Concussions in Handball

Concussions in handball is such an extremely important topic and this is going to be one really, really long post! But it will also be a very educational post, so take your time with it. I didn’t want to exclude or cut off any parts of it, because when you search online for information about “Concussions in handball” – you don’t get so many results… We definitely need more educational materials about this topic in handball!

So, let’s start!

How many times have you witnessed this kind of situation?

This video is for the educational purpose only and the original video is a property of ehftv.com .

Even more important question is: how many times have you (or your goalkeeper) returned to the game after that kind of situation?

As a handball goalkeeper, when you get a shot in the head – you are expected to only shake off your head little bit and continue playing. Very often it doesn’t even matter how hard the shot was. We are taught, since the very young age, that getting a shot in the head is just one more save, and that there is nothing wrong about it.

I have heard many goalkeepers even swearing by it – that they play better after they get shot in the head, it motivates them to focus even better. (Still doubting that goalkeepers are weird?) 😉

When you don’t know better – you play by the rules that exist. If you are expected to just be “brave” and ignore the shot in the head – you will ignore it and you will continue playing! Concussions in handball don’t happen only to the goalkeepers, they are happening to the players as well.

Now let me tell you something right away in the beginning- the point of this text is not that all goalkeepers should quit playing just because of possible fear from the shot in the head!!!

The point of this text is to help goalkeepers, coaches, players and parents in understanding how serious head injuries in handball can be and how important it is to NOT continue playing or to return to the game too soon after sustaining a concussion!

Goalkeeper Has to Be Brave

As we all know – one of the most important characteristics for every handball goalkeeper is Courage! Being brave and not having the fear from the ball!

I strongly support that idea! A good goalkeeper MUST be brave and not have the fear from the ball!

But also, a goalkeeper must be familiar with the possible consequences of getting a strong shot in the head and about concussions in handball so that s/he would be able to use that knowledge when needed and to take care of her/himself when needed.

When I was young – no one ever told me that there is anything really seriously wrong with getting very hard shots in the head, even several times in a row… Now, don’t get me wrong – this happened a very long time ago!

But now,  many years afterwards, we should all know better – coaches, goalkeepers, players, parents, we should all have more information about the consequences of possible concussions in handball and advises what would be the best to do if it happens!

Being Brave Sometimes Equals Being Not So Smart

Once I have got such a crazy strong shot in the head from the 6m line, that I had bigger consequences for a few months afterwards. This was back in 2000, I was 17 years old.

I’ve jumped in “x-jump” towards the player, she jumped towards me and shot directly into my head from about 1 meter distance. I landed flat on my back, that’s how strong the shot was. I couldn’t see or hear anything for a few seconds…when my team mates run closer to me, the only thing I was asking was: “Was it a save? Did I save it?”

I couldn’t see or hear, but the only thing that was important to me in that moment was if I saved the shot!?

I went on the bench for about 10 minutes and then the coach has asked am I going back into the game. I remember telling him that I feel funny and I see everything somehow “smooshed”, but if the team needs me – I will go back in the goal! So I went back into the game.

I don’t remember much from that game anymore…

But I do remember that I had big problems with headaches and with my left eye after that game.

I am afraid to confess how many concussions I have experienced in total during my active goalkeeping career, but no one ever taught me early enough anything about the danger or severity of repeated head blows.

It was only when I became obsessively interested about studying the neuroscience and the brain 7-8 years ago that I started to realize how important it is to know what to do and what to avoid after suffering a concussion.

What is a Concussion?

A concussion is very often described as a traumatic brain injury which affects the brain function. A concussion cannot be seen on routine x-rays, CT scans, or MRIs. Effects are usually temporary but can include headaches and problems with concentration, memory, balance and coordination. Concussions are usually caused by a blow to the head, face or the neck. But the direct impact to the head is not required!

Some concussions cause you to lose consciousness, but most of them do not! It’s also possible to have a concussion and not realize it! It’s very dangerous and it can lead to disastrous outcomes if a goalkeeper (or player) is returned to play too soon after the concussion! Long-term consequences of concussions are still widely underestimated and not very well known.

What actually happens during a strong impact to the head is that the brain gets immediately “squashed” out of its shape, it moves and twists. The head moves forward, the brain kind of falls behind, and then the brain catches up and smashes into the skull. It rebounds off the skull and then it continues to hit into the other side of the skull.

