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Knocking out concussions in sport
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Knocking out concussion in sports Carolyn Emery Professor, Faculty of Kinesiology Brent Hagel Associate Professor, Cumming School of Medicine October 20, 2016
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Transcript of Knocking out concussions in sport
Knocking out concussion in sports
Carolyn EmeryProfessor, Faculty of Kinesiology
Brent HagelAssociate Professor, Cumming School of Medicine
October 20, 2016
Welcome!
Webinar series by University of Calgary scholars Information presented is a summary of the
scholars’ research Please submit questions throughout the duration of
the webinar Keep the conversation live on Twitter during the
webinar using #exploreUCalgary
Carolyn EmeryFaculty of Kinesiology
Physiotherapist and epidemiologist Professor, Faculty of Kinesiology and Cumming
School of Medicine Chair, Sport Injury Prevention Research Centre Chair in Pediatric Rehabilitation PhD from the University of Alberta; MSc from
the University of Calgary; BScPT from Queen’s University
Research focused on injury prevention in youth sport and recreation and the prevention of consequences of injury
• In particular: a focus on concussion and joint injuries and their consequences in youth
Brent HagelCumming School of Medicine
Injury epidemiologist Associate professor, pediatrics and
community health sciences, Cumming School of Medicine
Adjunct professor, Faculty of Kinesiology PhD McGill University; MSc University of
Calgary; BPE University of Calgary Research focused on injury prevention in
youth sport and recreation
Objectives
To understand the public health impact of concussion in youth sport and recreation
To be exposed to evidence-informed examples evaluating concussion risk and prevention strategies in youth sport and recreation (i.e. hockey)
To discuss the relevance and impact of evidence in concussion prevention in youth sport in practice and policy considerations
To consider secondary prevention of consequences of concussion in sport
Concussion
“Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.”
• Direct blow to head or other part of body with force transmission to head
• Rapid onset of short lived neurological symptoms• Functional disturbance rather than structural injury• May not involve loss of consciousness
McCrory et al. Consensus statement on concussion in sport: the 4th International Conference on Concussionin Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258
Societal burden of concussion
Sport injuries requiring medical attention• 15-18 years: 40 injuries/100 students/year • 11-14 years: 30 injuries/100 students/year
• (Emery CA, Tyreman H. Paediatr Child Health, 2009; Emery et al. Clin J Sport Med. 2006)
Sport related head injuries in the ED• <20 years of age = 66% of all SR Head Injuries• 18.2% in <10 years of age• 53.4% in 10 to 14 years of age • 42.9% in 15 to 19 years of age
• (Kelly et al. Clin J Sport Med 2001)
Concussions 15% of the injuries in youth sport• (Emery CA, Tyreman H. Paediatr Child Health, 2009; Emery et al. Clin J Sport Med.
2006)
Sport-related Traumatic Brain Injury
Morbidity and Mortality Weekly Report. 2007;56(29):733-737
Top concussion-producing sports
Alberta Children’s Hospital - Canadian Hospitals Injury Reporting and Prevention Program, 2011-2015
Youth sport-related concussionincidence rates
Pfister T, Pfister K, Hagel BE, Ghali WA, Ronksley P. The Incidence of Concussion in Youth Sports: A Systematic Review and Meta-analysis. Br J Sports Med. 2016 Mar;50(5):292-7
Symptoms
Consequences of Youth Sport Injury
Participation in sport & recreationSchool attendance Physical activity = overweight/obesityPsychosocial consequences – child and familyHealth care and indirect costs are high
Post Concussion Syndrome
29%-31% will have ongoing symptoms• (Zemek et al. JAMA. 2016;315(10):1014-1025; Babcock
et al. JAMA Pediatr. 2013;167(2):156-161) Ash Kolstad: Consequences of Concussion Video
Alberta Program in Youth Sport and Recreational Injury Prevention
GOALReduce sport & rec injuries
by 20% by 2020
FOCUSConcussion & injury in hockey
School based NMTSki/Snowboard injury risk
PRIORITIESBuild research capacity – trainees
Community engagement - KT
Overview
• Injury Prevention Research Model• Public Health Impact• Risk factors for Injury and Concussion• Primary, Secondary Prevention, and Rehabilitation• Future Directions
Sport Injury Prevention Research
1. Surveillance(extent of injury
problem)
3. Develop an intervention(validation)
4. Introduce the
Intervention(implementation)
2. Find the risk factors
(cause)
ExtrinsicIntrinsic
Public health significance of concussion in youth ice hockey?
