Concussion in Pole: From innocuous hits to falls

Injuries in pole dancing vary from location and intensity. Starting from our fond pole kisses (bruises) all the way to the more serious injuries such as a shoulder dislocation. But there is one uncommon but serious injury we want to delve into today, and that is concussion.

Now we’ve all seen the pole fail videos on Instagram and groaned, looked away or even laughed (if you’re particularly sadistic) when someone falls off the pole. And whilst they appear funny at the time, some of these videos actually involve some nasty head injuries. And it’s this normalising of head injuries in pole that is doing some serious damage.

Now you could just put your head in the sand (pun intended), ignore this blog and look the other way. But we implore you not to. Instead take this chance to understand why head safety in any sport is a must, especially for us pole dancers and aerialists.

Life’s better upside down

Now most ‘normal’ forms of exercise are done in an upright position. But we don’t do normal! Pole and aerial dance challenges your body’s awareness, spatial perception and control in positions your body is not used to being in. But being upside down often feels counterintuitive for the brain! And this is why when we are upside down our risk of injury increases. And if one of those injuries ends up being a fall from the pole, we can see serious consequences occur.

Best case situation we may escape with a bruised ego, and in the worst case situation spinal injuries have been documented over the past 10-15 years. But there are a range of injuries in between that can occur such as whiplash, cervical joint injuries and concussion. Most of these falls and injuries can be avoided with quite simple interventions such as:

• A spotter

• A mat

• A correct and thorough understanding of the task/trick about to be performed

• Good grip

• Good strength

• Modification of the task/trick first before attempting full version

• Common sense/not taking poorly thought-out risks (with no back up plan)

Sometimes though, despite all good intentions, injuries do occur. And the result of these injuries can be life changing if not managed correctly. So, we want to help you know more about concussions so that you’re able to quickly identify signs of a concussion and get appropriate treatment.

Let’s get into the nitty gritty details and learn about concussions !

What is a concussion?

A concussion has been labelled as a complex pathophysiological process affecting the brain (1) and is most commonly caused by a direct or indirect force to the head. And it causes a transient change in mental state. Of key importance to understand is:

• The degree of force of the hit/blow does not correlate to the severity of symptoms

• Concussion does NOT always involve loss of consciousness

• You do not need to have a hit to the head for concussion to occur

Yes, these points seem to confuse people quite often. But it is important to understand you do not need to be knocked out to experience a concussion and concussions can occur without contact to the head. A blow does need to occur but this can be to the neck or elsewhere to the body.

Basically, there just needs to be enough force to shake the brain up inside the skull.

Concussion is present on the traumatic brain injury (TBI) spectrum and is sub-grouped usually under the minimal and mild TBI categories, where moderate and severe TBIs are thought to cause considerable permanent physical or mental disability.

Most concussion (80-90%) typically resolves within 7-10 days. However, it can take hours or days for symptoms to appear and it may take longer for children and adolescents’ concussive episodes to resolve (2). It’s important to remember that no concussion is the same and the pathway of recovery varies greatly between person to person.

First Aid Management of a Head Injury

The three R's should be used here:

• Recognise there's been a head injury

• Remove (if safe to do so)

• Refer for help

Here a list of how to manage a range of different head injuries:

Scenario 1: If a fall onto the head is experienced by a pole dancer or aerialist, and they lose consciousness, an ambulance should be immediately called and the poler should not be moved until a paramedic is present.

Scenario 2: If a fall onto the head is experienced by a pole dancer or aerialist, and they remain conscious throughout but experience neck pain, shooting pain, loss of arm/leg strength, incontinence and/or the onset of pins and needles, an ambulance should be immediately called and the poler should not be moved until a paramedic is present.

Scenario 3: If a fall onto the head is experienced by a pole dancer or aerialist, and they remain conscious throughout and don’t experience any symptoms listed above, they should be ‘removed from play’. Ie. No more pole for that day. And they should present for medical assessment urgently (either local doctor or an emergency department, dependent on severity of symptoms).

