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Dec 07

Get Concussion Smart: Making Headway in Sport

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The topic of Concussion has been at the forefront of news coverage for some time, whether in Professional or Amateur sports. While most incidents occur in team sports, there are instances in individual sports as well. Cheerleading, gymnastics (fall from High bar, uneven bars, balance beam, vaulting (landing), swimming (slipping on deck, crashing into pool wall), diving (High-Tower), trampoline, racquetball, tennis, etc.

There have been significant strides in the management and care of concussed athletes; however, there continues to be a lot of confusion among athletes, parents, and coaches regarding the proper management of an athlete with a concussion, particularly in the pediatric population.

The University of Calgary is one of the leading institutions on Concussion Research. The Integrated Concussion Research Program (ICRP) is a university-wide initiative to study concussion, which has brought together experts from the Cumming School of Medicine, Faculty of Kinesiology, and Faculty of Arts, with support from the Alberta Children’s Hospital Research Institute (ACHRI) and the Calgary based Hotchkiss Brain Institute (HBI).

The Problem ICRP is addressing

Mild traumatic brain injury (mTBI), including concussion, is a common occurrence. In Canada, approximately 250,000 concussions occur per year. However, concussions can be difficult to detect and diagnose, and can result in long-term problems. The ICRP was developed to address the growing concern about concussions, improve the lives of those who have experienced these injuries, and prevent concussions for upcoming generations.

The University of Calgary is leading a national study examining concussions and head injuries in high-school athletes in a $12-million project financed by the National Football League. The research effort, overseen by Calgary’s Dr. Carolyn Emery, involves 6,000 high-school students from across Canada who compete in rugby, hockey, football, lacrosse, wrestling, soccer, basketball and cheerleading. Thirty-five researchers, including the University of Calgary, monitor students over a three-year period before producing its findings and recommendations.

It is part of the NFL’s US$100-million Play Smart, Play Safe initiative that was organized in 2016 to improve player safety and has since expanded to include all levels of football as well as other sports. The NFL announced that it was paying out US$35-million for neuroscience research to five North American institutions, with the U of C being the only one in Canada (Calgary is coordinating its study with eight other Canadian universities from the University of British Columbia to McGill and Laval in Quebec).

According to Dr. Emery, there are three targeted areas to her latest study:

  1. An examination of rules and policy changes
  2. Equipment recommendations – proper-fitting helmets, mouth guards
  3. Training strategies, particularly when it deals with athletes new to a sport

“In rugby, we know a lot of players – particularly female players in high school – have often not been exposed to a contact sport before they engage in rugby in Grade 10.” Dr. Emery notes. “So we may be looking for things in terms of preparation for contact in games.”

Retired U.S. Army general Peter Chiarelli, chairman of the NFL’s Scientific Advisory Board, is a supporter of what the league has done after settling a class-action suit that will pay US$1-billion to thousands of former players who said they were suffering from football-related concussion issues. “I think we’re going to have a huge impact in reducing the burden of concussions in youth sports,” said Dr. Emery, who first pitched her study plan to the NFL’s Scientific Advisory Board in September 2017. “And I think we’re well-positioned to be a leader in this field internationally.”

Dr. Emery was celebrated for her work compiling and analyzing injuries in minor hockey over a five-year span. She conducted a comparison between peewee-aged kids in Quebec (11- and 12-year-olds) who played non-contact hockey and those in Alberta who played full-contact games. After it was learned Alberta peewees suffered three times as many injuries as their Quebec counterparts – a number higher than anticipated – Hockey Canada chose to ban bodychecking at the peewee level starting in the fall of 2013. Four years later, Hockey Canada announced that the new rule had produced “a 50-per-cent relative reduction in injury rate and a 64-percent reduction in concussion rate in 11-year-old and 12-year-old hockey players in Alberta.”

