1. Concussion Awareness in Sports
Elaine Keunen RN, BHScN,CCNC(c)
Think First Canada

2. Interesting facts about the brain
The brain weighs about 3 lbs.
The brain uses 30% of the oxygen and energy in your body.
The brain is encased by a skull with the thickness of three pennies.
The brain is not fully developed until about 25 years of age.

3. Lobes of the brain and their major functions
Frontal-personality, moral, ethical and social values, abstract thinking, long term memory, motor strip for the opposite side of the body
Parietal-sensory strip for the opposite side of the body, two point discrimination, reconigition of object by size, shape weight and texture, body part awareness
Temporal-hearing, senses of taste and smell, integrates sounds, thoughts and emotions
Occipital-vision, reading comprehension, and visual recognition of objects

4. Brain Cells There are 100 billion cells in the brain.
Most of the cells are called neurons.
Neurons are basically like on/off switches of a light switch.
Neurons are either resting or shooting an electrical impulse down a wire called an axon.
Each of the neurons spit out chemicals that trigger other neurons.

5. What is a concussion?
A concussion is a brain injury that results from a hit to the head, face or jaw or even elsewhere on the body. It may also result from a whiplash effect to the head and neck.

6. According to classic definition no structural brain damage occurs in a concussion. Symptoms are caused by temporary biochemical changes in neurons, taking place at their cell membranes and synapses.

7. A concussion may involve a loss of consciousness
A concussion may involve a loss of consciousness. However a concussion most often occurs without a loss of consciousness.

8. John Kumpf, executive director of the Ontario Brain Injury Association
“There are 100 billion neurons (brain cells) and 1000 axons which connect each neuron in our brain, which control all aspects of life. A concussion disrupts those pathways and can be catastrophic”
John Kumpf, executive director of the Ontario Brain Injury Association

9. The brain is surrounded by cerebrospinal fluid, one of the functions of which is to protect the brain from light trauma, but more severe impacts or forces associated with rapid acceleration may not be absorbed by this cushion.

10. Like a boat in a dock, the brain floats in liquid inside the skull
Like a boat in a dock, the brain floats in liquid inside the skull. When the head is hit with force, the brain rubs up against the inside of the skull.

14. Concussions may be caused by impact forces, in which the head strikes something or is struck by something or by impulsive forces, in which the head moves without itself being subject to blunt trauma (example: when the chest hits something and the head snaps forward.)

15. Common Symptoms
Headache Dizziness Feeling Dazed Seeing Stars Sensitivity to Light Ringing in the Ears Tiredness/Fatigue Nausea/Vomiting Irritability Confusion/Disorientation

16. Signs of a Concussion Poor Balance Slow or Slurred Speech
Poor Concentration
Delayed responses to questions
Vacant Stare
Decreased playing ability
Unusual emotions, personality changes and inappropriate behaviour

17. Included in the cascade of events unleashed in the brain by a concussion, is impaired neurotransmission, loss of regulation of ions, deregulation of energy use and cellular metabolism and reduction of cerebral blood flow.

18. Second Impact Syndrome
Why players should not play until symptoms have subsided.
Second-impact syndrome (SIS) is an extremely rare condition in which the brain swells rapidly and catastrophically after a person suffers a second concussion before symptoms from an earlier one have subsided. This deadly second blow may occur days or weeks after an initial concussion,[1] and even the mildest grade of concussion can lead to SIS.[2]

19. “If a person is brought back too soon into a sports games or work after a concussion, then those neuropathways may not have had a chance to stabilize and a person could experience recurrent symptoms or even death.” John Kumpf, executive director of the Ontario Brain Injury Association

20. Unfortunately concussions are the most common head injury but the most difficult to understand injury in the game of hockey

21. How do you diagnose a Concussion?
Unfortunately there is no definite test or scan that can determine that a concussion has occurred. It is based on a judgment call considering the situation and the signs/symptoms that one is exhibiting.

22. Proper diagnosis can be difficult because often some of the symptoms may have subsided by the time that the player is examined by the physician. Explain explicitly the symptoms and duration as well as the mechanism of injury.

24. Researchers are finding a linear correlation between severe concussions and a risk of both depression and mild cognitive impairment which is a precursor to Alzheimer's disease.

25. Researchers have found about a 20% increased risk of depression in individuals who have suffered 3 or more concussions.

26. Girls and Concussions
Researchers are finding that females are two to five times more likely to suffer a concussion- belief is that hormones and the strength of neck muscles play a role.
Their symptoms generally are more severe, and females generally take longer to recover from concussions, on average a week longer than the male brain.

27. “Concussions can have a cumulative effects on memory, judgement, social conduct, reflexes, speech, headaches, dizziness and personality changes.” Dr. Charles Tator-Professor of neurosurgery at Toronto Western Hospital and founder of Think-First Canada

28. “One of the most important things to know about concussions are that they are injuries to the brain. People don’t think that they are important, but every concussion is extremely important and it’s not something to pass on.” Dr. Michael Cusimano-Neurogurgeon at St. Michael’s Hospital, Toronto

29. “the immediate steps taken following a concussion are directly related to one’s recovery. He says the best thing to do following a hit to the head is to see a doctor for diagnosis and rest.”

