Part one of a three-part series. For Part 2, click here. For Part 3, click here.
By the time Brodie Needham suffered her fifth concussion, her brain was already showing the effects of multiple impacts.
A former competitive gymnast, her coordination wasn't the same and classmates had long since taken to using the nickname "Bad luck Brodie." Sentences didn't make sense. Her schoolwork suffered.
And then there was the constant ringing in the 18-year-old's ears, the persistent headaches, the inability to focus. That all worsened after her fifth and final (so far), concussion in June 2014.
"Lots of times, I've had situations where friends or kids at my school are like 'You got a concussion a year ago, why are you still out?' or 'Aren't you better now?'" said Brodie, who took the summer off before her Grade 12 year to rest and as a former A-student struggles to succeed with a lightened workload.
"But really no, I'm not because it's not just an injury that heals quickly like a broken arm."
"I can't have too much stress or a lot of work to do and I can't focus for long periods of time so I have to take lots of breaks. If I'm doing too much I usually get a headache. I get frustrated very easily," said Brodie, a DP Todd secondary student.
She's hit her head hard enough to see stars every year since Grade 8.
"The more that I've had, the worse that it's gotten."
Studying the young brain
Her words are echoed by the research. After a brain injury, a person may be more susceptible to repeat injuries. The second, third, fourth concussions are often worse. The symptoms escalate with successive concussions. The length of time in between impact matters.
The above findings are mixed, as are those on the connection between concussions and functional impairments, concluded a 2014 study on concussions in youth sport by the National Academies of Sciences. But, it noted more research shows prolonged negative changes in cognition connected to brain injuries.
"The more prolonged the concussion symptoms, the easier it is to be concussed again and the higher the risks," said Janet Ames, a Prince George doctor.
Age must be taken into account when managing concussions, the Los Angeles-based Sports Concussion Institute said. The brain's frontal lobes mature until age 25, making damage to a developing brain especially concerning.
According to U.S. research, 53 per cent of high school athletes have already had a concussion before they start school sports. An April 2014 study funded by the Canadian Institute of Health Research started off by noting half a million youth across both borders have had a traumatic brain injury. The article, published in Plos One, looked at the long-term effects related to cognitive, emotional and social functioning.
Typically Ames will see a patient months after the fact, when it becomes clear the symptoms aren't going away.
"The problem is if you don't do it properly at the beginning of the concussion it would appear that you have a greater chance of having post-concussion syndrome," said Ames, who was Chief Medical Officer for the Canada Winter Games.
Post-concussion syndrome refers to the severe cases where symptoms persist. The vast majority recover in a matter of weeks, but for some 10 to 20 per cent, according to a 2014 study by the Washington-based National Academies of Sciences, symptoms last months, even years.
That is Brodie's story.
A history of hits
Brodie's worst was her first five years ago, on a snowy November day as she and three friends hurtled on a toboggan down the Hart Highlands Ski hill.
The impact was hard enough to break the femur of the girl in front. Brodie, just behind her, lost consciousness, ultimately losing the hearing in her right ear, cracking her right temple and her jaw.
"I didn't really recover how I should have," she said. "No one really knew a lot about concussions then so we didn't really take the right precautions."
She took some time off school, but was back before long.
Ames stresses that athlete or not, those with brain injuries should follow "return to learn" guidelines. Athletes can then go through the "return to play" steps before they're competition-ready. Each approach stresses easing back into activities, and only proceeding to the next step when the former becomes manageable.
"There's just no excuse for not being up on concussion treatment, prevention, guidelines, what to tell parents, return to learn. It's all there," said Ames, referring to Parachute Canada as a good resource.
"It's really no different than any other injury," Ames said.
Take, for example, returning from a knee ligament injury.
"It takes less force to injure that ligament again because it hasn't healed."
A common misconception, Ames noted, is that a concussion equals blackout. In truth, less than 10 per cent of sports-related injuries leave athletes unconscious, according to the Sports Concussion Institute.
By the time Brodie's mother Lori Needham got to the hospital that November 2010 day, Brodie was awake, but dazed.
"They treated it like a trauma, and so Brodie was laying on stretcher totally out of it with blood gushing out of her ear," Lori said.
Brodie would remain deaf in that right ear for years until a surgery reversed the injury. It didn't solve the constant ringing.
"It's almost like static on a TV, like high pitch static all the time," Brodie said.
Eight months later in summer camp, she was clocked in the back of the head during an activity.
"I would get my letters mixed up, and when I was reading sentences, they wouldn't come out as proper sentences. They didn't make sense."
One year later, she was hitting rocks with a stick. Her hand-eye coordination was no longer reliable, so she grabbed a bigger rock, threw it up, missed and it knocked her out. The next summer, she got whiplash from a car accident, but movement of the brain constitutes damage. Then last June, a partner backflip gone wrong. Five-second blackout, her fifth concussion.
Lori said it has been hard to be the person constantly telling her daughter no.
"It must feel like to her that she's being punished," Lori said. "I hate to say if we would have done things way different, if we would've known. We might not of, because an active kid wants to be active and it's really hard to keep them at rest."
This time, Brodie had no choice but to change her daily routine. This school year she's enrolled in two academic courses and her only extracurricular is singing and even that is cut to the bare minimum. A yoga class has made a difference.
Hearing stories has helped her accept this new reality, and is one of the reasons Brodie is willing to share hers.
Calling it quits
It can be difficult convincing concussion patients to take a step back, not to rush their recovery, Ames said.
Seeing Sidney Crosby sit out 10 months before he was cleared to play hockey has helped parents, coaches and kids understand how dangerous hits to the head can be.
Ames remembered a comment to a young athlete during competition: "If they can take Sidney Crosby out, I can take you out."
She sees that as progress.
"It's not all doom and gloom but we're still not getting everybody," Ames said.
Ames is passionate about early intervention. She'd like to see all coaches be first responder trained and better understanding of the recovery steps.
"The assumption is that everybody's brain will eventually heal and they'll just be fine.
The problem is we don't know that and we don't know when they'll get better," said Ames. "There's no time frame. When else do we really say that? That's why when I counsel people I do it in little achievable bites, try not to say too much at the beginning."
For Brodie, who sees herself as an active overachiever, limiting herself is a constant struggle.
"I've definitely had to change a lot of who I used to be," said Brodie, who will have to take this summer off too and delay any plans for university. Doctors have told her it will likely take five to seven years before the end of her symptoms - a far off prospect for a teenager.
"She's been labelled in so many ways," added Lori. "There's so many little things that they say that are really not fair."
Brodie nodded, piling on her own examples.
"'Typical Brodie' or 'Bad luck Brodie.' That's what lots of people call me."
"But we're not sure if that would have been her normal way or if it's because of all (the concussions)," Lori said. "It's hard to know exactly who she is because of this, in a way."
"I try not to take a lot of stuff to heart," Brodie said. "I just understand that they don't really know what's going on."
Even so, she hopes her message helps people understand one thing: "You need to know that there are long term effects that can happen if you don't take the right precautions and do what you need to do to get better."