When the head twists and turns, the damage can happen between the left and right hemispheres of the brain.

Our brain is one of the softest substances in our body, and it is kind of like a jello. As the head is moving back and forth, the brain is twisting and turning, and the tissue in it is getting stretched.

More detailed – this stretches the axons – long trunks and branches of nerve cells that carry the information in the brain. The axons can manage a slow stretch, but if they get stretched quickly, by sudden impact – then the parts of those nerve fibers will get damaged. So it’s about the speed of the “stretch” that is going to have an impact on the consequences. It’s also about the degree of injury to the axons that predicts how severe  symptoms of a concussion will be, and how long it will take to recover from them.

Concussion is not likely to be something that’s happening on outer surface of the brain, but it’s something that’s happening much deeper towards the center of the brain.

In more serious cases – this type of brain injury may lead to bleeding in or around your brain, and these symptoms may develop immediately or later. Scary thing is that in some cases you don’t even need to be hit hard to have the brain damage! Sometimes you won’t even have physical symptoms, but that doesn’t mean you haven’t damaged your brain. The truth is – one hard hit will cause the concussion and the other hard hit will not cause it.

Interesting thing to mention here, as the newest research about concussion states –  a concussion is more likely to happen when someone is struck and when the head rotates to the left or to the right.

Movement forward/backwards is more common in handball (especially in the cases when the ball comes straight into the goalkeeper’s face), but the rotation to the left or to the right seems to be much more dangerous.

How Long Will it Take to Get Better? 

The signs and symptoms of a concussion often last for 7-10 days but may last much longer. In some cases, athletes may take many weeks or months to heal. Having had previous concussions may increase the chance that a person may take longer to heal.

Concussion Symptoms

Immediate signs:

• Unconsciousness (not necessary to happen)
• Headache or a feeling of pressure in the head (that can get worse and won’t go away)
• Blurred vision
• Slurred speech
• Confusion or feeling as if in a fog
• Nausea, vomiting
• Dizziness or “seeing stars”
• Ringing in the ears
• Decreased coordination
• Amnesia
• Delayed response to questions
• Loss of balance and unsteady walking
• Light sensitivity
• Sensitivity to noise…

The most common issues that tend to arise after a concussion include musculoskeletal issues to the cervical spine and head, oculomotor function, vestibular reflexes, positional habituation and balance, coordination, physical exertion and activity progression with change of direction, and attention issues.
However, the system that seems to be affected more often and consistently than the others is the visual system.
Convergence insufficiency is present in 1 out of 2 people with concussion.

Concussion Treatment

Proper concussion management and treatment is the most important in long term brain health!

Taking a break is extremely important!

If the concussion was sustained during the training or a game – stop playing and sit on the bench! Your brain needs time to properly heal, so rest is really important! Definitely DON’T go back to play the same day!

If you hit and bruise any other part of your body – it will feel sore, but when the same thing happens to your brain, it doesn’t have the pain receptors to tell you to slow down and to take it easier for a few days, that is what usually causes the problem in realizing that we should take care.

As neuro-optometrist Dr. Charles Shidlofsky often opens his lectures: “When you’ve seen one brain injury, you’ve seen only one brain injury.”

There are so many different dynamics to concussion, in the functional effects and in the symptoms, so it’s very individual how someone will react / recover after sustaining a concussion.

It’s interesting to mention that someone who has sustained 1 or more concussions is at bigger risk for being diagnosed with another concussion afterwards, which can double the damage!

Another interesting fact is that the first 10 days after a concussion seem to be the period of the biggest risk for being diagnosed with another concussion.

The current recommendation for athletes who have sustained a concussion is immediate removal from the game. Return to play shouldn’t be allowed until after assessment by a healthcare professional who has the experience in dealing with concussions. Even more careful approach should be performed with younger athletes, because their symptoms and neurocognitive performance take longer time to improve after a concussion.

For many years, complete rest for an extended period has been the most conventional treatment for concussions.

But the latest studies are finding that active rehabilitation after a concussion can enhance the recovery. The active rehabilitation involves resuming normal activities shortly after the injury. Of course – resuming to normal activities is only recommended if the symptoms don’t worsen!!!

Dr. Shidlofsky explains that about 40% of his neuro-vision practice is dedicated to mTBI (minor traumatic brain injury) treatment through a neuro-visual rehabilitation approach.

