There are those who believe that a few hard knocks to the head is just part of growing up.
The Don Cherryesque world view holds that we should allow kids to bodycheck in hockey, to play tackle football, to head the soccer ball, to ride their bikes and skateboards without helmets and so on because it supposedly builds character and it's fun.
There's nothing fun about "getting your bell rung" (or other cartoonish euphemisms for concussion) and there is no redeeming value that comes from a traumatic brain injury (TBI).
If anything, we are only now beginning to understand just how pervasive concussions are and how damaging they can be to short- and long-term health.
Injury is, by far, the leading cause of death for children, teens and young adults – and half those deaths are due to brain injury.
TBI is also the leading cause of acquired disability in young people. About 150,000 Canadians end up in emergency rooms each year with traumatic brain injuries and about half a million Canadians are living with permanent damage from blows to the head.
Of course, not all of these injuries occur in kids playing hockey or football – motor vehicle crashes are the cause of the largest number and most serious head injuries – but those numbers are not insignificant.
Somewhere between three and five in every 1,000 children will be diagnosed with a concussion each year – and the real number is likely quite a bit higher because we only count the kids who end up in the emergency room or in hospital.
Dr. Mike Evans, founder of the Health Design Lab at the Li Ka Shing Knowledge Institute in Toronto, has prepared a great little whiteboard video entitled "Concussions 101: A Primer for Kids and Parents" that explains concussion symptoms (headache, dizziness, loss of balance, blurry vision etc.) and makes the important point that you don't have to lose consciousness to have a significant TBI.
Symptoms can also linger. Karen Barlow, an associate professor of pediatrics and clinical neurosciences at the University of Calgary, found that 13.7 per cent of kids still had symptoms three months after a mild concussion and, for 2.3 per cent, symptoms persisted for a year or more.
A concussion or other brain injury (especially repeated injuries) can change a child's personality and lead to learning disabilities and other health and social problems. It also substantially increases the risk of developing mental-health problems and dementia later in life.
Yet there are few effective treatments for traumatic brain injury, aside from rest and pain medication to relieve some symptoms.
Worse yet, there is no effective way of predicting who will suffer from post-concussion syndrome and who will bounce back quickly. (More than 80 per cent of people who suffer a concussion will see their symptoms dissipate in four to six weeks, but they remain at much higher risk of suffering another concussion.)
In fact there is not even a way to diagnose a concussion, or its severity, using imaging or a blood test. Rather, doctors use cognitive tests, questions to try to measure concentration and memory loss.
"There's just so much we don't know about traumatic brain injury," says Dr. Jamie Hutchison, the research director in critical care medicine at the Hospital for Sick Children in Toronto.
Given the severity and urgency of the problem, "there's a real push to identify and fill the gaps," he said.
Hutchison is part of Canadian and international research projects dubbed inTBIR and CanTBI, whose aim is to improve the prevention, diagnosis and treatment of traumatic brain injuries.
There are three initial objectives: To adopt common definitions and platforms so data can be easily shared and compared; to promote more collaboration between researchers; and to ramp up comparative effectiveness research, or CER. (CER is an approach where the outcomes of existing treatments are compared and measured; it is an alternative to clinical trials, where patients are randomnly assigned to treatments, and then the outcomes examined; the latter approach is much more time-consuming and costly.)
Canadian researchers are focusing much of their efforts on biomarkers, identifying proteins that are present after a concussion. For example, there is a protein in the glial cells of the brain, S100B, whose levels soar after a blow to the head. By measuring levels of S100B in patients and then tracking their recovery, researchers may be able, in the future, to create a simple blood test that could predict how well/quickly (or badly/slowly) a patient will recover. Similarly, biomarkers and genetic markers may be used to predict who is at high risk of concussion, and to identify targets for drug treatments.
Much of this work is still speculative but, as Hutchison says: "TBI is so devastating that we have to do everything we can to improve the outcomes of these kids."
What we know about traumatic brain injuries now is sobering. And what we don't know is humbling.
Without decisive action, TBI will be a giant medical and economic headache for far too many individuals, and society more generally, for many years to come.