30. “The brain needs to rest and not be stimulated by light, noise or concentration of any kind. Most people who suffer one or two concussions recover normally. Repeated concussions or, in severe cases, concussions can be catastrophic and lead to permanent damage.” Dr. Charles Tator: Professor of Neurosurgery at Toronto Western Hospital and founder of Think-First Canada

31. We are treating and therefore managing less than 1 out of 10 concussion like experiences, the main reason stems from a simple lack of education

32. Post Concussion Syndrome (PCS)
Is a set of symptoms that a person may experience for weeks, months, or occasionally years after a concussion
It is not known what causes PCS to occur or persist, or why some people who suffer a concussion develop PCS while others do not
Occurs in about 10% of the people who have suffered a concussion

33. Symptoms of Post Concussive Syndrome
Headaches - the most common symptom
Dizziness-the second most common symptom
Sensitivity to noise and light
Blurred vision or double vision
Ringing in the ears (tinnitus)
Loss of hearing
Fatigue, sleeplessness or insomnia
Problems with concentration and memory
Irritability, depression and anxiety or changes in personality

34. It is believed that some individuals have a susceptibility towards concussions so players that have had a one or more concussions should be watched closely.

35. “Motivation to win, the wish to advance in their sport and earning acceptance of their teammates often outweigh the need to play it safe.” Dr. Michael Cusimano- Neurosurgeon at St. Michael’s Hospital, Toronto and professor of neurosurgery at The University of Toronto

36. “This mindset, coupled with the influence of media and behaviour of some parents, coaches and officials, unfortunately send a clear message that it is more important to continue play injured than take someone out of the game.” Dr. Michael Cusimano- neurosurgeon at St. Michael’s Hospital and professor of neurosurgery at The University of Toronto

37. Helmets
“When it comes to protection in the sport of hockey, the helmet is an athlete’s most vital piece of equipment.”
Mark Messier-NHL hockey icon and spokesperson for The Messier Project with Cascade Sports

38. Helmets are proven to significantly reduce the number of head injuries but the proper use and fit is important. However, wearing a helmet does not make a player invincible to concussions.

39. Helmets must be CSA approved, and remember that helmets have a life expectancy of 3-5 years only. Never wear a used helmet! Application of stickers can affect the manufacturers warranty if they are not approved for use on helmets.

40. “Time is an enemy, even to high quality helmets
“Time is an enemy, even to high quality helmets. The cushion layer becomes worn down over time as it is exposed to a lot of sweat and humidity. The layers shrink and stiffen, and after time they are unable to provide adequate protection.” Alain Hache author of the ‘physics of hockey

41. There are huge differences in the quality and padding of helmets so look around when purchasing a helmet. Have it properly fitted and buy the best quality that you can afford.

42. Every brand of helmet fits slightly different and every persons head is different so try on a variety of helmets and select the most comfortable and best fitting helmet for you!

43. The one-finger breadth rule for strap tightness
You should be only able to get one finger between the chin strap on a helmet and the chin. Helmets must fit properly to be effective!

44. Mouth Guards While there is no conclusive evidence that mouth guards prevent concussions there is no conclusive evidence to proves that they don’t. Mouth guards are part of mandatory equipment and must be worn!

45. All players should consult a physician after a concussion
All players should consult a physician after a concussion. Coaches/Trainers/Players and Parents should not attempt to treat a concussion without a physicians involvement.

46. If a Player sustains a concussion, you should:
*REMOVE THE PLAYER FROM THE GAME
Do not leave the player alone-monitor signs and symptoms
Do not administer medication
Inform the coach and parent or guardian of the injury
The player should be evaluated by a medical physician

47. If there is a loss of consciousness: Initiate the Emergency Action Plan and call an ambulance. Always assume a possible neck injury as well.

48. Why are concussions increasing?
Today's players are better trained and faster on their skates then ever before, therefore the acceleration of hits have increased. This is because of improved ice conditions and better quality skate technology.
“The faster the acceleration, the greater the impact the internal organs (including the brain) will suffer and the more shaken-up a player will be.” Alain Hache author of ‘The Physics of Hockey’

49. Harder and Larger Protective Equipment
The outsides of shoulder pads and elbow pads are harder on the outside to protect the player but the player who is hit with this equipment is at a greater chance of being hurt especially if hit in the head.

50. Players are larger and more muscular then in years past
Players are larger and more muscular then in years past. Therefore the smaller shorter player is going to come out the loser in a heavy check. The shorter smaller player is more likely to suffer a blow to the head than the larger player.

51. “There are many threats to a player’s head in a hockey game
“There are many threats to a player’s head in a hockey game. Pucks, elbows and highflying sticks are three of them, but there is also the danger of bumping against other players, crashing into the board or falling on the ice.” Alain Hache- author of The Physics of Hockey

52. Another theory is that perhaps there is not an increase in concussions but a greater awareness of them because of advancements in research and education. Limited tracking of data makes knowing exact numbers difficult.

