1. Epidemic of Sports Injuries: Need for a Collaborative Approach D.S. Mulder November 13 2013

2. Disclosures I have no qualifications in sports medicine My “day job” is as a Thoracic Surgeon at McGill My odyssey in sports injuries began as a surgical resident Mentors included Dr. Doug Kinnear and Ted Percy Montreal Jr. Canadiens and McGill Redmen

3. Mentorship There are three life threatening injuries you must be aware of: “A.B.C.”s 1. Injury to the Airway 2. Bleeding internal or external 3. Brain and spinal cord trauma There is a unique “doctor-player” relationship

4. Team Sports Benefits Sports should be fun! Discipline towards a common goal Work ethic Responsibility to team mates Application to life lessons

6. Evolution of Medical Care for the Elite Athlete Improved protective equipment Dramatic developments in medical imaging Minimally invasive surgery Tailored physiotherapy and rehabilitation based on scientific measurement Formal organizations with standards of care

7. Concussions “the elephant in the room” “A league of denial” Mark and Steve Fainaru N.F.L. class action settlement Prevalence in Canadian youth playing collision sports Mon. Nov. 4 2013 Rona Ambrose from Health Canada-major grant to study diagnosis and treatment

8. HEAD INJURIES in Collision Sports Lack of Metrics versus Current Reality

9. Trauma Related Deaths Injury remains the commonest cause of death up to age 45 in Canada Brain injury is a factor in 50% of deaths When considered as years of life lost, trauma exceeds cancer and heart disease combined Motor vehicle related deaths remain the major etiology in our youth Importance of athletic injury and traumatic brain injury

11. Head Injury Spectrum Concussions Epidural hematoma Subdural hematoma Intracerebral bleed and/or edema

12. Mild Traumatic Brain Injury M.T.B.I. Spectrum Glasgow Coma Scale (13-15) Concussion is a separate entity

13. Concussion in Collision Sports Hockey, football, soccer, rugby, commonest Spectrum of clinical presentation Acute symptoms “Second impact” Post concussion syndrome

14. Player dies in a fight! Helmet off when head hit ice Canadian Press Jan 2009 Brantford Ontario Ontario Hockey Assoc Whitby Dunlops Involved in a fight ? Chin strap loosely fastened

16. Concussion Definition An immediate and temporary alteration of mental function due to injury Exact mechanism unknown ?rotational acceleration +/-axonal injury Biochemical versus structural “jiggle” Helmets do not prevent concussions

17. Nature of a Concussive Injury Direct blow to head, face, or neck producing an “impulsive” force to the head Rapid onset of short-lived impairment of neurologic function,resolving spontaneously Acute symptoms reflect a functional disturbance rather than a structural injury A graded set of clinical symptoms may involve LOC. May be prolonged post- concussive symptoms No abnormality on standard structural neuroimaging studies

18. Concussion Symptoms-Somatic, cognitive, emotional Physical signs-LOC, Amnesia Cognitive- reaction time Behavior Lack of orientation-time, person, or place

19. Concussion Evaluation Medical exam-complete neurological 2009 SCAT Card away from bench Should not be left alone Serial observations for deterioration Should not drive Look for associated injury- neck, facial fractures

20. Remember Associated Injury

21. SCAT 2009 Sport Concussion Assessment Tool Numerical symptom score Cognitive measures-word or number recall Balance Impact of exercise

22. Cognitive Testing Modified Maddocks questions recent memory Attention-digits backward or months in reverse order Memory-5 words immediate/delayed recall Effect of exercise

23. Balance Double leg stance Single leg stance – eyes open and closed Tandem stance Finger to nose tasks ( Zurich Consensus 2008)

24. NHL Study Prospective study 1997-2004 Headache (71%) Dizziness (34%) Nausea (24%) Neck pain (24%) Benson et al

25. NHL Study Prospective Study 1997- 2004 Fatigue/low energy (22%) Blurred vision (22%) Amnesia (21%) LOC (18%) Benson et al

26. Zurich International Symposium on Concussion in Sport No simple/complex classification Most concussions will settle in a week Modifiers will alter management Lack of metrics for diagnosis, treatment, return to play, and long term effects

27. Concussion Modifiers LOC > 1 minute Amnesia Recent/frequent concussion Recurrent concussions with less force Age and Gender Medication and pre-existing conditions