The NHL agreed to a non-class settlement that would pay US$18.9-million to more than 300 retired players who accused the league of failing to warn them about the risks of head injuries. “What we were looking for was translation,” Chiarelli says. “What that means is we wanted research we believed – and researchers had proven – is going to help patients in the short order; not necessarily research that is going to spawn a lot of research papers. We were looking for translational medicine, from the bench to the bedside.” The NFL had also funded a study based in London, England, that focused on head injuries and chronic traumatic encephalopathy (CTE) in jockeys. The research began in horse racing but was adjusted to include athletes in contact sports. It is not known how much funding the jockey study has received from the NFL. Chiarelli says the issue of head trauma has focused largely on football when it’s very much a societal matter. “There are 3.5 million Americans who report to emergency rooms every year with head trauma. This is a public-health crisis.” According to additional reports, youth account for more than half of the three million concussions that occur annually in North America. An estimated 1.6-3.8 million sports (and recreation) related concussions occur in the United States each year. During 2001-2005, children and youth, ages 5-18 years, accounted for 2.4 million sports-related emergency department (ED) visits annually, whereby 6% (135,000) involved concussions.

Sport     

Injury Rate per 1,000 Athletic Exposures

Women’s ice hockey                         0.91
Men’s spring football (American)   0.54
Men’s ice hockey   0.41
Women’s soccer   0.41

Concussions among US High School and Collegiate Athletes

Despite researchers reporting in 2007 that an estimated 300 000 sport-related traumatic brain injuries, predominantly concussions, occur annually in the United States, progress has been slow. Sports are second only to motor vehicle crashes as the leading cause of traumatic brain injury among people aged 15 to 24 years, according to researchers Gessel, Fields, Collins, Dick and Comstock.

The 6 Steps: Return to Play Guidelines Following a Concussion

The Canadian Coaching Association has provided its Guidelines for Concussion Protocol management. Although these are directed toward team sport athletes the 6-step guidelines can be applied appropriately to individual sport athletes.

Step 1: Symptom-Limited Activity

After an initial period of short Rest of 24-48 hours, light cognitive and physical activity can be initiated as long as they do not worsen symptoms. A physician, preferably one with expertise in managing concussions, should be consulted before beginning a step-wise return to learn and sport strategy

Step 2: Light Aerobic Exercise

Someone who can help monitor for symptoms and signs should supervise the athlete. The intensity and duration of aerobic exercise can be gradually increased over time if no symptoms or signs return during the exercise or the next day.

Step 3: Sport-Specific Activities

If team sport athlete – there should be no body contact or other jarring motions such as high-speed stops. If individual sport, avoid jarring motions. If symptoms or signs appear, return to the previous stage and only engage in activities that can be tolerated.  

Step 4: Training without Contact

If symptoms or signs return – return to the previous stage and only engage in activities that can be tolerated. If no symptoms or signs return– the time needed to progress from non-contact exercise varies with the severity of the concussion and with the individual athlete. Proceed to Step 5 only after 100% medical clearance.

Step 5: Training with Contact

If symptoms or signs return – return to the previous stage and only engage in activities that can be tolerated. If these persist consult the physician. If no symptoms or signs return, proceed to Step 6 the next day.

Step 6: Game Play or Competition

If the all-clear has been provided by a qualified health professional, the athlete can return to participation in gameplay or competition.

References:

Canadian Coaches Association (2018). Inside Coaching. 6 Step Return to Play Guidelines Following Concussion. Ottawa, ON, Canada.

Gessel, L.M., Fields, S.K., Collins, C.L., Dick, R.W., & Comstock, D. (2007). Concussion among United States high School and collegiate athletes. Journal of Athletic Training, 42(4), 495-503. Oct-Dec.

Maki, A. (2018, November 15). University of Calgary launches study on concussions with funding from NFL. The Globe and Mail. Retrieved November 20, 2018, from: https://www.theglobeandmail.com/canada/ alberta/article-university-of-calgary-launches-study-on-concussions-with-funding-from/

Patel, D.R., Fidrocki, D., & Parachuri, V. (2017). Sport-related concussions in adolescent athletes: a critical public health problem for which prevention remains an elusive goal. Translational Pediatrics, 6(3), 114-120. July.

University  of Calgary. Integrated Concussion Research Program (ICRP). Retrieved November 26, 2018, from: https://icrp.ucalgary,ca

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