Concussion Archives - The Sport Information Resource Centre

Wayne Gretzky, Canadian ice hockey legend, is famous for the quote “Skate to where the puck is going, not where it has been.” Behind this saying is the thought of instead of chasing what’s already happened, try to get a step ahead. When it comes to concussions in sport, we are often reacting: reacting to an injury, reacting to a diagnosis, reacting to symptoms. But what if instead of reacting to everything in a concussion, we start going to where a concussion trends towards. That is, recovery and return to sport.

In health care, this is what is known as preventive measures. Parachute, a national organization dedicated to injury prevention in Canada, outlines in their concussion guidelines that athletes of all ages with an alleged concussion receive timely and appropriate care. While the focus is often on an initial diagnosis (which is most certainly the most important point of care), follow-up visits are regularly neglected.

Returning children and youth to school and normal daily activities are the primary focus after the acute period of concussion, as school provides an educational environment, and both school and physical activities facilitate social development and mental well-being (Choe & Barlow, 2018). The goal is to increase cognitive or other activities to the point where no current symptoms are worsened or new symptoms are triggered, known as sub-symptom threshold cognitive activity (Master et al., 2012). If at any point symptoms worsen, then the individual is bumped back to the previous stage. This graded return strategy needs to be individualized to each child and youth’s specific needs, as this can help with resuming their pre-injury activities sooner (Kelleher et al., 2014). The overall management of pediatric concussion involves decisions around both return to school and return to activity, underscoring the importance of follow-up with a primary care provider after an initial concussion diagnosis.

Gaps in research

Follow-up visits are important for reassessment, management, and education, particularly for children and youth. Guidelines created by the Ontario Neurotrauma Foundation (ONF) specify that follow-up for a concussion (after the initial visit) should occur with a physician or nurse practitioner by 4 weeks after the initial injury (Velinkonja et al., 2017). However, we have identified in a review of the literature that children and youth are not consistently followed-up after an initial concussion diagnosis (Ramsay et al., 2023). Also, little can be concluded about the time from initial diagnosis to the first follow-up visit, and the factors that influence the number of follow-up visits. This is why we conducted the Pediatric Concussion in British Columbia (PCBC) Project, a population-based study using administrative data to identify the rates and the timing of the first follow-up visit for children after a diagnosis of concussion, factors associated with follow-up timing, and the impact of time to first follow-up on children’s health.

Key findings from the data

The study provides new insights into the rates and timing of follow-up visits, factors associated with the timing of the first follow-up visit, and the impact of that timing on residual health outcomes based on the administrative data from concussed children and youth aged 5 to 18 years in BC during 2016 and 2017. Linking datasets, a sample of 22,697 cases with an initial concussion diagnosis were identified. The 4 key findings from this study were:

Follow-up visit rates are low for concussed children and youth in BC: less than 25% had any type of follow-up visit, of which only 19% had a timely follow-up visit.
Among the children and youth who had a follow-up visit within 3 months of initial injury, 75% of cases attended a follow-up visit within 22 days, thus meeting the ONF recommended time of 28 days.
Older age, living in a rural area, higher socioeconomic status, and seeing a specialist physician at the initial concussion diagnosis were associated with a timely first follow-up visit, but there may be other factors that contribute to timely follow-up.
Concussed children and youth with a delayed follow-up visit were more likely to experience a health related to concussion compared to those with timely follow-up up to 12 months post-injury.

What to do next?

The results of the PCBC study identified the timing of the first follow-up visit after an initial concussion diagnosis and the health outcomes that happen. The findings from this study suggest that children and youth are not consistently followed-up after an initial concussion diagnosis. Historically, follow-up was either not required as part of concussion care or required only for patients with more severe brain injuries. However, given the potential for long-term health problems when follow-up is delayed, there needs to be a reframing of pediatric concussion care in Canada.

To do this, our sporting bodies must enact concussion policies to protect athletes, so that we are not constantly reacting after every concussion. These policies include:

training for sports personnel,
concussion education for children and youth and their parents,
return-to-play procedures,
return-to-learn procedures, and
medical clearance to return-to- sport.

