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"It’s just a little bump" - Concussion - A case study by Cheer Coach & GP, Anna Mead

"It’s just a little bump" - Concussion - A case study by Cheer Coach & GP, Anna Mead

"It’s just a little bump"

As coaches we always try to minimise injury - safe progressions, drills to build skills, education of our athletes on safe catches - these all help, but injuries will inevitably occur.
 

Cheerleading is reported to be one of the safest sports in terms of numbers of injuries but when injuries occur they tend to be more significant. Are you doing your best to prevent and manage injuries?
 

Within our programme, ALL athletes requiring first aid, or time out of practice, are sent home with an accident form. From a plaster for a scratch, to ice for a sprain, to an ambulance being called. Data is analysed annually looking for trends on when injuries occurred during the session, which equipment was involved, the coaches present, the age of the athlete and even which point of term or competition season it occurred in. This may seem overboard, but trends can lead to possible causes and therefore strategies to prevent further injuries can be implemented. Why wouldn’t we try and reduce risk? Ever thought “It’s always before comp” - look closer and you may find a reason.
 

Our accident forms also ensure good communication with the athletes parents / guardian / friend. But what advice do you give? How qualified are you to make a diagnosis? Are you insured to make the diagnosis? How confident are you to say “It’s just a little bump”?
 

Some injuries are easier to give advice. Clearly a scratch needs no more advice than parental common sense. But a sprain may actually be a small fracture. That ongoing back pain may be a stress fracture or undiagnosed scoliosis. The crying may actually be concussion. The list goes on! Clearly we do not want to be overwhelming the NHS with every bump, but as a coach you are responsible for child safeguarding. If you are not sure, others will be.
 

We are not alone in analysing injuries. Since 2009, cheerleading in North America has been part of the USA National Injury Surveillance Programme within high schools. A step made to try and make the sport safer. There is no such programme in the UK, other than through National Governing Bodies. Until the UK cheerleading community unites, allowing a NGB to establish, each club should strive to take steps to improve safety within their own gym and at competitions. Let’s stop those "ooooww" moments, let’s make cheerleading safer!
 

A recent study showed that of all cheerleading injuries in US high schools, concussion was the most prevalent. Truth - not the sprained ankle or broken arm. It’s hard to argue with the evidence, which probably means we are not aware of the signs and therefore it is being undiagnosed. Can you think of times when an athlete has had a knock to the head? I know I can count multiple. What advice did you give? Did you think concussion? What rehab did you implement for the athlete?
 

In 2016, our junior 3 team were preparing for Nationals by upgrading their difficulty. They were a very competent team, had perfected the progressions and had been working the new sequence for a few sessions - all was going well. Then a base pair caught low, forcing their chests forward and resulting in colliding heads. One athlete had no evident injury - denied any pain, and in their words “it was just a little bump”. The second athlete sustained a fracture to the eye socket. Not a diagnosis we made - rather we suggested a trip to A&E. But even without the fracture, the impact would still have been significant enough to cause their brain to jiggle inside their skull.
 

In the hours and days to follow, the athlete started to show symptoms unrelated to the fracture. The ongoing headache, feeling dizzy, having difficulty concentrating at school and becoming more emotionally sensitive. All symptoms of concussion. In this athletes’ case they were out of cheerleading for a over three months. But if they didn’t have the fracture, they would have been back in the gym pushing for the National title. Clearly they would have struggled. Now think of a youth or mini athlete - they are unlikely to report symptoms of dizziness or recognise their inability to concentrate. Rather they may lose their tumble abilities, struggle to remember the routine, struggle to react to a stunt bobble or may feel too 'unwell' to stunt. If you are worried after a head injury - think ‘could this be concussion?’.
 

This athlete was already under the hospital who recognised the signs of concussion. 'Time' was her recommended treatment. How long? However long it takes. Yes, that would mean not being in the team for Nationals. Remember it’s just one competition - health is far more important.
 

Just like our incident, a recent study from Colorado showed that 69% of concussion injuries in cheerleading occur during stunting with the majority involving contact with another athlete, with bases being the most prone to injury. They identified the straight cradle as the highest offending stunt (73%) with understandable increased risk from extension compared to prep level. Interestingly less concussion injuries occurred during a full twist cradle, and even less during a cradle with double twist (5%). Whether this reflects the safe progressions of high school cheerleading, or less of these skills being practiced, it remains unclear. But the take home message - safe cradle progressions, may help prevent concussions.
 

Equally we should not neglect concussions during tumbles. Athlete head's verses the floor should be no more, however, it is still seen at competitions. We see it all the time especially with the younger athletes, and normally on social media, athletes practicing skills with poor technique. Watching their role models and trying to have a go themselves. Ultimately a coach can explain the risks of practicing outside of the gym but the 'tumble police' cannot keep up with the enthusiasm of our athletes. However, within the gym and particularly if a tumble skill is deemed competition ready, there should be no doubt that arms do not bend in walkovers or back handsprings, and arial skills will rotate to feet. Let’s try and make these scary scenarios extinct.
 

Cheerleading in general is more susceptible to concussion injuries due to the athlete demographics. Younger athletes are not only more prone to concussion, but also take longer to recover. Their larger head to body ratio, weaker neck muscles and increased vulnerability of the developing brains are all contributing factors. Where adults are often back to full activity within 10-14 days, children are only said to have ‘prolonged symptoms’ after 4 weeks.
 

So what should we be looking for (and not limited to):

- Symptoms: headache, feeling like in a fog, lability and/or emotional symptoms
- Physical signs: loss of consciousness, memory concerns, weakness of muscles
- Balance impairment: unsteadiness, dizziness
- Behavioural changes: irritability
- Cognitive impairment: slowed reaction times, difficulty concentrating
- Sleep disturbance: somnolence, drowsiness


If any of these have occurred and there is not an official health care provider trained in concussion available, the guidelines suggest an urgent review by a doctor. In the UK this would be a GP, Out of Hours GP, Walk in Centre, or A&E if none of these are available. The athlete should not be left alone, and monitored until they have seen a doctor. In addition, if the athlete has sustained a serious head injury in which they develop a swelling on the skull, they are vomiting, having a seizure or bleeding from the ears - immediate medical advice at A&E is required. A broken arm you can see, a head injury is more difficult.
 

In addition to the accident form, what else can we do? Unfortunately there is no medical intervention to help and there is little evidence suggesting exact amount and duration of rest required. In addition, there is very limited research around concussion recovery in children and teenagers. The general advice is of 24–48 hours of complete rest after injury, followed by gradual and progressive increase in activity that does not bring on or worsen symptoms. For adults this often means being back to full sporting activities after 1-2 weeks however children take much longer. It would therefore be reasonable to expect an athlete not to engage fully in training for 4 weeks.
 

So the moral of the story - be safe by following drills and progressions to prevent head injuries and concussion. But if they do occur, be patient and give the athlete time. If this means re-choreographing or replacing the athlete, do it. Let’s build a nation known for it’s safe cheerleading community.

 

The article is not intended as a clinical practice guideline or legal standard of care, and should not be interpreted as such. Please find further information at:

https://www.nhs.uk/conditions/concussion/
https://www.nhs.uk/conditions/minor-head-injury/

Dustin et al. Cheerleading injuries in United States High Schools. Pediatrics (Official journal of the American Academy of Pediatrics) January 2016, volume 137/issue 1

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