A concussion isn’t just a bump on the head; it’s a brain injury. And concussions from sports and recreation-related activities are a major health problem in Canada, particularly among youth. Through their Alberta Program in Youth Sport and Recreational Injury Prevention, researchers Carolyn Emery & Brent Hagel hope to reduce youth sports injuries by 20 per cent by 2020. In this webinar Carolyn and Brent examine: • How and where concussions occur in sport • How targeted interventions can prevent concussions from happening in the first place • New treatments to help concussion patients recover faster

1. Knocking out concussion in sports
Carolyn Emery
Professor, Faculty of Kinesiology
Brent Hagel
Associate Professor, Cumming School of Medicine
October 20, 2016

2. Welcome!
 Webinar series by University of Calgary scholars
 Information presented is a summary of the
scholars’ research
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3. Carolyn Emery
Faculty of Kinesiology
 Physiotherapist and epidemiologist
 Professor, Faculty of Kinesiology and Cumming
School of Medicine
 Chair, Sport Injury Prevention Research Centre
 Chair in Pediatric Rehabilitation
 PhD from the University of Alberta; MSc from
the University of Calgary; BScPT from Queen’s
University
 Research focused on injury prevention in
youth sport and recreation and the prevention
of consequences of injury
• In particular: a focus on concussion and joint
injuries and their consequences in youth

4. Brent Hagel
Cumming School of Medicine
 Injury epidemiologist
 Associate professor, pediatrics and
community health sciences, Cumming
School of Medicine
 Adjunct professor, Faculty of Kinesiology
 PhD McGill University; MSc University of
Calgary; BPE University of Calgary
 Research focused on injury prevention in
youth sport and recreation

5. Objectives
 To understand the public health impact of
concussion in youth sport and recreation
 To be exposed to evidence-informed
examples evaluating concussion risk and
prevention strategies in youth sport and
recreation (i.e. hockey)
 To discuss the relevance and impact of
evidence in concussion prevention in youth
sport in practice and policy considerations
 To consider secondary prevention of
consequences of concussion in sport

6. Concussion
 “Concussion is a brain injury and is defined as a
complex pathophysiological process affecting the
brain, induced by biomechanical forces.”
• Direct blow to head or other part of body with force
transmission to head
• Rapid onset of short lived neurological symptoms
• Functional disturbance rather than structural injury
• May not involve loss of consciousness
McCrory et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion
in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258

7. Societal burden of concussion
 Sport injuries requiring medical attention
• 15-18 years: 40 injuries/100 students/year
• 11-14 years: 30 injuries/100 students/year
• (Emery CA, Tyreman H. Paediatr Child Health, 2009; Emery et al. Clin J Sport Med.
2006)
 Sport related head injuries in the ED
• <20 years of age = 66% of all SR Head Injuries
• 18.2% in <10 years of age
• 53.4% in 10 to 14 years of age
• 42.9% in 15 to 19 years of age
• (Kelly et al. Clin J Sport Med 2001)
 Concussions 15% of the injuries in youth sport
• (Emery CA, Tyreman H. Paediatr Child Health, 2009; Emery et al. Clin J Sport Med.
2006)

8. Sport-related Traumatic Brain Injury
Morbidity and Mortality Weekly Report. 2007;56(29):733-737

9. Top concussion-producing sports
Alberta Children’s Hospital - Canadian Hospitals Injury Reporting and Prevention Program, 2011-2015

10. Youth sport-related concussion
incidence rates
Pfister T, Pfister K, Hagel BE, Ghali WA, Ronksley P. The Incidence of Concussion in Youth Sports: A Systematic Review and Meta-analysis. Br
J Sports Med. 2016 Mar;50(5):292-7

11. Symptoms

12. Consequences of Youth Sport Injury
Participation in sport & recreation
School attendance
 Physical activity = overweight/obesity
Psychosocial consequences – child and family
Health care and indirect costs are high

13. Post Concussion Syndrome
 29%-31% will have ongoing symptoms
• (Zemek et al. JAMA. 2016;315(10):1014-1025; Babcock
et al. JAMA Pediatr. 2013;167(2):156-161)
 Ash Kolstad: Consequences of Concussion Video

14. Alberta Program in Youth Sport
and Recreational Injury Prevention
GOAL
Reduce sport & rec injuries
by 20% by 2020
FOCUS
Concussion & injury in hockey
School based NMT
Ski/Snowboard injury risk
PRIORITIES
Build research capacity – trainees
Community engagement - KT

