Dr. Shelina Babul-Wellar Associate Director / Sports Injury Specialist BC Injury Research & Prevention Unit Clinical

1. BC School SportsAssociation Presidents MeetingNorth Surrey Secondary SchoolOctober 23, 2010 Dr. Shelina Babul-Wellar Associate Director / Sports Injury Specialist BC Injury Research & Prevention Unit Clinical Assistant Professor Department of Pediatrics, UBC

2. Agenda • Concussion in sport • ThinkFirst BC

3. Youth are being hurt?

4. Is it stupidity?

5. Or Unavoidable?

6. Concussion in Sport

7. Teenagers account for 32% of all catastrophic injuries in sport • The best defense against injury is prevention. This does not mean hibernation. It means getting trained, wearing the gear and using wisdom to navigate risks. • Innumerable benefits to participation in sport • physical, mental, social

8. Nature of the Game – New awareness • "I couldn't watch games and the stress of that isn't good for your brain,“…Willie Mitchell NHL (ex-Canuck) • "You hate to say it, but eventually there's going to be a fatality in this game“… Jeff Beukeboom NHL (ex-player) whose career ended because of post-concussion symptoms. • “I’ve had knee issues, and you come back a little early and you just play through it… I guess with your brain and your head I probably learned that wasn’t the best thing to do.”…Marc Savard NHL (Boston)

9. The Scope of the Problem • Approx. 1.6-3.8 million sport & recreation-related TBIs occur annually in the US • Underreporting (recognition / player) • Most not treated in hospital / emergency department • Am. Acad. Peds report an increase of 200% in sport-related concussions between 2001-2005 • 75-90% of the million+ TBI-related deaths, hospitalization and ED visits that occur annually are concussions or other forms of MTBI • Direct/Indirect costs estimated at $12 billion in the US, 2000 • Canadian data limited • 2004, 5000 Canadians under 19 were hospitalized for head trauma

10. Points to Ponder… • Misnomer that a concussion = loss of consciousness • INVISIBLE EPIDEMIC • Concussions misunderstood until recently • media attention (football, hockey, snow sports, soccer) • Vary from person to person

11. Falls • Motor Vehicle • Unintentional struck by/against object • Assault • Sports Leading Causes of mTBIs (Emerg. Dept.)

12. Infants & children (0-4 years) • Children & young adults (5 to 24 years) • Older adults (75 years+) Groups at highest risk for mTBI

13. Sports • Football • studies indicate a 47-63% reporting of mTBI (non-professional) • 35% multiple concussions • Hockey • checking leagues 3-4x the rate • study reports 10-12% minor hockey players receive head injuries each season • amateur and professional as high as 20%/year • interestingly, more skilled, higher probability of concussion • Basketball • TBIs were up 70% in kids/teens who sustained bball-related injuries • Snow Sports • 22% reporting of head injuries

14. Sports • Cycling • fall from a bike most likely cause of ED visit for kids under 9 • Skates/Skiis/Snowboards • 10-14 year olds ED visits • Soccer • concussions on the rise • head to head/ball/post/ground/elbow/foot • children under 10?

15. Repeated episodes may cause permanent deficits • dementia • seizures • movement disorders • depression Multiple Concussions

16. Player size • Speed of the game • Increased agression • Violence What Contributes?

17. Accurate Detection • Expert management What is the Key?

18. Definition • Complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. • mTBI caused by a blow or jolt to the head that disrupts the function of the brain • Typically associated with normal structural neuroimaging findings • Constellation of clinical, physical, cognitive, behavioral/emotional and/or sleep-related symptoms • MAY OR MAY NOT INVOLVE LOC • SIGNS/SYMPTOMS MAY NOT APPEAR IMMEDIATELY / SUBTLE • Duration variable: several minutes to days, weeks, months and longer

19. Signs and Symptoms • Physical Cognitive Emotional Sleep • • Headache • Feeling mentally • Irritability • Drowsiness • • Nausea “foggy” • Sadness • Sleeping less/more usual • • Vomiting • Feeling slowed • More emotional • Trouble falling asleep down • Nervousness • • Balance • Difficulty • problems concentrating • • Dizziness • Difficulty • • Visual problems remembering • • Fatigue • Forgetful of • • Sensitivity to recent • light information or • • Sensitivity to conversations • noise • Confused about • • Numbness/ recent events • Tingling • Answers • • Dazed or questions slowly • stunned • Repeats questions

20. Return to Play Guidelines • Removed from activity immediately • Assessed for S&S • level of injuries (mild-moderate-severe) • neuroimaging? • NEVER return to activity if experiencing symptoms • Completely symptom free at rest and with physical/cognitive exertion • Gradual entry/return • Carefully monitored throughout

21. REST • Aerobic exercise (e.g. stationary bike, walking – 70% max. HR) • Sport specific training (e.g. drills but no head impact) • Non-contact drills (e.g. cutting, lateral movements, light resistance training) • Full contact/normal controlled training (after medical clearance) • Return to play Concussion in Sport Guidelines

22. Lystedt Law • 13 year old athlete – junior high football (Washington State) • Hard hit to the head • Sidelined 15 minutes and returned to game • Collapsed at end of game • Last words – “Dad, I can’t see” • 9 months later….. • wheelchair bound • impaired speech

23. Lystedt Law • Youth athletes suspected of sustaining a concussion/head injury be removed from play. • “When in doubt, sit them out.” • School districts work with the Washington Interscholastic Activities Association (WIAA) to develop information and policies on educating coaches, youth athletes and parents • nature and risk of concussion, including the dangers of returning to practice or competition after a concussion or head injury. • All student athletes and their parents/guardians sign an information sheet about concussion/head injury prior to the youth athlete’s initiating practice at the start of each season. • Youth athletes who have been removed from play receive written medical clearance prior to returning to play from a licensed health-care provider trained in the evaluation and management of concussion.