28. Concussion Treatment 2012

29. Concussion Treatment Physical Rest Emotional Rest Cognitive Rest Lack of Metrics

30. Stepwise Program for Return to Play Complete rest Aerobic exercise measured heart rate Sport-specific drills Practice non contact Contact Practice Asymptomatic with each progression

31. Return to play

32. Consensus No difference between and amateur athletes Physician expertise Role of Neuropsychological testing ? Rapid progression of return to play

33. Same Game R.T.P. Short duration of symptoms Normal testing Scat 2009 No provocation with exercise No modifiers

34. NHL Return to Play in Same Game Evaluated and R.T.P. same game 26% out > 10 days Unreported and remained in game 14% out >10 days Removed from game 31% missed > 10 days

35. NEUROPSYCHOLOGICAL TESTING Important tool in return to play Only done when player is asymptomatic Must meet return to baseline measures Final decision on return to play is always a medical one

36. Return to Play

37. Prevention is the Cure!

38. Concussion Prevention Helmets Mouth guards Full face masks Arena standards- boards, ice conditions, Rules and regulations-officiating Concept of risk compensation:-use of protective equipment alters playing behavior Equipment becomes a weapon rather than protective device

39. Consequences of Concussion Early and Late Second impact syndrome ? Too early return to play Post concussion syndrome Psychosocial Epilepsy Chronic traumatic encephalopathy- dementia pugilistica, Parkinsons

40. Concussion Reality Increasing prevalence at all levels Lack of an accurate diagnostic study Current treatment based on physical, and mental rest. No metric for safe return to play Lack of a clear cut strategy for prevention specific for all age groups

41. Concussion Reality Impact on player, acute and long term Impact on team, loss of skilled player, replacement costs Economic impact on player, team, and NHL Medico-legal implication for league, current class action suit in NFL Impact on our youth who emulate our NHL stars

42. Time for the NHL to Get Head Smart Immensity of the number Prominence of the names Threat of long term disability ?dementia Global ‘head smart’ hockey movement Ken Dryden Sept 30 2011

43. Hockey Concussions: Is it child abuse? Stampede of Canadian youth out of amateur hockey Registration in hockey Canada is below 572, 471 in 2010-2011 Ontario legislation re teachers and coaches to follow strict guidelines re concussion care Hockey Calgary eliminates body checking at the Pee Wee level Failure to implement stringent concussion measures is nothing short of child abuse C.M.A.J.,May 15, 2012

44. ‘Fight’ versus Fighting Ken Dryden The debate about head shots and fighting is not a debate about Canada, Canadian hockey or the Canadian spirit. It is about giving up the fighting; keeping the fight Toronto Globe and Mail Jan 7 2012

45. Concussion Research Clinical Validation of SCAT 2009 testing On-field injury predictors Rehabilitation Strategies Best practice Neuropsychological testing Concussion surveillance using consistent definitions and outcome measures

46. Concussion Research Basic New imaging modalities for diagnosis such as functional MRI, may detect axonal injury and monitor treatment Genetic studies, predisposition to concussion Biochemical markers Neuropathology studies in C.T.E.

47. Concussions in the NHL: Waiting for Science Premature deaths of former players, suicides, career ending concussions and the future of Sidney Crosby Evolution of equipment, medical treatment, and ‘tweaks’ to the rules Create a structure to study concussions sponsored by the NHL hosted by a University Ken Dryden Dec 14 2011

49. Paciorretty Foundation Created in 2012 Goal to develop a world class research unit using a research functional M.R.I. Collaborative effort by M.G.H. in Montreal and Boston Led by Dr. Reza Faviar Support from industry, Federal Govt, league and players

50. Proposals for Improval Adopt I.I.H.F. rules re head hits Ban fighting from hockey at all levels olympic or world cup rules Re-evaluation of all equipment as to weapon versus protective device Broad education program for players, coaches, officials, parents and health care providers Accelerated research to develop metrics for diagnosis, treatment, and prevention.

51. Sport Concussion Library www.sportconcussionlibrary.com “concussion is a serious brain injury that can cause short and long term injury among our athletes. We can no longer turn our collective heads when a concussion occurs.” Dr. Paul Echlin London Ontario

54. How Not To Do It!

55. Zurich Conference 2009

56. Advanced Trauma Life Support

57. Basal Skull Fracture