Head Trauma

I play football and suffered a concussion just a couple of weeks ago. I'm planning a vacation to go diving; could my concussion be a problem?

"Head trauma" refers to a head injury sufficient to cause prolonged unconsciousness or persisting brain dysfunction. Mild head injury without unconsciousness rarely has lasting effects.

Fitness & Diving - Two principal concerns exist:

1. Post-traumatic epilepsy. This risk is directly related to the severity of the injury and the time elapsed between the injury and your plans to dive. Penetrating head wounds with brain disruption have a high risk of post-traumatic seizure; head injuries resulting in brief unconsciousness do not. With mild head injuries, risk falls sharply with time; with penetrating head wounds, long-term risk is less predictable.
2. Cognitive loss. Defects in memory, understanding and concentration are obvious risks in diving. This is best evaluated by social, school and job performances. If these skills are intact, there is probably no reason to restrict diving. Diving in itself does not worsen the effects of head injury.

Concussion is a condition shrouded in misunderstanding and management myths, in spite of the vast amount of research and publications on the subject over the past 10 – 20 years.
In essence, concussion involves an alteration in mental status as a result of trauma. This need not involve a loss of consciousness and, by definition, results from a functional brain disturbance rather than a structural injury. The symptoms can include ‘somatic’ symptoms (headache, photophobia, dizziness, nausea, fatigue, etc.), cognitive symptoms (impaired concentration, decreased memory, etc.) and emotional symptoms (anxiety, sadness, irritability, etc.). In addition, there are various clinical signs that may occur with concussion, including cognitive (‘thinking’) changes, behavioural abnormalities and physical signs (including poor balance).

The mainstays of management of concussion are physical and cognitive rest.  There is little else that is usually required, in the vast majority of cases, other than the relief of the concussed patient’s specific symptoms – eg. simple analgesics for a headache. Most concussions have resolved within 1 – 2 weeks.

However, the concern with this apparently simple condition is that concussion can be complicated. These complications can include:

Post-concussion syndrome
the symptoms of concussion can continue for some months, impairing not only the patient’s sporting performance but even their activities of daily living.

Intracranial structural injury
concussion can accompany a more severe brain injury, like a bleed on the brain, which may only become evident some hours – days after an initial assessment of the patient has been made.

Diffuse cerebral injury
sometimes referred to as the ‘second impact syndrome’, a second concussion occurring before the complete resolution of the first concussion can cause a severe swelling of the brain, which is often fatal.

Chronic traumatic encephalopathy
repeated concussions have been shown to cause long term brain dysfunction, like the ‘punch drunk’ dysfunction of boxers who have taken too many blows to the head.

The concerns regarding scuba diving and concussion, therefore, are the following:

• Physical exertion is currently thought to delay the resolution of concussion. Carrying heavy dive equipment, pushing a boat on a shore launch, swimming against a current, etc. are all activities that might delay the healing of a concussion.
• The diving environment is not without the risk of contact or collision – in fact, far from it. So if a diver bangs his head during a dive, before the complete resolution of a previous concussion, there is a risk that he may develop the ‘second impact syndrome’. Although extremely rare, this potentially devastating injury can be prevented by simply not incurring the risk.
• The ongoing symptoms of the post-concussion syndrome are indistinguishable from some of the symptoms of decompression sickness. Diving while still symptomatic of a concussion may result in a diver being evacuated for recompression therapy. This will do nothing to hasten the resolution of the concussion (according to the published research), but will almost certainly result in the inappropriate use of resources.

The advice then if you have suffered a concussion and are planning a dive vacation, is that you consult a physician well-versed in the management of concussion. A complete resolution of the condition is required before you can be declared fit to dive.