24. Chronic Traumatic Encephalopathy (CTE) • Boston University • autopsy on professional football players • tremendous brain damage • brown tangles flecked througout brain in young men (30-40s) • closely resembles what found in 80-year-old with dementia (Alzheimer’s disease) • damage affects part of brain that controls emotion, rage, hypersexuality, even breathing • CTE progressive disease eventually killing brain cells Center for the study of Traumatic Encephalopathy (CSTE)

25. Protective Equipment • Wear protective equipment (i.e. helmets) • Follow the safety rules • Good sportsmanship • Education • Coaches • Trainers • Parents • Players/participants

27. Some Initiatives Currently Taking Place

28. Helmets are effective for cyclists of all ages and all types of crashes. • When worn properly, helmets reduce risks for brain injury by 88%. • Cycling related head injury decreased in children by 45% in provinces with legislation (BC,ON,NS,NB) compared to a 27% reduction in provinces without legislation.

29. Helmets

30. Wipeout Wipe Out tells the story of three young men living with permanent brain damage as the result of head injuries they suffered pursuing extreme sports. Through their stories, the documentary explores the science of thrill-seeking, and reveals how cultural forces and ignorance are propelling young men to dangerous new heights.

31. Effective June 1, 2010, BC Football adopts policy specific to concussion/brain injuries • requires ALL coaches to participate in a yearly education program before the season to ensure that an athlete suspected of a head injury be removed from play and NOT be allowed to return until cleared by a doctor BC Football

32. Concussion Management Card

33. Whistler • Intrawest To Recommend That All Resort Guests Wear Helmets • New helmet use guidelines receive industry support from the National Ski Areas Association and Canada West Ski Areas Association • Mandatory helmet requirements for all children and youth participants in Ski and Snowboard School Programs as well as all students participating in freestyle terrain park programs, regardless of their age. • 2010-2011 season, employees to wear a helmet at all times: • while skiing or snowboarding on-duty in any freestyle terrain park at its resorts. • staff at Intrawest’s Ski and Snowboard Schools will also be required to wear a helmet if they serve as a guide or an instructor for any program that requires mandatory helmet use by a resort guest.

36. ThinkFirst BC • ThinkFirst’s Mission: To prevent brain and spinal cord injury by educating children and youth • ThinkFirst teaches school-aged children and youth, sports teams, and community volunteers, to safely participate in the activities they enjoy.

37. ThinkFirst Elementary School Program • ThinkFirst school presentations engage the students through stories and games to learn about the brain and spinal cord and how to protect them. • ThinkFirst will spend a half day at the school, making 20 to 45 minute presentations to two grade levels at a time (K/1,2/3,4/5,&6/7).

38. What is the brain and what does it do? • What is the spinal cord - what does it do? • What happens when you hurt your brain or spinal cord? • Ways to protect the brain and spinal cord • Proper helmet fitting • A survivor (VIP) tells their experience of brain-injury Content

40. What Needs to Be Done! • Encourage mandatory education • Reevaluate • how the game is practiced • protective equipment • techniques of play • rules • enforcement/role of referees • Develop • consistency in methods for detection/diagnosis • better methods of management • Consider medical resources on-hand • CULTURE

41. THANK YOU! Thank You Dr. Shelina Babul-Wellar 604-875-3682 sbabul@cw.bc.ca

42. Overview of Unintentional Injuries

43. Injury is the fastest growing and least researched of all modern epidemics World Bank, 2008 Canada’s Invisible Epidemic SMARTRISK Foundation, 2005

44. Accidents! • 85 – 90 % of all injuries are the result of predictable and preventable events!

45. n = 9,505 The Scope of the Problem Unintentional Injury Deaths in Canada Source: SMARTRISK (2009) The Economic Burden of Injury In Canada. SMARTRISK, Toronto, ON

46. n = 194,268 n = 62,500 The Scope of the Problem Unintentional Injury Hospitalizations & Disability in Canada Source: SMARTRISK (2009) The Economic Burden of Injury In Canada. SMARTRISK, Toronto, ON

47. The Scope of the Problem • Unintentional injuries: • Kill more Canadians ages 1 to 34 years of age than any other cause • Kill more Canadian children and youth than all other causes combined • Are the leading cause of Potential Years of Life Lost

48. The Scope of the Problem • In just one year • 9,505 Canadians died - 1,097 on-the-job deaths1,2 • 194,268 were hospitalized1 • Over 3.25 million required medical treatment3 • 335,000 on-the-job injury claims - one in every 39 employed workers2 • Over 62,500 disabled3 • 5,000 were left with a total lifelong disability3 1. PHAC. Injury and Child Maltreatment Section 2. Association of Worker’s Compensation Boards of Canada 3. SMARTRISK. The Economic Burden of Injury In Canada