Having an up-to-date concussion policy is a must. While this may protect some athletes from a concussion, it is important to remember that a concussion can still occur, and our research indicates that timely and ongoing care of a concussion will lead to better outcomes.

Up and coming research from a PhD student at the university of Alberta combines art therapy with concussion recovery science. The research explores communication challenges faced by youth post-concussion and showcases the power of art as a tool for self-expression, calling for a reimagining of rehabilitation in concussion management.

In the halls of BC Children’s Hospital in Vancouver, Scott Ramsay witnessed a disconcerting pattern: children with concussions were being referred to the hospital too late, their symptoms already complex and challenging to manage. For Ramsay, a former professional hockey player turned nurse, this scene triggered a flashback to his own teenage years, marked by 4 concussions and the repercussions of post-traumatic concussion syndrome that followed.

As Ramsay recently earned his Ph.D. in nursing from the University of British Columbia, his journey from the hockey rink to the hospital compelled him to take a closer look into an issue facing the health care system. The absence of educational interventions and post-concussion follow-ups for children in British Columbia. The issue caught his attention, prompting him to embark on a groundbreaking study for his dissertation involving just shy of 23,000 children and youth with concussions; a study now recognized as the largest of its kind in the province.

The results of his research shed light on a concerning reality: most concussed children and youth lack timely follow-up visits in BC, a finding that goes against the guidelines set by the Ontario Neurotrauma Foundation. Dr. Ramsay discovered that only 19 percent of young patients received a first follow-up within the recommended 4 weeks after diagnosis, leading to a higher incidence of persistent post-concussive symptoms.

Dr. Ramsay’s personal experiences, combined with the findings of his study, have fueled his commitment to advocating for change. His journey, from facing the challenges of post-concussion syndrome to becoming a dedicated nurse and researcher, highlights the critical need for improved education and awareness surrounding concussions in children.

Following in line with more education, Ramsay, along with SIRC’s extensive concussion in sport resources, provides an overview of what you need to know when it comes to concussions in children and youth.

What are the most common signs and symptoms of concussions in children?

Children often exhibit several common signs and symptoms when experiencing a concussion:

Headache
Dizziness
Nausea and Vomiting
Difficulty concentrating
Sensitivity to light
Ringing in the ears/Sensitivity to noise
Behavioural Symptoms: inattention, irritability, heightened anxiety.
Sleepiness
Double or blurry vision

These symptoms serve as vital indicators for parents, coaches, and teachers to detect potential concussions in children early on.

Are there differences in signs and symptoms of concussions between children and adults?

Ramsay said due to the anatomical and physiological distinctions between children and adults, symptoms can sometimes be more intense in children.

Anatomical differences: Children’s larger surface area and smaller bone structures can result in more pronounced injuries. This is crucial to understanding the severity of symptoms such as headaches and dizziness, which can be more intense in children due to their unique anatomical features.
Cerebral blood flow: Variances in blood flow due to growth and development contribute to different symptom presentations.
Hormonal factors: Differences in hormone levels, especially in the youth, may have associations with mental health issues like anxiety and depression.

How do you distinguish between a mild concussion and a more severe one in children?

Recognizing concussions in children poses unique challenges, Ramsay explains it starts with:

A process of elimination: Ruling out other potential causes through a thorough medical history.
A history examination: Investigating the circumstances leading up to the injury and understanding the symptoms.
Reporting challenges: Children may not always communicate incidents of head injury, making accurate diagnosis challenging.

Ramsay also emphasized the importance of listening to children, highlighting the difficulty in cases where children may not readily communicate their head injuries. This insight underscores the complexity of diagnosing concussions in children and the need for careful consideration of the circumstances surrounding the injury.

What immediate steps or first aid measures should be taken if a child is suspected of having a concussion?

Removal from activity: Taking the child out of the sport or event immediately.
Get medical attention: the child should not be left alone and should be seen by a medical health professional as soon as possible that day.
Check for red flag symptoms: seizures, posturing, vomiting, and unequal pupils.
Urgent Medical Attention: Contacting 911 if red flag symptoms are present or the child loses consciousness.

This immediate response is crucial in preventing further harm and initiating the necessary steps for proper diagnosis and care.

How long do symptoms of a concussion potentially last? Are there any factors that can influence recovery time?

