Epidemic of Sports Injuries: Need for a Collaborative Approach

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 InjurySpectrum • Concussions • Epidural hematoma • Subdural hematoma • Intracerebral bleed and/or edema

12. Mild Traumatic Brain InjuryM.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 2009Sport 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 StudyProspective study 1997-2004 • Headache (71%) • Dizziness (34%) • Nausea (24%) • Neck pain (24%) • Benson et al

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

26. Zurich International Symposium onConcussion 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 ConcussionEarly 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 FightingKen 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 ResearchClinical • 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 ResearchBasic • 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.