As it can take hours for signs of a concussion to appear, they should be under the care of either a medical professional, close friend or family member for a minimum of 4 hours following the head knock. If they develop any symptoms or their symptoms worsen during that period of time they should be taken to emergency (even if they have previously attended and have been discharged). Hence it is important that concussion is seen as an evolving injury and monitored over many days.

Common symptoms of concussion as shown in a cohort study of 276 professional Australian Rules Football players and their likelihood of occurrence:

• Headache 83.3%

• Dizziness 64.9%

• Blurred vision 56.2%

• Drowsiness 44.9%

• Loss of consciousness 40.2%

• Feeling confused 39.1%

• Post-traumatic amnesia 37.3%

• Difficulty remembering 31.5%

• Difficulty concentrating 28.3%

• Nausea 22.8%

• Balance problems 22.8%

• Sensitivity to light 14.1%

• Sensitivity to noise 12.7%

• Vomiting 12.0%

Additional symptoms include: irritability, sadness, anxiety, slowed reaction time, and sleep disturbance/insomnia.

Note how only 40% of these athletes were unconscious at the time of injury.

Any poler with a suspicion of concussion should be evaluated immediately. A range of tests should be undertaken by a qualified health care professional to assess clinical symptoms, physical signs, cognitive impairment, sleep disturbances, balance and neurobehavioral features. And any head injury requires clearance by a doctor before returning to sport/exercise.

The legalities behind head injuries

If you are a studio owner or instructor it’s important your studio has a head injury policy that is adhered to and implemented after such injury. Along with immediate assessment of all suspected head injuries after they occur, it is recommended that all studios implement a policy which requires medical clearance of a head injury prior to resumption of classes – ideally that the poler is assessed by a doctor who is familiar with the Sport Concussion Assessment Tool (SCAT).

Concussion Modifiers

Now we mentioned earlier that no two concussions are ever the same, making it hard to deem their recovery pathway. And this is for a variety of reasons. However, patients with ‘concussion modifiers’ present have been shown to have a prolonged or even persistent concussion.

Some of these modifiers include:

• High number of previous concussions

• Previous concussions of higher severity

• Previous concussions lasting >10 days

• Prolonged period of loss of consciousness > 1 minute

• Amnesia

• Convulsions

• Frequent concussions, particularly those that were recent or close together in timing

• Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion

• Age < 18 years old

• Medical history of migraines, depression, anxiety, ADHD, learning disabilities, sleep disorders

• Psychoactive or anticoagulant medication

• Dangerous style of poling (high risk taker)

• Higher contact/collision sport

Concussion Management

Most concussions are managed well by your local doctor and physiotherapist with a step by step graduated return to pole/aerial required. Referrals to neuropsychologists and sports doctors are recommended for more complex concussions or those that don't seem to be settling with appropriate medical guidance. An example of a graded return to pole program for concussion is shown below for the use by health care professionals only. This is not considered medical advice & is not for individuals to use on themselves.

The program is based off the International consensus for return to exercise and the AFL's concussion protocol. Rehab for concussion requires complete physical and cognitive rest at the start until the acute symptoms have settled. And then this program takes the athlete through a return to light aerobic exercise, off the pole strengthening exercises, light pole conditioning through to heavy pole conditioning and a full return to tricks. Considerations for static & spin pole should also be included. And a gradual increase in cognitive load (work/schooling) is also recommended and should be guided by a medical professional.

💥 Disclaimer: This infographic is not medical guidance nor is it intended to substitute medical guidance. All polers/aerialists with a suspected concussion must seek an urgent medical assessment with a registered doctor. The purpose of this infographic is purely to educate pole dancers on the complexity of returning to pole after a concussion, and to provide a framework for other HCPs out there who treat pole dancers with concussions. This framework is based off an amalgamation of information from the International Consensus guidelines on return to exercise post concussion (2012) and the recently updated AFL concussion guidelines (2021) whilst we await the new concussion management guidelines from the Paris agreement in 2022.

Long-term consequences

There are serious complications associated with early return to pole post concussion when the symptoms haven’t resolved. The main two which are cumulative include cognitive deterioration (aka chronic traumatic encephalopathy - CTE) and second impact syndrome. Both of these topics are hotly debated in the concussion world at the moment but are associated with devastating effects. So, simple moral of the story is to not try to rush back after a concussion but to listen to your health care professional throughout.

