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Head start

Pan Am Clinic is taking a lead role in the research, diagnosis and treatment of concussions.

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Winnipeg Health Region
Wave, September / October 2012

It's hard to keep a young athlete away from a game she loves.

Just ask Sara Vis.

A couple of the years ago, Vis, then in Grade 10, was playing in a hockey tournament in Regina when she was cross-checked into the boards. It was a classic dirty hit, one that left the Winnipeg teenager with a brief loss of consciousness and a concussion.

"I don't remember anything from the time of the hit until the ambulance ride," she says.

But she does remember the common concussion symptoms that followed: muddled memories of what happened, nausea for the first few days, difficulty reading or watching screens, and "massive headaches" when she did an activity that raised her pulse rate. In the aftermath of the hit, she missed one week of school and the symptoms lingered for about three weeks.

Still, her love of hockey prompted her to return to the ice just two months later at a tournament in Brandon where she very nearly suffered another concussion when a collision with the boards gave her a whiplash injury.

"My doctor was not happy with me when I saw him and told him I went back," she says.

That should not come as a surprise. Recent studies suggest children with concussions appear to be more susceptible to second-impact syndrome, in which even a minor second injury can lead to serious results. And another study suggests that girls are more at risk of serious consequences from concussions, and may take longer to recover.

Fortunately, Vis has had no lingering effects from her head injuries. But her experiences with concussions have taught her that they are not to be taken lightly. "I definitely wouldn't have been so quick to go back to that tournament, but if you really love something like I loved playing hockey, you don't want to stop."

Vis, now 18, out of hockey and beginning studies at the University of Manitoba, is sharing her experiences with concussions as concern grows over the potential impact of head injuries, especially on young athletes.

Her story illustrates several of the research, treatment and prevention challenges facing both the health-care sector and the sports community. Among those challenges: better understanding of what kind of impact causes a concussion, developing a protocol for deciding when an athlete can return to sport, and educating players, coaches and parents so that all concussions result in medical attention.

 

Dr. Wayne Hildahl, Chief Executive Officer of the Winnipeg Health Region's Pan Am Clinic, which specializes in sports medicine, says the growing interest in head injuries is a good thing.

A former football player with the University of Manitoba Bisons in the 1970s, Hildahl says concussions were not always taken seriously. As he explains, players and coaches alike used to shrug off "having your bell rung" as a part of the game. "You'd go back in the next play and have no idea what you were doing."

That started to change in the last decade or so as it became clear that concussions were a serious health issue, and new research confirmed that head injuries could have lingering effects.

Dr. Peter MacDonald, Head of Orthopedics with Pan Am Clinic and Leader of Orthopedics for the Winnipeg Health Region, says the new research underscores the fact that concussions are not just a temporary injury and that there is much more to learn about how they affect the brain.

"With concussions," explains MacDonald, "we're injuring the chemical pathways of the brain. You're shaking those neurons to the point that they're not functioning."

Compounding the problem is the fact that the damage is taking place at a microscopic level, making it virtually impossible to say how long someone might take to recover. "Nobody in the world is able to say, 'You're going to be out for two days and you're going to be out for two months,'" MacDonald says.

In response to the growing concern about head injuries, Hildahl says the Pan Am Clinic is taking action to better understand the causes and prevalence of concussions and ensure that the Winnipeg Health Region is following the best practices for diagnosing and treating them.

"As the research gives us more answers, I want to be able to evolve our treatment protocols," he says. Indeed, Hildahl would like to see Winnipeg become a world leader in research, diagnosis and treatment of concussions. To that end, the Pan Am Clinic team is building research collaborations across disciplines, involving neurosurgeons, neurologists, neuropsychologists, anaesthesiologists, sports medicine physicians, primary care physicians and athletic therapists. They're also collaborating across the border with a colleague from the Mayo Clinic in Minnesota, Dr. Mike Stuart, who serves as medical director of USA Hockey and whose son, Mark Stuart, plays for the Winnipeg Jets.

One of the first steps in the effort to learn more about concussions was taken in July when the clinic sent surveys to more than 15,000 amateur hockey players, parents and coaches to get a better handle on the prevalence of concussions and how they were being treated within the health-care system.

With support from the Winnipeg Jets Foundation, the Clinic surveyed 7,443 Manitoba hockey players aged 13 to 21, 6,627 hockey parents and 1,392 coaches. So far, preliminary data from the first 700 responses shows 46 per cent of those who responded to the survey suffered concussions last season. Twenty-six per cent went to an Emergency Department, 35 per cent sought treatment in their doctor's office, while 23 per cent went to a sports medicine clinic.

"What we've seen is it's definitely higher than what's reported in the (scientific) literature," says Dr. Jeff Leiter, Albrechtsen Research Chair at the Pan Am Clinic and Executive Director of the Pan Am Clinic Foundation.

