Karolina Wisniewska is an eight-time Paralympic medalist in alpine skiing, a World Champion, and an Overall World Cup Champion. In 2007, Karolina was the first Paralympian to be awarded a place in the Canadian Ski Hall of Fame, and in 2017, she was inducted into the Canadian Paralympic Hall of Fame. During her career, she won countless medals and podium places. But she also suffered many crashes and concussions. In fact, in 2003, she retired for the first time from sports after a concussion. Her story is a first-hand experience on what it means to suffer a concussion as an elite athlete within a competitive environment.
Dr. Jamie Kissick is a sports physician who has dedicated himself to sports concussion. Their fireside talk is educative and gives both sides of the story.
THE RISK OF CONCUSSION IN PARASPORTS
Dr. Jamie Kissick (JK): Karolina, as a former alpine ski racer, I know you have had some experience with concussion.
Karolina Wisniewska (KW): Yes, this is a sport in which crashing and injuring yourself is pretty common. That being the case, and that I started ski racing at the age of six, I’m not sure that every single concussion I have had was diagnosed. Still, I have had at least seven diagnosed concussions. And likely five or more that went undiagnosed. Most (but not all) happened over a long—and generally happy!—ski racing career.
I think I am slightly more susceptible to concussions due to my disability. My cerebral palsy affects my balance, my motor coordination, and my depth perception. I also wonder whether I am more susceptible to concussion as a woman?
JK: Unfortunately, our current level of knowledge regarding concussion in Parasport athletes is not great. There has generally been a lack of research on this subject. This is something the IPC Medical Committee and clinicians and scientists throughout the world are working towards changing. Most of the concepts are the same. But, for example, the balance tests in common assessment tools can’t be used for athletes in a wheelchair.
FEMALES MAY SUFFER CONCUSSION MORE OFTEN THAN MALES
The evidence does indicate that once you have a concussion, you are at an increased risk of having another concussion in the future. But let me respond to your question about whether you are more susceptible as a female. There are indeed studies suggesting that females have a higher rate of concussion than males in comparable sports, for example skiing. Fairly recent studies showed that females report higher post-concussion symptom scores than males. In other words, they experience more and more severe symptoms. Women also had a longer recovery period.
Why this is the case, we don’t know… There are many theories. Some say that the weaker neck muscles in females allow more head movement with impact. Others describe hormonal and blood flow differences. And then there are those that say females are more likely to report symptoms than males. We need a lot more knowledge here, just as with Para athletes.
KW: A few years ago I spoke on a panel about concussions in sport set up by Canada’s Governor General. He is a former athlete himself. It was really interesting to compare the two panels: all of the professional athletes were men, and all of the amateur Olympic and Paralympic athletes were women. Of course, each athlete’s story was their own. Still, there were clear differences between the two groups: not only in terms of financial status but also in terms of how concussions were diagnosed, etc.
YOU DON’T NEED TO HIT YOUR HEAD TO SUFFER A CONCUSSION
KW: It seems that people are aware now of the dangers of concussion in sports like football and hockey. But they are perhaps less aware of it in other sports like alpine skiing, speed skating, trampoline, etc. And I think there is also a bias that says that women don’t go as hard or crash as hard. So, they aren’t as likely to get concussions. I even had a coach say to me once, “You hit your face, not your head, so it can’t be a concussion.”
JK: In fact, you don’t even have to hit your head to get a concussion! The rapid, sudden movement of the head after an impact can cause a concussion. Interestingly, one study showed that athletes of both genders who sought care earlier post-injury had a shorter recovery. At the same time, other studies suggest females may take longer to seek care after a concussion. And we know some athletes don’t seek care at all but try to “play through”. What is your experience?
KW: I never actually did not report a concussion. But there were many times that I crashed and thought I was okay—only to find out later that I had concussion symptoms. For me, and for those around me, it was a question of lack of knowledge and education about concussions.
RECOGNIZING THAT YOU HAVE A CONCUSSION IS PARAMOUNT
JK: The 5th International Conference on Concussion in Sport’s consensus statement described the 11 “R’s” of concussion. The first of these, and in my mind, the most critical, is “Recognition”… Recognizing that a concussion may have occurred. And taking the right steps to keep yourself or your athlete safe. That begins with stopping the sport or activity. In fact, everything starts with this.
If it is not recognized the athlete may be concussed, and they stay in the game, they risk a more severe injury. There is the rare, but usually fatal “second impact syndrome.” It describes a situation where a further impact to someone with an acute concussion causes brain swelling. However, the most likely risk is more severe and prolonged concussion symptoms. A further risk is another injury. As a high-speed athlete in ski racing, if your judgment or reaction time is impaired, even just a bit, you are at greater risk of a crash.
KW: I agree. It is critical that all those involved in sport—not just athletes, but coaches, officials, teammates—are well educated about concussion. They must know what needs to be done if a concussion is suspected. It is important to see a doctor, not just ski patrol! You want to make sure you are properly assessed.