53. As researchers learn more about this injury, it is becoming clear that the most common and the most dangerous injury is the one that, at the youth level, we are the least prepared to treat. Quote from Chris Nowinski from the Hockey Journal

54. Do concussions occur in every sport?
Just about every sport has a potential for concussions to occur. Hockey, football, soccer, basketball, rugby are all high risk sports for concussions.
Surprisingly the most concussions occur in football and boys and girls soccer at a high school level.
(This is according to a study from the Center for Injury Research and Policy at Nationwide Children's hospital in Columbus Ohio)

55. Concussions account for almost 1 in 10 sports injuries, according to the Centers for Disease Control and Prevention. For young people ages 15-24, sports injuries are second only to motor vehicle accidents as the leading cause of brain injury.

56. How a concussion is handled in the minutes, hours and days after a concussion can significantly influence the extent of damage from a concussion.

57. A Little Known Fact About Hockey \
The first testicular guard "Cup" was used in hockey in 1874 and the first helmet was used in 1974.
It took 100 years for us to realize that the brain is also important.

58. Remember that hockey is a part of my life, not the rest of my life.”
Quote from Paul Dennis
2010 HOCKEY CANADA CONCUSSION SEMINAR

62. You’ve had a concussion! How to return a player to the game
Elaine Keunen RN, BHScN, CCNC(c)
Think First Canada

63. No return to play if signs and symptoms still persist, remember that signs and symptoms may return later that day or the next and not necessarily when exercising!

64. Step 1 No activity, only complete rest!
Only precede to step 2 when symptoms are gone!

65. The return to play is gradual and begins only after a player has been given clearance to return to activity by his/her physician

66. Step 2
Light aerobic exercise, such as walking or stationary cycling. Monitor for signs and symptoms. No resistance training or weight lifting during this step

67. No advancing to the next step if signs or symptoms return
No advancing to the next step if signs or symptoms return. The player must return to the previous step until symptoms subside. The player should be re-evaluated by his or her physician should symptoms return or worsen.

68. Step 3 Sport specific activities and training.
Begin player back on the ice skating

69. Step 4
Drills without body contact. May add some light resistance training and progress to weight training.

70. Begin drills with body contact
Step 5
Begin drills with body contact

71. Step 6
Game Play!

72. The length of each step will vary depending on the severity of the concussion and the individual player. Only progress to next step when there is no return of signs and symptoms

73. The minimum length of time between each return to play steps should be 1 day. Therefore no player should be returning to game play before about one week after suffering a concussion.

74. Prevention tips/Player specific

75. Make sure that your helmet fits snugly and that the strap is fastened
Make sure that your helmet fits snugly and that the strap is fastened. One finger breadth between the chin and chinstrap is the rule for tightness.

76. Make sure that the helmet is in a good state of repair with no missing screws or pieces of internal foam. Carry a screwdriver and extra helmet screws in your hockey bag or trainers kits to be prepared for repairs.

77. Get a custom fitted mouth guard and make sure that it is in the players mouth!
Replace your mouth guard each season, when worn from chewing and with changes in teeth i.e.. new molars etc.

78. Respect the other players!
They want a concussion or a hockey injury about as much as you do. You got to be respectful to get respect!

79. No intentional hits to an opponents head!
Be aware of where your body is hitting and keep control of your stick!

80. No hits from behind!!!!

81. Prevention tips for coaches/trainers/ and referees

82. THIS IS YOUR RESPONSIBILITY AS A TRAINER ON THE TEAM!
Do routine checks of equipment to ensure that helmets and mouth guards are in a good state of repair and fit properly!
THIS IS YOUR RESPONSIBILITY AS A TRAINER ON THE TEAM!
Carry a screwdriver and extra screws in your trainer box for repairs during practices and games

83. REFEREES
You set the tone for the game. Dirty hits or dangerous play can get out of hand quickly.

84. Be able to recognise the signs and symptoms of a concussion
PROVIDE EDUCATIONIONAL
SEMINARS IN YOUR ASSOCIATIONS .
ASK FOR INFORMATION FROM PROVIDERS SUCH AS THINK FIRST
WE ARE HERE TO HELP EDUCATE!

85. Think First Canada has lots of educational information and handouts available on concussions, brain injuries and spinal cord injury prevention available on their website Videos such as Smart Hockey are also available on the website and are great resources for coaches, parents and trainers.

86. REFEREES SHOULD BE ASKING FOR THIS SO BE PREPARED
HAVE YOUR EMERGENCY ACTION PLAN IN PLACE IN CASE OF A HEAD INJURY THIS ALSO IS A TRAINERS RESPONSIBILITY
REFEREES SHOULD BE ASKING FOR THIS SO BE PREPARED

87. Never allow a player back into the game if a suspected concussion has occurred.

88. Only allow a player back on the ice when the player has been cleared by a physician. A written note is mandatory!

89. Inform and educate players about the risks of concussions and make sure that they know that they should inform you if they feel any of the signs and symptoms of a potential concussion!

90. Do not encourage dirty play during a game
Do not encourage dirty play during a game. Intentional hits to the head or hits from behind should be discouraged!!!

91. The End