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In Ontario, over 150,000 people are diagnosed annually with concussion in emergency departments and by primary care physicians. In 2016 there were 15,736 concussions diagnosed in the Champlain LHIN. It remains evident that both healthcare providers and patients feel ill-prepared to effectively navigate the healthcare system with respect to concussion care and management of persistent concussion symptoms.
The Ontario Neurotrauma Foundation,ONF has been working to provide clarity and evidence-informed direction with respect to post-concussion care for healthcare providers and patients by releasing the Standards of Post-Concussion Care and the 3rd Edition Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms for Adults over 18 Years of Age. Providers can use the resources to learn about up-to-date evidence-informed practices and recommendations. ONF’s goal is to streamline visits with healthcare providers and provide direction to patients and families to increase confidence about how, what and when care should be provided.
In October 2016, world leaders in the field of sport-related concussion (SRC), of which a large proportion are Canadian, met in Berlin to develop the latest statement on our current knowledge of the science of SRC. As a quick review, an SRC is a traumatic brain injury induced by biomechanical force transmitted to head causing functional disturbance. It does not require a direct blow to the head. Some of the new developments and highlights from the statement include:
– Assessment of mental status, cognitive functioning, sleep/wake disturbance, ocular function, vestibular function, gait, and balance is recommended
– Insufficient evidence for investigations such as EEG or MRI
– A new Sports Concussion Assessment Tool Version 5 (SCAT) was developed
– A brief period (24–48 hours) of cognitive and physical rest is appropriate for most patients
– Subsymptom threshold activities and submaximal exercise are encouraged (as long as symptoms are not exacerbated)
– Cervical spine rehab is recommended for neck pain/headaches
– Vestibular rehab is recommended for dizziness
– Return-to-play and return-to-school/work protocols can advance in parallel
– Children and adolescents should not return to sport until they have successfully returned to school
– Physiological dysfunction may be delayed relative to clinical recovery, suggesting that using a ‘buffer zone’ of a graduated return to activity/return to play progression before full return to contact risk may be appropriate
– Preinjury mental health problems and prior concussions appear to be risk factors for persistent symptoms.
– Greater acute and subacute symptoms are a consistent predictor of worse clinical outcome.
– The teenage years might be a particularly vulnerable time for having persistent symptoms—with greater risk for girls than boys.
– Strongest evidence exists for disallowing body checking in youth ice hockey
– Strong recommendations to mandate helmet use in skiing/snowboarding
– Mixed evidence for mouthguard but there may be an overall protective effect
The top 5 key messages from the 5th International Consensus Statement on Concussion in Sport
- McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport—the 5thinternational conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847.
- Shields, MD, CCFP, Sport and Exercise Medicine Fellow, University of Ottawa
Advisor: Taryn Taylor, MD, CCFP (SEM), Dip Sport Med
A concussion is a serious event, but you can recover fully from such an injury if the brain is given enough time to rest and recuperate.
Each year, U.S. emergency departments treat an estimated 173,285 sport and recreation-related concussions among children and adolescents. Concussion represents 9% of injuries reported in the National Surveillance in US high school sports.
In 2010-11, 19,880 Ontario residents visited an emergency room for a concussion, with children accounting for nearly 38 per cent of those visits. This represents an increase of 60% over the last decade.
Definition of Concussion
A concussion is a complex process affecting the brain caused by traumatic forces either by direct blow to head, face or neck or a blow elsewhere with a transmitted force to head. Rapid development of short term impairment in function occurs.
No loss of consciousness is necessary. It is a functional injury, no structural damage to the brain. 85-90% of concussed young athletes will recover within 1 to 2 weeks.
Diagnosis of Concussion
- Often under-recognized, under-diagnosed and under-reported!
- The most important step in diagnosis and management is reporting the injury to the coach, trainer or parent
- Evaluation by a physician should occur in the first few days following a concussion
There are many excellent Sport Medicine Physicians in Ottawa to help manage a concussion and assist with safe return to learning and play.
Implications of Concussion
- Post Concussion Syndrome: risk of prolonged or permanent symptoms such as headache, depression, concentration and learning difficulties if premature return to sport or if a 2nd concussion occurs before full recovery
- Chronic Traumatic Encephalopathy (CTE): progressive degenerative disease of the brain found in people with a history of repetitive brain trauma
- Second impact syndrome: although rare, it is not just a “scare tactic”, and most often occurs in athletes under 21 years
- Catastrophic increase in intracranial pressure causing paralysis, massive brain swelling, herniation, and death
- REST! It is the only known effective treatment for concussion
- Mental Rest (studying, working, reading, art/music)
- Physical rest (phys-ed class, practice, weights/resistance training, dry-land training)
- Monitor screen time (computers, video games, TV, texting, smart boards, tablets)
- It is always unsafe to return to play the same day/game while symptomatic
Concussion Return to Play/Activity Protocol
Rest completely until asymptomatic and return to baseline on IMPACT testing suggests resolution of concussion.
Progress to a step-wise return to play protocol:
- Day 1: Light Aerobic Exercise
- Walking or stationary cycling 10-15min
- Day 2: Increased Intensity Aerobic Exercise
- Increase resistance on stationary bike, jogging
- Day 3: Individual sport-specific training with no risk of contact (e.g. skating in hockey, sprint training for field/court sports)
- Day 4: Sport-specific drills only without body contact, may add light resistance training (simple drills, weights, sit-ups, push-ups)
- Day 5: Full team practice/scrimmage, non-contact (e.g. “red shirt”) and full participation in drills
- Day 6: Full participation in practice/scrimmage with contact
- Day 7: Game play
Athlete should only continue to the next level if asymptomatic at the current level. If post concussive symptoms occur then they should drop back to the previous asymptomatic level and then try to progress again after a day or so. Too rapid of progression will prolong the post concussive course.