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

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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