15. Overview
•Injury Prevention Research Model
•Public Health Impact
•Risk factors for Injury and Concussion
•Primary, Secondary Prevention, and Rehabilitation
•Future Directions

16. Sport Injury Prevention Research
1. Surveillance
(extent of injury
problem)
3. Develop an
intervention
(validation)
4. Introduce
the
Intervention
(implementation)
2. Find the
risk factors
(cause)
ExtrinsicIntrinsic

17. Public health significance of
concussion in youth ice hockey?
• 20-35% of all injuries in youth ice hockey (ages 11-17)
• Incidence Proportion = 5-20 concussions/100 players (1-4
concussions /team)
• 13-30% of concussions are recurrent
• 14% of children still symptomatic at 3 months (Barlow et al
2010)
• 72% (10 days or greater) - Elite youth ice hockey (Schneider
et al 2014)
• 31% of NHL players symptomatic >10 days (Benson et al
2010)
NIH 2007, Emery et al 200,2010,2012, 2013

18. Youth vs adult ice hockey
concussion rates
Emery & Meeuwisse (2006, 2010, 2011, 2013)
Atom (9-10): 0.24/1000 player hours
Pee Wee (11-12): 1.47/1000 player hours
Bantam (13-14): 1.3/1000 player hours
Midget (15-17): 1.3/1000 player hours
Agel & Harvey (2010)
NCAA Males: 0.72/1000 athlete exposures
NCAA Females: 0.82/1000 athlete exposures
Benson et al (2011)
NHL: 1.8/1000 player hours over 7 seasons

19. National Hockey League
Pee Wee (11 and 12 years old)

21. A dynamic, recursive model of
etiology in sport injury Meeuwisse et al 2007
Previous
concussion
Previous
concussion
Body checkingBody checking
GameGame
Contact SportsContact Sports
Dizziness, Neck pain,
Headaches at baseline
Dizziness, Neck pain,
Headaches at baseline
Smaller sizeSmaller size
Clinical
Measures?
Clinical
Measures?
Sport-related
Concussion
Modifiable?

22. Injury prevention
Specific strategies used to prevent injuries:
 Rule changes
 Body checking policy
 Head contact rule enforcement 2011
 STOP program
 Fair play

23. Alberta (BC) vs. Quebec (no BC)
Pee Wee game injury rates
012345
Gameinjuryrateper1000gamehourswith95%CI
injury concussion injury>1week time loss concussion>10days
Alberta Quebec
Game-related injury rates in Pee Wee (age 11-12 years)
All Injury: IRR = 3.26 (95% CI; 2.31 – 4.60)
Concussion: IRR = 3.88 (95% CI; 1.91 – 7.89)
Injury (>7 days time loss): IRR = 3.30 (95% CI; 1.77 – 6.17)
Concussion (>10 days time loss): IRR = 3.61 (95% CI; 1.16 – 11.23)

24. Bantam game injury rates
by province
0246
Gameinjuryrateper1000gamehourswith95%CI
injury concussion injury>1week time loss concussion>10days time loss
Alberta Quebec
Game-related injury rates in Bantam (age 13-14 years)
All Injury: No difference IRR = 0.85 (95% CI; 0.63 – 1.16)
Concussion: No difference IRR = 0.84 (95% CI; 0.48 – 1.48)
Injury > 7 days time loss: IRR = 0.67 (95% CI; 0.46 – 0.99)
Concussion > 10 days time loss: No difference IRR = 0.6 (95% CI; 0.26
– 1.41)

25. Alberta (BC) vs. Ontario (no BC)
Non-Elite Pee Wee injury rates
Injury: IRR = 2.97 (95% CI; 1.33 – 6.61)*
Severe Injury(>7 days): IRR = 1.76 (95% CI; 0.77 – 4.04)
Concussion: IRR = 2.83 (95% CI; 1.09 – 7.31)*
Severe Concussion (>10 days): IRR = 2.08 (95% CI; 0.62 – 6.94)
Emery et al 2014