When Can You Return to Training?

It is very important that you do not go back to sports if you have any concussion symptoms or signs.

To make this whole topic little bit more easy for coaches, goalkeepers, players and parents, it’s good to become familiar with the stepwise progression return-to-play protocol following a concussion.

Return to sport and activity must follow a step-wise approach:

STEP 1) No activity, only complete mental and physical rest. Proceed to step 2 only when all symptoms are gone. This includes avoiding both mental and physical stress.

STEP 2) Light exercise such as walking or stationary cycling, for 10-15 minutes. Monitor for symptoms and signs. No resistance training or weight lifting.

STEP 3) Sport specific aerobic activity (for example: running in handball), for 20-30 minutes. NO CONTACT.

STEP 4) On the court practice such as different ball drills, coordination, save reaction movements, and other activities with NO CONTACT and no shooting practice yet (no risk to get the shot in the head!!).

Only go to step 5 after medical clearance!!!

STEP 5) Once you get a “green light” from the doctor – on the court practice including the shooting training and saving the shots.

STEP 6) Playing the game. (The earliest a concussed athlete should return to play is one week).

Important: Each step must take a minimum of one day! But it may take many days to progress through one step, especially if the concussion is severe!! As soon as symptoms appear, the goalkeeper (or a player) should return to rest until symptoms have resolved and wait at least one more day before attempting any activity. The only way to heal a brain is to rest it.

If you have any symptoms of a concussion (e.g. headache, feeling sick to your stomach) that come back either with activity, or later that day, STOP the activity immediately and rest until symptoms resolve, for a minimum of 24 hours. See a doctor and be cleared before starting the step wise protocol again.

You should not go back to sport until you have been cleared to do so by a doctor!

Never return to play too soon if symptoms persist!

Even though there are lot of potentially dangerous negative implications from suffering a concussion, they can be reduced with early recognition and proper management. One could wonder why then there are still problems when it comes to dealing with concussions in handball and sports overall?

Well, simply because it’s always much harder to deal with something unknown.

That being said – if you are a coach, parent, a goalkeeper, a player – do your best to get more familiar with the concussion symptoms, treatment, step-wise approach, general “what to do / what to avoid”, because then we will all win!

Expand your knowledge, because by knowing more – we will all be able to act more proper when dealing with the possible concussion!

References:

1. Paul McCrory, Willem Meeuwisse, Jiří Dvorak, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016
2. Chris Nowinski, Head Games: Football’s Concussion Crisis; Drummond Publishing Group, 2006.
3. David Camarillo, TEDx talk at Stanford 2016, Why helmets don’t prevent concussions
4. Lin AP, Ramadan S, Stern RA, Box HC, Nowinski CJ, Ross BD, Mountford CE. Changes in the neurochemistry of athletes with repetitive brain trauma: preliminary results using localized correlated spectroscopy. Alzheimer’s Research and Therapy. 12/2015; 7(1).
5. Robbins CA, Daneshvar DH, Picano JD, Gavett BE, Baugh CM, Riley DO, Nowinski CJ, McKee AC, Cantu RC, Stern RA. “Self-Reported Concussion History: Impact of Providing a Definition of Concussion,” Open Access Journal of Sports Medicine. 5: 99-103. 2014
6. Omalu, B.I., DeKosky, S.T., Hamilton, R.L., Minster, R.L., Kamboh, M.I., Shakir, A.M. and Wecht, C.H., 2006. Chronic traumatic encephalopathy in a national football league player: part II. Neurosurgery, 59(5), pp.1086-1093.
7. Omalu, B.I., DeKosky, S.T., Minster, R.L., Kamboh, M.I., Hamilton, R.L. and Wecht, C.H., 2005. Chronic traumatic encephalopathy in a National Football League player. Neurosurgery, 57(1), pp.128-134.
8. Prins, M.L. and Giza, C.C., 2012. Repeat traumatic brain injury in the developing brain. International Journal of Developmental Neuroscience, 30(3), pp.185-190.

If You Want to Learn More About Concussions

If you still didn’t, definitely take a look at these two movies about the concussions in NFL:

• Movie: Concussion
• Documentary Film (Concussions in American sports)  The Head Games

Talk by David Camarillo

To learn more about why helmets don’t prevent concussions, check this talk by David Camarillo:

Katherine’s concussion story

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