Previous research done elsewhere between 2007 and 2011 turned up a wide range of incidence rates for concussions, from less than one concussion per 1,000 player-hours to more than 21 per 1,000 player-hours. The number of player-hours refers to the number of players on the ice, times the length of the game or practice. One team generates six player-hours in a one-hour game and 18 player-hours in a one-hour practice. At the Midget level (15 to 17 years of age) alone, Manitoba has 110 teams generating a total of 89,000 player-hours in games and practices in a season.

 

Leiter cautions that the numbers aren't complete enough to provide an estimate of the concussion rate among players. It's likely that players (or parents of players) affected by concussions would be much more likely to respond to a survey than those who weren't injured. But even so, the early response indicates that concussions affect a large number of young athletes - and the health-care system needs to prepare for a growing number of patients as awareness of concussions increases. In fact, Hildahl believes the health-care system will experience a "tsunami" of new patients in the years to come.

Leiter says data gathered through the clinic's survey will help the Region prepare for the surge in new patients. "If we're going to set up a concussion treatment program, how many people are we going to expect to see?" asks Leiter, who played university and minor league hockey before getting his Master's in sport biomechanics and PhD in anatomy.

Of course, the survey has other goals beyond quantifying the problem. The project also examines the level of knowledge about concussions among players and coaches and the administrative systems in place regarding return to play, such as team or league policies regarding players receiving medical approval before coming back.

Players were asked if they were familiar with the ThinkFirst Smart Hockey concussion education program, which includes a video aimed at young players about causes, symptoms, prevention and follow-up after a concussion. Few players knew about the program, says Leiter, suggesting that more needs to be done to educate young players.

The Pan Am research also looks into the impact of concussions, asking participants how long it took them to return to play, if they missed school as a result of their concussion and how much school they missed.

While the majority of people with concussions are back to normal in seven to 10 days, says Leiter, some of the respondents to the survey indicated that they missed entire seasons of hockey. That variation in recovery time is another mystery to researchers. Why, they want to know, do some people recover more quickly? Are some people more predisposed to concussion?

"About almost every aspect of concussion we have lots to learn," says Dr. Anthony Kaufman, a neurosurgeon who practises at the Health Sciences Centre and has worked with the Winnipeg Jets.

Part of the challenge for medical science is that the damage in a concussion is at a microscopic level. Then there's the complexity of the brain.

"The connections between neurons are so complex," says Kaufman. "It's like the spreading of roots of a tree.

"It's apparent that an injury in a concussion is a reversible injury, so it's not the destruction of nerve cells. It may be that the connections can be restructured," he says.

Knowing when a player like Vis can return to sport - or to other activities - is one of the big mysteries of concussions. Pan Am staff members hope their research will help them get a better handle on both recovery times and predicting which kinds of impacts are most likely to cause concussions.

Leiter also intends to launch a research project to help better understand the causes of concussion. He plans to place cameras at the MTS Iceplex hockey complex in order to record games. Then, when there's a report of a player suffering a concussion, he will be able to analyze the hit that caused it.

Outside of professional hockey, where television cameras capture every check and collision, there's seldom any way of examining the impact that led to a concussion, notes Leiter. Equipping the Iceplex with cameras will allow for hits to be examined in detail.

Leiter also plans to use accelerometers - instruments that measure acceleration - attached to players' helmets in order to obtain more data on the hits. Other research with accelerometers has shown that impacts involving 50 to 120 times the force of gravity (G force) cause concussions. "But some players hit with 100+ Gs don't get concussions, while some do with 50 Gs," he says.

Blindside hits are particularly likely to cause concussions, perhaps because the person being hit is unable to brace for impact. As well, hits involving rotational movement seem more likely to cause concussion than straight-on hits. Part of that is basic physics. When there's a rotating movement, shear forces are created in the brain that may tear connections in the brain loose. Data from the accelerometers will help to clarify the subject.

Of course, MacDonald, who also serves as Medical Director with the Winnipeg Jets, and before that for all 15 seasons of the Manitoba Moose, has a pretty good idea of at least one reason for the recent rise in concussions, especially at the professional level: bigger players colliding at higher speeds. "Before, you might see one or two concussions a year (with a professional team)," he says. "Now you see one or two a month."

And then there is the equipment, especially what he calls "Robocop" style shoulder and elbow pads that allow players to check each other much harder. "You look at the old Wayne Gretzky-style shoulder pads and they were paper thin," he says. The new armour-style equipment and the hard-hitting play it allows have made their way into youth hockey as well.

