1. Dr. Alison Macpherson, Associate Professor, School of Kinesiology and Health Science, York University The epidemiology of pediatric sports concussions

2. 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

3. 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.”

5. 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

6. Later symptoms Decreased Processing Speed Short-Term Memory Impairment Concentration Deficit Irritability/Depression Fatigue/Sleep Disturbance General Feeling of “Fogginess” Academic Difficulties

7. 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 10 th 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

8. 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

9. Defining the problem: Pediatric sport-related concussions in Ontario

10. 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

11. 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

12. Sport-related concussions in Ontario

13. Sport-related injuries in Ontario

14. Sport-related concussions in Ontario

15. Identifying risk factors for concussion in high school sports Schultz et al, 2004 Exposure variableOdds Ratio (95% CI) No history of concussion1.0 History of concussion2.28 (1.24-4.19) Non-contact sport1.0 Limited contact sport2.01 (0.70-5.73) Full contact sport3.84 (1.42-10.40) BMI in highest 80%1.0 BMI in lowest 20%0.40 (0.18-0.90) 10 th grade and higher1.0 9 th grade0.60 (0.30-1.20)

16. Identifying risk factors for concussion in PeeWee hockey (Emery et al, 2010) Risk FactorRR of concussionRR of severe concussion Previous concussion 2.14 (1.28-3.55)2.76 (1.10-6.51) First year of play1.03 (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 play1.28 (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.

17. 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%

18. 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

19. Return to play and concussion prevention in sport

20. Compliance with return to play, Yard and Comstock, 2009

21. 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

23. Sources of concussion/injury prevention information The ThinkFirst Foundation of Canada www.thinkfirst.ca -lots of information on concussion for players, parents, coaches SafeKids Canada www.safekidscanada.ca -information on helmet use, injury prevention

24. Acknowledgements Thanks to: Dr. Lauren Sergio Cindy Hughes The Donald Sanderson Memorial Foundation