Over the past 10 + years there has been a massive increase in discussions
around concussions. The topic seems to be everywhere—in professional sports
such as football, hockey, soccer, legal battles between players and their
leagues. And, amateur sports have also been in the headlines with one pro-
found case resulting in the Ontario legislature passing a law referred to as
“Rowan’s Law” — named for Rowan Stringer, a high school rugby player
who died as a result of her multiple concussions (second impact syndrome).
This lawmandates that all school boards in Ontario have appropriate con-
cussion prevention, recognition andmanagement strategies in place. Despite
all of the attention to concussions in the media there still seems to be a lot
of confusion, misinformation and in many cases, poor management of con-
cussions. Hopefully this article will help answer more questions than it cre-
ates.
There is a specific and technical definition
ofwhatwenow
consideraconcussion, one thatwewill not boreyouwith: the scientific
definition. Theunderstandingofhowaconcussionoccursand thephys-
iological changeswithin the brainwhich occurs as a result of trauma
have changed. It was previously believed that as a result of a trauma
such as a slipand fall, apunch or hitting the head into the boards in
hockey, that thebrain is slammed into the skull, backand forthcausing
a “Coup” or “Coup Contrecoup” mechanism. Such a violent insult
wouldmost likely result in focal brain injurybleedingor structural dam-
agewhich isnotobservedorevidentwithconcussions. Themost recent,
acceptedunderstandingofaconcussionalsoknownasMildTraumatic
Brain Injury (MTBI) inbriefest terms, is as a result of a traumatic event,
thebrain tissues are slightly stretchedwhich causes a large number of
neurons to fire simultaneously. This brings onmass firingof neurons re-
sulting in thedepletionof thebrainsenergysourcesatan incredible rate.
This reaction in thebraincauses the initialpresentationof symptomssuch
asheadache,nausea, vomiting,dizziness, confusion, sensitivity to light,
balance problems andmore, affecting every person differently or in
varyingdegrees.
Inaddition tochangingknowledge regarding themechanicsbehind
aconcussion,previousbeliefs regardingdiagnosisandpreventionhave
beendisproven.Other commonmyths ormisconceptions are that you
have tostrikeyourhead,youmust loseconsciousness tohavesustained
aconcussion, and that helmetsandmouthguardshelpprevent concus-
sions. Theevidence is that youdonot have tohit your head to suffer a
concussion.Rapidacceleration/decelerationcanbesufficient tocause
a concussion. Themajorityof our patientswhohave sustained concus-
sions havenot lost consciousness andunfortunately there is no conclu-
sive researchevidence thathelmetsormouthguarduse reduces the risk
of concussions.
Who is getting concussions?
Mostpeopleassumeconcussionsprimarilyoccurbecauseof sports,par-
ticularlycontact sports.While it is true thatmanywho sustainaconcus-
sionare involved in sports, an increasingproportionof thepatientswe
seeat the clinicpresent with concussion symptoms related to slips and
falls,work injuriesandmotorvehicle“whiplash”mechanismevents.Any
incident which introduces significant acceleration/deceleration forces
in theheadandneckcanpotentiallycreatean injuryandmaycausea
concussion.
Adatacollectionorganizationwhich tracksER (EmergencyRoom)vis-
its and relateddiagnoses inOntario reported that in2010 therewere
a total of13, 493concussionsdiagnosed.
About 15%were related tomotor vehicleaccidents,38% from falls,
and37%were frombeing struck by someone or against something.
Dataobtained in theUSAbetween2006-2011 shows3.8millioncon-
cussions a year, with an estimated cost of $5.6 billion in healthcare
costs. A reviewof numbers fromWSIB (Workplace Safety and Insur-
anceBoardofOntario) indicates in2015 therewerea totalof229,000
claims, 7-8%of whichwere classifiedas cranial/concussion injuries.
Thiswouldmeangreater than16,000work related concussionswere
diagnosed in2015. Thisdoesnot countmanyconcussion injurieswhich
are undiagnosedor misdiagnosed. A reviewof the existingdata sug-
gests thatover50%ofall concussionsarenever reportedordiagnosed.
As it relates tosports thehighest concussion ratesareassociatedwith
Rugby (maleand female)Hockey (maleand female), Football (male),
LacrosseandSoccer (maleand female).Concussionsarealsoverycom-
mon and seem tobe increasing inAlpine SkiingandSnowboarding;
11.8%of injuriessustainedbycompetitiveskiers/snowboardersare in-
juries to thehead/faceofwhich81.6%areconcussions. Additionally,
skiingand snowboardingcombinedaccount for18%of all sportsand
recreational related injuryhospitalizations inwinterwith10-20%of in-
juries to theheadandneck.
Evolving concussionmanagement, responding to
the research.
Recommendations topatientswhohavebeendiagnosedwithaconcus-
sionhave traditionallybeen inconsistent andnotwell based in research.
Recommendations fora return tonormalactivitiesofdaily living including
work, leisureand sportshave traditionallybeenvague—“whenyou feel
better”. Researchhas nowprovideduswithmuchmore structured treat-
ment/managementand return toplay/activity recommendations.
Complete Rest (Home a few days only)
Light cognitive activity (1/2 hour reading)
Half day of school (restrictions)
Full day of school (restrictions)
Light physical activity - Bike or treadmill test (completed treatment if non-athlete)
Sport Specific activity (gradual removal of restrictions still no gym)
Non-contact training drills (more complex)
Retesting of baseline for contact clearance
Advise athlete to have at least 1 full practice prior to full game play
Game play and completed treatment for athlete
130
|
AUTUMN
|
EARLY WINTER
2016
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
Stage 7
Stage 8
Stage 9
Stage 10
This graphic illustrates our return to work/play protocol
which requires at least 24 asymptomatic hours before
progressing to the next stage.
CONCUSSIONS
:
Myths&Misconceptions