In addition to understanding how to better diagnose and treat concussions, MacDonald believes research will also lead to changes in the game at the youth level, and may influence the current debate on the age at which body checking is allowed in hockey. Part of the problem in youth hockey, he says, is the large differential in size and speed among children who are the same age. As well, he says, growing understanding may lead to new rules for penalizing all contact to the head - accidental as well as intentional.

While the discussion in Canada focuses largely on hockey, concussions are a concern in many other sports, including football and soccer. In soccer, one of the concerns is with deliberate impact to the head when players head the ball. MacDonald recalls spending three or four days feeling not quite right as a youth after a concussion in a flag football game.

Leiter plans to send the concussion survey to football players, parents and coaches following this year's season in order to get a better idea of the problem in that sport as well.

Bob Armstrong is a Winnipeg writer.

***

Can concussions be prevented?

Generally speaking, a concussion occurs when the brain is subject to stress, usually due to the brain bumping up against the skull. A head injury of this kind can result in memory loss, dizziness and headaches. Repeated concussions can cause permanent memory loss, loss of brain function and personality change. There are ways to reduce the risk of concussion and its effects. Here are a few suggestions:

  • Always wear protective equipment when partaking in sports, such as hockey. Although equipment will not necessarily prevent a concussion, proper helmets and mouthguards can reduce severity of injury.
  • Practise good sportsmanship. Don't bodycheck someone from behind. Sporting organizations should consider changing rules to reduce the risk of head injuries.
  • Play smart. Be aware of where the other players are on the ice. Do not skate close to the boards. Face the other player.
  • When accidents do happen, concussions can be severe. It is important to understand that receiving a second blow to the head before the first injury is fully healed can be fatal, even if the second injury seems minor.

***

When you suspect someone has a concussion

Diagnosing and treating concussions requires awareness of the problem on the part of all concerned: players, coaches and parents. Coaches must be up to speed on the latest information about concussions, learn about the kinds of situations that can lead to concussions and recognize potential symptoms in players. Likewise, players must understand that coaches watching a game may not always see a hit on a player than can lead to a concussion. That's why it is important for young athletes to tell their coaches any time a hit leaves them feeling dizzy.

The signs of concussion are:

  • Sensitivity to light or noise
  • Loss of consciousness
  • Seizure or convulsion
  • Pressure in the head
  • Nausea or vomiting
  • Balance problem
  • Blurred vision
  • Headache
  • Neck pain
  • Amnesia
  • Dizziness
  • More emotional / irritability
  • Nervousness or anxiety
  • Fatigue or low energy
  • Feeling "slowed down" or "in a fog"
  • Difficulty concentrating
  • Difficulty remembering
  • "Don't feel right"
  • Confusion
  • Drowsiness
  • Sadness

When a player is showing signs of a concussion, he or she should be taken to a quiet room so that a coach or trainer can conduct a sideline concussion assessment known as a SCAT 2.

The SCAT 2 is a simple checklist test that can be performed by a non-physician. The checklist includes 22 symptoms, such as headache, sensitivity to light or noise, nausea and confusion. As well, the SCAT 2 contains a few simple tests of concentration, memory and cognitive ability.

Here is a brief version of a SCAT 2, which can help identify possible symptoms of a serious head injury:

Memory function

Failure to answer all questions correctly may suggest a concussion.

  • What venue are we at today?
  • Which period is it now?
  • Who scored last in this game?
  • What team did you play last game?
  • Did your team win the last game?

Balance testing

Instructions for the tandem stance: Have the person suspected of suffering a concussion stand heel-to-toe with their non-dominant foot in back. His or her weight should be evenly distributed across both feet. The person should try to maintain stability for 20 seconds with his or her hands on their hips and their eyes closed. Observe the athlete for 20 seconds. If they make more than five errors - such as lifting their hands from hips, opening their eyes, lifting toes or heels, stepping, stumbling or falling - or remain out of the start position for more than five seconds, this may suggest a concussion. An athlete with a suspected concussion should be immediately removed from play, urgently assessed medically, should not be left alone, and should not drive a motor vehicle.

There are several SCAT 2 programs that can be downloaded to a smart phone or tablet device.

If the SCAT 2 test reveals any hint that a player may have suffered a concussion, he or she should be taken to the Emergency Department, their family doctor, or the Pan Am Minor Injury Clinic or Legacy Sport Medicine.

People, especially youth, with suspected concussions need to be watched as well, in case their condition worsens.

Dr. Peter MacDonald, Head of Orthopedics for Pan Am Clinic and Leader of Orthopedics for the Winnipeg Health Region, says the problem of concussions in sports creates special concern in areas where access to care is more difficult. In rural areas, he says, there's an even stronger onus on the coach to make sure that a player with a suspected concussion gets to a regional hospital where they can be diagnosed. "Most concussions don't get diagnosed properly," says MacDonald. "Most of the time, the kid comes off the ice and has a bit of dizziness."

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