• 20-35% of all injuries in youth ice hockey (ages 11-17)• Incidence Proportion = 5-20 concussions/100 players (1-4
concussions /team)• 13-30% of concussions are recurrent• 14% of children still symptomatic at 3 months (Barlow et al
2010)• 72% (10 days or greater) - Elite youth ice hockey (Schneider et al
2014) • 31% of NHL players symptomatic >10 days (Benson et al 2010)
NIH 2007, Emery et al 200,2010,2012, 2013
Youth vs adult ice hockey concussion rates
Emery & Meeuwisse (2006, 2010, 2011, 2013)Atom (9-10): 0.24/1000 player hoursPee Wee (11-12): 1.47/1000 player hours Bantam (13-14): 1.3/1000 player hoursMidget (15-17): 1.3/1000 player hours
Agel & Harvey (2010)NCAA Males: 0.72/1000 athlete exposuresNCAA Females: 0.82/1000 athlete exposures
Benson et al (2011)NHL: 1.8/1000 player hours over 7 seasons
National Hockey LeaguePee Wee (11 and 12 years old)
A dynamic, recursive model of etiology in sport injury Meeuwisse et al 2007
Previous concussion
Body checking
Game
Contact Sports
Dizziness, Neck pain, Headaches at baseline
Smaller size
Clinical Measures?
Sport-related Concussion
Modifiable?
Injury prevention
Specific strategies used to prevent injuries: Rule changes
Body checking policy Head contact rule enforcement 2011 STOP program Fair play
Alberta (BC) vs. Quebec (no BC) Pee Wee game injury rates
01
23
45
Gam
e in
jury
rate
per
100
0 ga
me
hour
s w
ith 9
5% C
I
injury concussion injury>1week time loss concussion>10days
Alberta Quebec
Game-related injury rates in Pee Wee (age 11-12 years)
All Injury: IRR = 3.26 (95% CI; 2.31 – 4.60)Concussion: IRR = 3.88 (95% CI; 1.91 – 7.89) Injury (>7 days time loss): IRR = 3.30 (95% CI; 1.77 – 6.17) Concussion (>10 days time loss): IRR = 3.61 (95% CI; 1.16 – 11.23)
Bantam game injury ratesby province
02
46
Gam
e in
jury
rate
per
100
0 ga
me
hour
s w
ith 9
5% C
I
injury concussion injury>1week time loss concussion>10days time loss
Alberta Quebec
Game-related injury rates in Bantam (age 13-14 years)
All Injury: No difference IRR = 0.85 (95% CI; 0.63 – 1.16)Concussion: No difference IRR = 0.84 (95% CI; 0.48 – 1.48)Injury > 7 days time loss: IRR = 0.67 (95% CI; 0.46 – 0.99)Concussion > 10 days time loss: No difference IRR = 0.6 (95% CI; 0.26 – 1.41)
Alberta (BC) vs. Ontario (no BC) Non-Elite Pee Wee injury rates
Injury: IRR = 2.97 (95% CI; 1.33 – 6.61)*Severe Injury(>7 days): IRR = 1.76 (95% CI; 0.77 – 4.04) Concussion: IRR = 2.83 (95% CI; 1.09 – 7.31)* Severe Concussion (>10 days): IRR = 2.08 (95% CI; 0.62 – 6.94)
Emery et al 2014
National policy change; Alberta before and after Pee Wee policy change
Multivariable Poisson Regression
Game Injury: IRR = 0.50 (95% CI; 0.33 – 0.75)*Severe Injury(>7 days): IRR = 0.40 (95% CI; 0.24 – 0.68) Concussion: IRR = 0.34 (95% CI; 0.21 – 0.56)* Severe Concussion (>10 days): IRR = 0.52 (95% CI; 0.29 – 0.92)
*Adjusted for cluster, year of play, previous injury/concussion, level of play, position, attitudes toward body checking, player size, exposure hours offset
Estimated reduction of 1000 injuries
(>400 concussions) in Pee Wee players
in Alberta – evidence-informed
Pee Wee hockey
Bruce #15 – 11 years oldElite + Previous hx
Alberta 2012/13
John #5 – 11 years oldElite + Previous Hx
Alberta 2013/14
Concussion 26%
Concussion 6%
What has happened?