The signs and symptoms of a concussion often last for 1 to 4 weeks but may last longer.
In some cases, children may take many weeks or months to heal.
Factors influencing recovery:
- Prior concussion history (If your child has had a concussion before, they may take longer to heal)
- Pre-existing conditions, and external factors like stress can impact recovery time.

What role do cognitive and physical rest play in the recovery process for child with a concussion?

Initial Rest Period: Recommending rest for 24-48 hours, followed by gradual reintegration into daily activities.
Cognitive rest: The child may find it hard to concentrate in class, may get a worsening headache, or feel sick to their stomach. If so, the child should stay home if being in class makes their symptoms worse. Once they feel better, they can try going back to school part-time (half day) and then a full day.
Return-to-Sport or physical activity:
- Stage 1: Symptom-limiting activities: After an initial short period of rest of 24 to 48 hours, light physical activity can begin, as long as these don’t worsen symptoms.
- Stage 2: Light aerobic activity: Such as walking or stationary cycling, for 10 to 15 minutes. The duration and intensity of the aerobic exercise can be gradually increased over time if symptoms don’t worsen, and no new symptoms appear during the exercise or in the hours that follow. No resistance training or other heavy lifting.
- Stage 3: Individual sport-specific exercise with no contact: Activities such as skating, running, or throwing can begin for 20 to 30 minutes. There should be no body contact or other jarring motions, such as high-speed stops or hitting a ball with a bat. No resistance training.

Medical clearance and a full return to school are required to progress to Step 4

- Stage 4: Begin training drills with no contact: Add in more challenging drills like passing drills. There should be no impact activities (no checking, no heading the ball, etc.). Start to add in progressive resistance training.
- Stage 5: Full contact practice following clearance by a doctor.
- Stage 6: Return to Sport

MORE INFORMATION: Living Guideline Return to Activity/Sports Protocol

What are the potential long-term effects of repeated concussions in children?

Delving into the long-term effects, Ramsay pointed out the limited evidence regarding the precise outcomes of repeated concussions in children. Drawing on studies in adults, he highlighted cognitive impairments, decreased quality of life, and psychosocial challenges as potential consequences.

While acknowledging the gaps in current knowledge, Ramsay’s insight and research provide a foundation for understanding the potential risks associated with repeated concussions in the pediatric population.

Fact or Myth: Children and youth who sustain a concussion have a higher risk of experiencing mental health issues than children and youth who experience other types of injuries. By Dr. Roger Zemek, MD, pediatric emergency physician at Children’s Hospital of Ontario (CHEO).

How would you go about educating parents, coaches, teachers, about the signs and symptoms of concussions, to ensure early detection and appropriate care?

Ramsay advocates for active listening and taking children’s symptoms seriously. He underscored the importance of open conversations to reduce stigma and creating a supportive environment for reporting head injuries. By emphasizing that there’s no shame in admitting to a head injury, Ramsay encourages a cultural shift toward recognizing and addressing concussions in children.

His approach to education involves instilling a sense of responsibility among parents, coaches, and teachers to prioritize the well-being of children and actively engage in conversations that contribute to early detection and appropriate care.

Want to learn more about sport-related concussions and what education programs and tools are available. Find out more through this comprehensive list of programs put together by SIRC and their partners.

In your experience, what are some challenges in recognizing and managing concussions in children and how can these challenges be addressed?

Ramsay acknowledged the challenges in recognizing and managing concussions in children, pinpointing the underreporting of concussions as a significant hurdle. He stressed the importance of establishing reporting mechanisms in sports settings and encouraged seeking care from qualified healthcare professionals for accurate diagnosis and management.

Why is it important to talk about this specific topic like signs and symptoms and kids based on your experience? Why should we be talking about this?

Highlighting the significance of the conversation, Ramsay emphasized the role of timely care in improving the likelihood of a child returning to normal life sooner. He stressed the importance of proper management throughout the recovery trajectory to minimize post-concussion symptoms.

Ramsay underscored that talking about the signs and symptoms of concussions in children is not just about raising awareness; it’s about fostering an environment where early detection, appropriate care, and continuous support are prioritized for the well-being of the younger population.

