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Dr. Alison Macpherson,Associate Professor, School of Kinesiology and Health Science, York University
The epidemiology of pediatric sports concussions
Overview
• What is a concussion?• A brief history of concussion in sport• Data on sport-specific concussions in
Ontario• Risk factors and prevention strategies• Return to play and second impact
syndrome• Some suggestions to
reduce concussions in hockey• Conclusions
What is a concussion?
“A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.
Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness or memory dysfunction.
Typically results in a rapid onset of short-lived impairment of neurological function that resolves spontaneously.
Acute symptoms largely reflect a functional disturbance rather than a structural injury.”
Guidelines for stopping play
• If mechanism of injury is a direct blow (hit to the head, body check, etc)
AND• ONE symptom• Athlete should be removed from
activity• Should be seen by a sport medicine
physician
Later symptoms
• Decreased Processing Speed• Short-Term Memory Impairment• Concentration Deficit• Irritability/Depression• Fatigue/Sleep Disturbance• General Feeling of “Fogginess”• Academic Difficulties
A brief history of sport-related concussion
Concussion is not a new problem: The earliest documented sports-related head injuries were by
Galen of Pergamon (130-201 AD)- wrote about head injuries during gladiator games
Rhazes in the 10th century further defined concussion as different from other brain injuries-defined symptoms of tinnitus (ringing in the ears), giddiness, photophobia (sensitivity to light)
• Concerns about head injuries in football prompted President Roosevelt to bring together clinicians and athletes in 1905
A brief history of sport-related concussion
In the 1990’s a great deal of attention was paid to concussion in contact sports including football, soccer, hockey, rugby
The first International Symposium on Concussion in Sport was held in Vienna in 2001
Defining the problem: Pediatric sport-related concussions in Ontario
Sport-related concussions in Ontario
How do we measure them? All patients presenting to an Emergency
Department in Ontario are captured in the National Ambulatory Care Reporting System
Includes information on age, sex, type of injury, and cause of injury
In Ontario, certain sports are coded, including hockey, soccer, football, bicycling, tobogganing, skiing, snowboarding
We know that we miss other sports (gymnastics, wrestling), so the numbers presented here underestimate the problem
Sport-related concussions in Ontario
There were 197,092 Emergency Department visits for specific sports-related injuries in Ontario from 2002-2005
Of these, 6429 (3.3%) were concussions
Sport-related concussions in Ontario
ED visits for concussions by age, Ontario 2002-2005
0
100
200
300
400
500
600
700
800
900
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Nu
mb
er
of
vis
its
Sport-related injuries in Ontario
ED visits for sports-related injuries, Ontario 2002-2005
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
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ycle
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Sport-related concussions in Ontario
Percent of ED visits for concussions by sport
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
Per
cen
t C
on
cuss
ion
s
Identifying risk factors for concussion in high school sports Schultz et al, 2004
Exposure variable Odds Ratio (95% CI)
No history of concussion 1.0
History of concussion 2.28 (1.24-4.19)
Non-contact sport 1.0
Limited contact sport 2.01 (0.70-5.73)
Full contact sport 3.84 (1.42-10.40)
BMI in highest 80% 1.0
BMI in lowest 20% 0.40 (0.18-0.90)
10th grade and higher 1.0
9th grade 0.60 (0.30-1.20)
Identifying risk factors for concussion in PeeWee hockey (Emery et al, 2010)
Risk Factor RR of concussion RR of severe concussion
Previous concussion 2.14 (1.28-3.55) 2.76 (1.10-6.51)First year of play 1.03 (0.62-1.70) 0.57 (0.14-2.36)
Alberta vs Québec 3.88 (1.91-7.89) 3.61 (1.16-11.23)Low weight (<37 kg) 1.32 (0.78-2.23) 0.69 (0.23-2.09)
Top 20% level of play 1.28 (0.75-2.17) 0.83 (0.30-2.31)
Attitudes towards checking (high vs low)
0.99 (0.61-1.60) 2.52 (1.0-6.35)
Defense (vs forward) 1.00 (0.62-1.60) 0.22 (0.06-0.84)Goalie (vs forward) 0.51 (0.16-1.64) 0
Emery, C. A. et al. JAMA 2010;303:2265-2272.
Protective equipment for concussion prevention in sport
Helmets have been shown to be effective in many sports
Hagel et al examined skiing and snowboarding helmets-reduction in head injuries by up to 29%
Thompson et al examined bicycle helmets-reduction in head injuries by up to 70%
The role of officiating/coaching
In rugby, 41.7% of injuries related to foul play were concussions (Collins, 2008)
In basketball, 67.4% of concussions were due to contact with another player (Borowski, 2008)
In soccer, collision, rather than purposeful heading, was associated with head injury, BUT children need to learn proper heading techniques and develop head/neck muscles (Koutures, 2010)
Referees and coaches can help to prevent these injuries
Return to play and concussion prevention in sport
Compliance with return to play, Yard and Comstock, 2009
Conclusions
• Concussions are a common and serious problem in sports• Hockey players are at higher risk of both injury and concussion• Football, ATV and snowmobiles, tobogganing, skiing/snowboarding
and bicycling are other sports where the risk of concussion is high• Risk factors include participation in contact sports, rules related to
contact, and history of concussion• Protective factors are use of protective equipment, particularly
helmets, rules that discourage contact, and adherence to return to play guidelines
• A multi-faceted approach has the potential to make a difference- but evidence is still lacking
Sources of concussion/injury prevention information
The ThinkFirst Foundation of Canadawww.thinkfirst.ca
-lots of information on concussion for players, parents, coaches
SafeKids Canadawww.safekidscanada.ca-information on helmet use, injury prevention
Acknowledgements
Thanks to:
• Dr. Lauren Sergio
• Cindy Hughes
• The Donald Sanderson Memorial Foundation