USA Hockey Board (June 2011) – policy change
Ontario Hockey (May 2011) and BC Hockey (June 2012) – eliminate body checking non-elite levels (ages 11-17 – 70%)
Hockey Canada Board (June 2013) – national policy change
Hockey Calgary/Edmonton (June 2015) - eliminate body checking non-elite levels Bantam (ages 13-14 – 70%)
SUCCESS – DRIVEN BY COMMUNITY SUCCESS – DRIVEN BY COMMUNITY NOT RESEARCHERNOT RESEARCHER
What about other rules and regulations?
Did “zero tolerance for head contact” rule enforcement in 2011 change the risk of game related concussions in
youth ice hockey players?
Did “zero tolerance for head contact” rule enforcement ↓ risk of game related concussions in youth ice hockey players?
Maciek Krolikowski MSc
Concussion Risk pre- and post- 2011zero tolerance head contact rule change
Head contact mechanism?Referral bias?
M Krolikowski
Head Contact Policy Change
Not evidence-informed
Injury prevention
Early detection of concussion andprevention of progression,complications, and disability Pre-season examination
identify risk factors (i.e. previous concussion, symptoms, clinical measures)
Pre-season trainingmodify risk factors related to symptoms,
strength, balance, other clinical measures
2. Secondary
“Safe to Play”A longitudinal research program to establish best practice in the prevention, early diagnosis, and management of sport-related concussion in youth ice hockey players
Safe to Play
Safe-to-Play MR Study B Goodyear, R Frayne
Diffusion Tensor Imaging (DTI)• investigates the integrity of the
functional connections of the brain
Resting-State fMRI• measures the diffusion (random motion)
of water molecules in tissue
Perfusion MRI• provides whole-brain images of cerebral
blood flow
Hockey Canada Skills Test
• Forward agility weave Forward/backward
speed skate Transition agility 6-Repeat Endurance
Skate
Cervical and vestibular measures K Schneider
Cervical Flexor Endurance test Cervical Flexion Rotation test Cervical Rotation Side Flexion test Head Perturbation Test
Clinical Dynamic Visual AcuityComputerized Dynamic Visual Acuity Functional Gait Assessment Walk While Talk Test SCAT3: BES and Tandem Gait
Management and rehabilitation
Primary outcome: # days to medical clearance RTP
Treatment Group Education General range of motion /stretching/strength Orthopaedic physiotherapy Vestibular rehabilitation
Control Group Education General range of motion /stretching/strength
Physiotherapy Management Schneider et al 2012
Results
The participants in the treatment group were 10X more likely to be medically cleared to return to sport than the participants in the control group at 8 weeks
Education - RCT
Future directions?Thinking outside the bubble!
• Focus shifting from elite to recreational youth hockey where public health impact will be the greatest
• Build research capacity through interdisciplinary opportunity (basic science, clinical, population health)
• Continue to develop, implement and evaluate Injury Prevention Strategies (Primary, Secondary, Rehabilitation)
• Continue to validate measures of risk – extrinsic and intrinsic
• Develop Standard of Practice in Concussion prevention, evaluation and management
• Continue emphasis on Knowledge Translation
Resources
Parchutecanada.org
www.sportmed.ucalgary.ca (acute injury clinics)
Acknowledgements
IOC Research Centre
Ebook
For tips on recovery, please download our ebook athttp://www.ucalgary.ca/explore/concussions-top-
tips-recovery
Thank you
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Information presented today was a summary of the scholar’s research and the opinions expressed were based on the scholar’s field of study
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