Ok, let’s fast forward now to after your concussion has resolved. You’re symptom free, you’ve received medical clearance and you’re back at pole. Everything’s good right? Erm kind of..

Short Term Consequences - Musculoskeletal injury Risk

There is a growing body evidence suggesting athletes with concussion have a significantly increased risk of sustaining musculoskeletal injury when they RTP. Here are a few recent studies demonstrating that increased risk:

• Players who sustained a concussion in a group of elite European soccer players were at a 50% increased risk of musculoskeletal injury within the next 12 months, and were at a 70% increased risk to sustain an acute injury as opposed to an overuse injury (3).

• In a group of college athletes, concussion resulted in a close to 2x-increased risk of a lower extremity injury within 6-12 months post concussion compared to normal (4).

• A group of NCAA division 1 athletes who sustained concussion demonstrated a 3.4x high risk of sustaining a lower extremity injury compared to non-concussed athletes within the first 3 months of returning to sport (5).

• A slightly earlier study that involved NCAA athletes who sustained a concussion had a 2.5x increased odd of sustaining an acute lower limb injury within 3 months of returning to sport (6).

• A cohort of professional Rugby Union players who returned to play in the same season that they were diagnosed with a concussion, experienced a 60% increased risk of time lost due to an additional musculoskeletal injury compared to players without concussion (7).

• A lastly a giant meta-analysis confirmed synthesised all of these results and confirmed that athletes who had a concussion had 2 times greater odds of sustaining a musculoskeletal injury than athletes without concussion (8).

You get the gist!

There is obviously a lot to be said for the need to prevent subsequent musculoskeletal injuries in the post-concussion population!

There is a huge focus for us Physiotherapists in working with these athletes after concussion to ensure they are strong, have good active awareness and a good training load to prevent an overload injury.

So if you’re recovering from a concussion or if you know someone who is, send them this blog (after their period of cognitive rest) so they can learn more about the importance of recognising concussion and, most importantly, correctly treating concussion.

Online telehealth appointments can be booked with the Pole Physio via our ‘Book Online’ page that can be found here. Assessment and tailored rehabilitation are provided in accordance with best practice and evidence-based treatment to help you unleash your 'poletential'.

Until next time, train safe

The Pole Physio

x

We are looking forward to updating this blog with any change in information after the 6th International Concussion Consensus which is to be held by the International Olympic Committee in 2022.

References

1. McCrory P, Meeuwisse, WH, Aubry M et al., Consensus statement on concussion in sport: The 4th Internatinal Conference on Concussion in sport held in Zurich, November 2012. BJSM 2013; 47(5): 250-8.

2. McCrory P, Johnston K, Meeuwisse W et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. BJSM 2005; 39(4):196-204.

3. Nordström A, Nordström P, Ekstrand J. Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players. Br J Sports Med. 2014; 48:1447–1450

4. Lynall RC, Mauntel TC, Padua DA, Mihalik JP. Acute Lower Extremity Injury Rates Increase after Concussion in College Athletes. Medicine and Science in Sports and Exercise 2015; 47(12):2487-2492.

5. Herman DC, Jones D, Harrison A et al. Concussion May Increase the Risk of Subsequent Lower Extremity Musculoskeletal Injury in Collegiate Athletes. Sports Medicine 2017; 20:1-8.

6. Brooks A, Peterson K, Biese K, et al. Concussion Increases Odds of Sustaining a Lower Extremity Musculoskeletal Injury After Return to Play Among Collegiate Athletes. Am J Sports Med 2016; 44(3):742-7.

7. Cross M, Kemp S, Smith A, Trewartha G, Stokes K. Professional Rugby Union players have a 60% greater risk of time loss injury after concussion: a 2-season prospective study of clinical outcomes. BJSM 2016; 50:926-931.Munro CC, Mansinghani S, Conover H, Hart J.

8. McPherson AL, Nagai T, Webster KE, Hewett TE. Musculoskeletal Injury Risk After Sport-Related Concussion: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2019;47(7):1754-1762.