REMOVE, RE-EVALUATE, AND REST
JK: You’re absolutely right. Appropriate concussion management starts with recognition and removal, and assessment by a physician. This is important to rule out structural injury like skull fractures and bleeding in the brain. The athlete should rest for a day or two. Then, they can resume daily activities that don’t worsen their symptoms. This may mean some time off school or work as well as sport. When their symptoms improve, they may gradually increase physical and cognitive* activity—as long as this does not aggravate symptoms. This includes a sport-specific graduated return to play or competition program.
Only when symptoms are entirely gone, and after this graduated program and clearance by a physician, should the athlete return to full training. And only afterwards to competition. In my experience, many athletes don’t want to miss training and competition and try to return too early, before their symptoms have resolved. This most often only leads to even more time away—because symptoms usually get worse.
In looking back at your concussions, is there anything you would have done differently?
DON’T TRY TO BE TOUGH
KW: I think the number one thing I would do differently is not to be so tough. My instincts after a crash were always the same: get up as fast as possible and get off the course. It’s not actually a good instinct. If you’re injured, it’s OK to stay where you are and wait for someone to come to you.
You mentioned athletes wanting to return too soon after a concussion. When I was still competing, there is no question that I wanted to get back on skis as fast as possible. Every time I ever hit my head I would immediately think, “Oh no! Is this another concussion??” and be filled with dread. Sometimes it would take a few hours or days for me to realise and admit just how bad it was.
JK: You are retired from ski racing now. I know that is usually one of, if not the most, difficult decisions an athlete has to make.
KW: Absolutely. I actually retired twice, once in 2003 and lastly in 2011, from ski racing—both times because of concussions. Especially in 2011, I had a really hard time deciding what to do. I wanted to get back on skis. I didn’t want to retire. My coaches and teammates were wondering when I would be back on snow.
DON’T TRY TO MAKE TOUGH DECISIONS
At the same time, I actually had post-concussion syndrome and was in no shape to make such a huge life decision. A big lesson for me here is that, as an injured athlete, and one with a brain injury no less, you are 100% within your rights to focus on your recovery first. You can tackle any bigger decisions at a later time. This may sound obvious to some, but in the throes of a post-concussion situation, it is extremely hard to think straight, to be able to prioritize, or to make life-changing decisions.
After I finally decided to retire, it took me a long time to fully comprehend that I am no longer a ski racer or a high-performance athlete. And, without ski racing, I lost a huge chunk of my identity, of my life. I did a lot of things to try to feel better and, much like when I was an athlete, I tried to have a team of people around me to help me, whether that was Dr. Kissick, my friends and family, massage- and physiotherapists, or mental health professionals. I am really happy to say that I am healthy now and able to give back to the Canadian sport community through volunteering, whether as a coach or in my newest role as an athlete ambassador with Team Canada at the Tokyo 2020 Paralympic Games.
JK: Karolina, thank you so much for sharing your experiences. Any final advice to athletes reading this?
HONOUR YOUR RECOVERY
KW: I think it’s really important for all athletes to educate themselves about the risks in their sports and to educate themselves about concussions. Even better is when your coaches, your teammates, and team administrators are all also educated about concussions. That way, when you’ve hit your head you’ll at least know what to do: speak up about your symptoms and be your own advocate! Most importantly from my experience, you then have to have the patience to rest and follow post-concussion protocols in order to recover.
One of my team doctors said something to me that I have found so helpful in concussion recovery: “Having a concussion is like looking at the sun. If you stare at the sun all day, you don’t notice its path across the sky. It’s the same with concussion symptoms. You’re like the sun, you’re making tiny movements and improvements – you just don’t see it because you’re too close to it right now.”
*Cognitive refers to cognition: the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.
If you want to learn more about concussion, there are a number of excellent educational resources. Here are a few of them:
The Concussion Awareness Training Tool (CATT) website has a specific page for athletes: https://cattonline.com/player-participant/
Parachute Canada explain everything about concussion in a comprehensible way: https://parachute.ca/en/injury-topic/concussion/
The Heads Up Program of the Centers for Disease Control and Prevention focuses on tools for children, parents, and sport s:https://www.cdc.gov/headsup/index.html
Pink Concussions is dedicated to brain injury in females suffered in sports, violence, or the military: https://www.pinkconcussions.com
World Rugby Concussion Management is one of the most comprehensive resources out there and offers information in multiple languages: https://playerwelfare.worldrugby.org/concussion
Sport Australia also offers information specifically targeted to athletes: https://concussioninsport.gov.au/athlete
England Rugby‘s Headcase programme also offers modules for players, coaches, teachers, and officials: https://www.englandrugby.com/participation/playing/headcase
And, finally, a French resource from the Association québécoise des médecins du sport et de l’exercice: https://aqmse.org/outils-pratiques/coffre-a-outils-commotions-cerebrales/