26. National policy change; Alberta before
and after Pee Wee policy change
Multivariable Poisson Regression
Game Injury: IRR = 0.50 (95% CI; 0.33 – 0.75)*
Severe Injury(>7 days): IRR = 0.40 (95% CI; 0.24 – 0.68)
Concussion: IRR = 0.34 (95% CI; 0.21 – 0.56)*
Severe Concussion (>10 days): IRR = 0.52 (95% CI; 0.29 – 0.92)
*Adjusted for cluster, year of play, previous injury/concussion, level of play,
position, attitudes toward body checking, player size, exposure hours offset
Estimated reduction of 1000 injuries
(>400 concussions) in Pee W
ee players
in Alberta – evidence-informed

27. Pee Wee hockey
Bruce #15 – 11 years old
Elite + Previous hx
Alberta 2012/13
John #5 – 11 years old
Elite + Previous Hx
Alberta 2013/14
Concussion 26%
Concussion 6%

28. What has happened?
 USA Hockey Board (June 2011) – policy change
 Ontario Hockey (May 2011) and BC Hockey (June 2012) –
eliminate body checking non-elite levels (ages 11-17 – 70%)
 Hockey Canada Board (June 2013) – national policy change
 Hockey Calgary/Edmonton (June 2015) - eliminate body
checking non-elite levels Bantam (ages 13-14 – 70%)
SUCCESS – DRIVEN BY COMMUNITYSUCCESS – DRIVEN BY COMMUNITY
NOT RESEARCHERNOT RESEARCHER

29. What about other rules and
regulations?
Did “zero tolerance for head contact” rule enforcement in 2011 change the
risk of game related concussions in youth ice hockey players?

30. Did “zero tolerance for head contact” rule enforcement
↓ risk of game related concussions in youth ice hockey
players?
Maciek Krolikowski MSc

31. Concussion Risk pre- and post- 2011
zero tolerance head contact rule change
Head contact mechanism?
Referral bias?
M Krolikowski
Head Contact Policy Change
Not evidence-informed

32. Injury prevention
Early detection of concussion and
prevention of progression,
complications, and disability
 Pre-season examination
identify risk factors
(i.e. previous concussion, symptoms,
clinical measures)
 Pre-season training
modify risk factors related to symptoms,
strength, balance, other clinical
measures
2. Secondary

33. “Safe to Play”
A longitudinal research program to
establish best practice in the
prevention, early diagnosis, and
management of sport-related
concussion in youth ice hockey players

34. Safe to Play

35. Safe-to-Play MR Study B Goodyear, R Frayne
 Diffusion Tensor Imaging (DTI)
• investigates the integrity of the
functional connections of the brain
 Resting-State fMRI
• measures the diffusion (random motion)
of water molecules in tissue
 Perfusion MRI
• provides whole-brain images of cerebral
blood flow

36. Hockey Canada Skills Test
• Forward agility weave
 Forward/backward
speed skate
 Transition agility
 6-Repeat Endurance
Skate

37. Cervical and vestibular measuresK Schneider
Cervical Flexor Endurance test
Cervical Flexion Rotation test
Cervical Rotation Side Flexion
test
Head Perturbation Test
Clinical Dynamic Visual Acuity
Computerized Dynamic Visual
Acuity
Functional Gait Assessment
Walk While Talk Test
SCAT3: BES and Tandem Gait

38. Management and rehabilitation

39. Primary outcome:
# days to medical clearance RTP
Treatment Group
 Education
 General range of motion
/stretching/strength
 Orthopaedic physiotherapy
 Vestibular rehabilitation
Control Group
 Education
 General range of motion
/stretching/strength
Physiotherapy Management
Schneider et al 2012

40. Results
The participants in the treatment group were 10X more likely to be
medically cleared to return to sport than the participants in the control
group at 8 weeks

41. Education - RCT

42. Future directions?
Thinking outside the bubble!
• Focus shifting from elite to recreational youth hockey
where public health impact will be the greatest
• Build research capacity through interdisciplinary
opportunity (basic science, clinical, population health)
• Continue to develop, implement and evaluate Injury
Prevention Strategies (Primary, Secondary,
Rehabilitation)
• Continue to validate measures of risk – extrinsic and
intrinsic
• Develop Standard of Practice in Concussion
prevention, evaluation and management
• Continue emphasis on Knowledge Translation

43. Resources
Parchutecanada.org
www.sportmed.ucalgary.ca (acute injury clinics)

44. Acknowledgements
IOC Research Centre

45. Ebook
For tips on recovery, please download our ebook at
http://www.ucalgary.ca/explore/concussions-top-
tips-recovery

46. Thank you
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Information presented today was a summary of the scholar’s research and the opinions expressed
were based on the scholar’s field of study

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