotional responses and difficulties with concentration. PCS is not unusual, and typically resolves within around 2 weeks of the concussion, however it can effect some individuals for several months. If any symptoms persist after the initial concussion, medical advice should be sought to rule out any more serious causes than PCS.

Return to Sport/Dance

Follow the guidelines given to you by your doctor or nurse. In cases of mild concussion, this will usually be rest, fluids and paikillers such as paracetamol to control any headache symptoms. However as a severe concussion does have the potential to be catastrophic, and on rare occasions initial symptoms may mask a more serious injury, it is imperative that medical guidelines are followed and the athlete or dancer is monitored and not encouraged to return to activity before they are ready.

A gradual build up of physical activity, from light aerobic work to light strength training to sport-specific work that minimises the chance of repeated head trauma and finally to full training should be followed only when symptoms have cleared. Providing no symptoms reappear and the individual is in good health, return to full training can occur after 7 days of the last notable symptoms.

The Controversy of Second Impact Syndrome

Second Impact Syndrome is the term given to what is believed to be a catastrophic outcome of a repeated head injury in sport. There is a lack of scientific evidence to support this, however following recent tragic events involving the deaths of young athletes in the United States, something of a panic has emerged surrounding the notion of a 2nd impact within hours or days of an initial concussion as being responsible for catastrophic brain injury.

Due to the lack of scientific evidence, it perhaps appears more likely that the initial blows in these cases of concussion were either not reported, or not adequately treated, and that it was the initial concussion that was the cause of death. A seemingly minor head injury that is not examined and assessed has the potential to be more severe than it initially presents itself. It is therefore recommended that following a head injury, the individual does not return to performance or competition on the same day and that all symptoms are monitored. Visible and apparent manifestations of cerebral swelling or cerebral bleeding may not be obvious immediately following the initial blow, however if left untreated can have devastating results.

Further research is needed in this area, however it stresses the importance of addressing all blows to the head and all concussions to ensure that if medical advice and treatement are required, they are sought in the first instance and not left to chance. Although rare, catastrophic head injuries do occur in sport and unfortunately the dance, gymnastics and cheerleading communities cannot consider themselves exempt from the risks. All head injuries should be treated and monitored appropriately.

I love this video, the cheerleaders are nothing short of impressive, but it gives an idea

of the risks involved in stunting.

References:

Eckner, J.T. et al., (2012) Effect of sport-related concussion on clinically measured simple reaction time. British Journal of Sports Medicine, 10.

www.headway.org.uk

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