Repeated concussions may disrupt the heart-brain axis, causing irregularities in heart activity and long-term health implications. This new insight emphasizes the importance of measures to reduce the occurrence of concussions in sports. Implementing and strictly enforcing safety protocols can contribute to minimizing the risk of head injuries and subsequent cardiac implications.

Body checking is a large part of hockey, but there is a risk of concussion. The Amsterdam 2022 International Consensus Statement on Concussion in Sport suggests that body checking should be eliminated in hockey for children and most adolescents. In addition, they found that mouth guards are proven to be effective in reducing concussions and should be mandatory not only in hockey, but in other contact sports as well.

The Concussion Recognition Tool (CRT6), previously called the CRT5, is a guide that can be used by non-medically trained individuals to identify and manage suspected concussions in children, adolescents, and adults. It highlights red flags, visible clues of a suspected concussion, symptoms of a suspected concussion, and awareness. Everyone involved in sport whether it be parents or coaches, should be familiar with this tool to help keep sport participants safe.

As new research around concussions in sport is published, best practices must adjust to reflect new findings. To that end, a new Consensus Statement on Concussion in Sport has been published. The statement includes an updated return to sport strategy and new and updated tools to support the identification and management of concussions for athletes across more ages.

Canada’s most trusted partner in advancing sport knowledge will be raising awareness of the importance of concussion education during Concussion Awareness Week as we feature best practices and examples from the sport sector

Ottawa – Concussion Awareness Week, a nationwide initiative aimed at raising awareness about concussions and promoting safe participation in sports, will take place from September 24th to September 30th, 2023. This annual event is a collaborative effort involving various stakeholders, including the Government of Canada, National Sport Organizations (NSOs), Provincial and Territorial Sport Organizations and Community Sports to educate and empower individuals across the country. Thank you also to the Federal, Provincial and Territorial partners for their role in raising Concussion Awareness.

Concussions are a serious concern, especially in sports and recreational activities. The goal of Concussion Awareness Week is to foster a culture of safety and responsibility in sports by providing valuable information and resources to athletes, coaches, parents, and healthcare professionals.

To access a wealth of information on concussions, including prevention tips, recognition, and recovery guidelines, please visit https://sirc.ca/concussion/.

How we are getting the word out this week:

Social Media Promotion: We encourage you to use your social media platforms to share relevant information, stories, and resources related to concussions. By using the official hashtag #WeAreHeadstrong, we can amplify our collective voice and reach a wider audience.

Event Promotion in SIRC Sport Calendar: If your organization is hosting any events, webinars, or workshops during Concussion Awareness Week, we urge you to promote them widely. Sharing these events will help foster a sense of community and encourage dialogue around this critical issue. Make sure to add your Concussion Awareness Week events to the SIRC sport calendar. The SIRC sport calendar is a centralized platform which will help others discover and participate in your activities and contribute to the success of the overall initiative.

Concussion Awareness Week is made possible by the continued support of the Government of Canada. And thank you to our National Sport Organizations for your continued efforts to provide sport programs where everyone can participate, safely.

About SIRC

Incorporated in 1973, SIRC, the Sport Information Resource Centre, is Canada’s leader and most trusted partner in advancing sport through knowledge and evidence. SIRC is committed to engaging with organizations and individuals involved in the development of sport, recreation and physical education in Canada and around the world, to enhance the capacity of our shared community to foster growth and the pursuit of excellence.

Join us for an informative Concussion Workshop, presented by Dr. John Van-Herbert!

Dr. John Van-Herbert is a British trained Osteopathic Manual Practitioner (OMP), having graduated in 2013 specializing in sports injuries, and works with athletes of all levels and ages. John works as an OMP for the Niagara IceDogs OHL team and leads the medical staff for England’s men’s lacrosse team.

Dr. John Van-Herberis is concussion certified and will provide an overview of the pathophysiology of concussions, some simple tests and assessment tools, as well as some easy to conduct treatment techniques.

Attendees will learn about current national concussion guidelines and advice for any athlete with a suspected concussion. The seminar will be both theory and practical based learning. Whether you are an athlete, a parent, or simply interested in learning more about concussions, this workshop is perfect for you.

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