Knocking out concussion in sports

Carolyn EmeryProfessor, Faculty of Kinesiology

Brent HagelAssociate Professor, Cumming School of Medicine

October 20, 2016

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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)

http://images.google.ca/url?sa=i&rct=j&q=play+at+your+own+risk&source=images&cd=&cad=rja&docid=DZM9RwNjHQgvvM&tbnid=6iqnUXr9mWyv6M:&ved=0CAUQjRw&url=http://www.leadsexplorer.com/blog/2010/01/02/what-is-the-most-important-in-the-b2b-buying-process&ei=tDFuUfDqLeahiALo-YBY&bvm=bv.45368065,d.cGE&psig=AFQjCNGYLpjNvWC21e8FIBVvDQRq76QvIQ&ust=1366262565762236

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

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