Concussion In Hockey Players – Guidelines 2013

IMG_1706Hope your week is off to a great start!  Mine is cranking along nicely.  I was in a golf tournament on the weekend to support two of my athletes.  It was a great time.  I am not a golfer at all, but we got to cruise around in a golf cart that looked like a Hummer and had a pretty good stereo, so that helped!

In this post I am not trying to give you medical advice, just share some information I have gathered and some experiences I have had.  In the past year I have had no fewer than 4 athletes get concussed while participating in their sport.  I am still amazed at the misinformation they are getting and the denial that is still taking place on the part of athletes, parents and coaches.

I had emails from parents who were outraged that the doctor told the athlete that they could not participate in the tournament on the weekend after they had already paid for the a hotel.  They were asking me if I thought the athlete was fine to play, after all they felt fine with only slight headaches and they were really, really upset to be missing the tournament, to the point where they were in tears.

Here is the thing we need to remember when dealing with an athlete who is concussed, they are not in their right mind – they can be over emotional and they can even become depressed.  So the fact that an athlete is uncharacteristically emotional about staying out of sport, goes along with the symptoms of concussion.

Then I see this happen in the game last week – – Orpik takes a regular old check and is left staggered on the ice – he had that look like someone just teleported him to the ice and he was thinking, ‘now how the hell did I get here!’.

Then Pierre chirps in – ‘I think maybe his head hit the stanchion and that is what caused the problem’ – thanks Pierre!  And here I was thinking that his brain just rattled off his cranium and caused the problem.

Then the play by play guy jumps in saying something like – –  ‘well we just saw him sitting on the bench looking as normal as anyone else’.

The Clinical Journal of Sport Medicine from March 2013 (23:89-117) included the “Consensus Statement on Concussion in Sport – the 4th International Conference on Concussion in Sport Held in Zurich, November 2012”.  A collection of over 20 medical doctors and related health care providers, including Dr. Karen Johnston, gathered to discuss diagnosis and treatment of concussion in sport, these are their recommendations.

Get treatment from an expert…

The authors start off by acknowledging that the study of concussion is in its infancy and that management decisions will rely heavily on clinical judgment.  To me this highlights the importance of seeking medical care from a physician with experience managing athletes recovering from concussion.  Your regular family doctor may not have experience.

I have even had athletes who visited their doctors office after a head impact and acute symptoms be told that they were fine – ‘just had your bell rung a little’.

If you ‘had your bell rung’ you have a concussion.

The authors defined concussion as…

A brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.

It can be caused by either a direct blow to the head, face, neck or elsewhere on the body.  This is an important point, since how many times to you see a slow replay when watching hockey on TV where the commentators say – – ‘Nope, see no contact with the head so he won’t have a concussion’.

Quick Facts:

  • 80-90% of concussion resolve in 7-10 days
  • Symptoms can include, but are not limited to: headache, feeling foggy, irritability, slowed reaction times, insomnia, loss of consciousness, changes in emotional state, sensitivity to light.  The presence of any ONE should make you suspect concussion.
  • In the early stages, the injury can develop; it can go from mild to serious over the first hours, so the athlete needs to be monitored.
  • Physical and cognitive rest is the key during the early stages of concussion management, this means no sport and may mean a few days off school for the first 24-48 hours.
  • There should never be same day return to play where a concussion is suspected, this is independent of the level of play from recreational to professional.
  • It may take children longer to recover
  • Athletes will lie about their symptoms, so if what they say does not jive with what you see, hold them out.

There is a return to play protocol and each stage takes 24 hours, so the earliest an athlete with a mild concussion should return to play is 6-days from the injury.

The recurrence of symptoms at any stage requires the athlete to back track one stage for 24 hours before proceeding again.

Day 1 – No Activity

Day 2 – Light aerobic exercise

Day 3 – Sport specific exercise i.e. skating.  No contact

Day 4 – Non contact training drills. More complex training drills

Day 5 – Full contact practice

Day 6 – Normal game play

What about protective equipment…

There is no evidence that mouthguards prevent concussion, but they do help prevent dental injury.

Helmets reduce impact force to the brain, but have not been shown to reduce the incidence of concussion.  They will reduce the risk of skull fracture.

This is probably due to the fact that concussion occurs when the brain is rattled around in the cranium, this can be from a hard body check without any contact to the head at all.

Summary…

When in doubt, err on the side of caution when returning to play.  Oddly enough, I still see parents insist their child is good to go.  If that child was limping on a sprained ankle they would never let them step on the ice, but with a brain injury they are happy to put them back out there.

There are some great screening tools that can be used by anyone.  The SCAT3 is one such tool and you can download it here – http://bjsm.bmj.com/content/47/5/259.full.pdf

There is also a Child-SCAT3 – http://www.thinkfirst.ca/downloads/concussion/scat3-child.pdf

Hockey Canada also has a free concussion awareness app – http://www.hockeycanada.ca/en-ca/news/2012-nr-130-en

So that is probably more than you wanted to know about concussion, but it is serious and the effects can be cumulative.  I would love to know how many concussions Sidney Crosby had before he even made it to the NHL.

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After posting this yesterday, I received the following email:

Hi Maria,

Thanks so much for posting your blog about concussions today. It’s so important to get people to understand them more. I was a little surprised by your time table though. I received a concussion back in December.  It was like you mentioned.  A guy ran into me, but I honestly do not remember there being hard contact to my head.  It wasn’t until the following days that I even realized something was wrong.  When I went to the doctor and they concluded it was a concussion, they told me I was not allowed to do any physical activity (I wasn’t even suppose to watch TV) until the symptoms were completely gone for a week.  Then and only then could I do light activity.  If that didn’t bother me I could bump it up gradually.  If symptoms came back (which they did my first outing) I needed to take it back a step.  I ended up being off the ice for 2 1/2 months.  Yikes!  I may or may not have had a concussion once before.  I don’t really know since this is the only time I have ever seen a doctor, but starting back up activity in the first week sounds fast to me. Anyway, no complaints. I loved the post.  Just thought I would add in my two cents.  Keep up the great work!
So I think it worth highlighting once again the acknowledgement in the paper that –  the study of concussion is in its infancy and that management decisions will rely heavily on clinical judgment.  There are no hard and fast rules.  The guidelines for return to play that I posted are straight from the Consensus Statement, they are not my personal opinions.
Note also that the paper is saying, this is the shortest timeline for return to sport, not the recommended timeline, that is important to understand.  For some athletes it may take longer for their initial symptoms to subside.  For some athletes their initial symptoms may subside very quickly, but it may take a prolonged period before they can exert themselves without symptoms so they may need more time before proceeding from step one to step two.
This should help you appreciate the importance of finding a doctor with experience managing athletes after concussion. It is not like a regular injury that follows a similar recovery path for all athletes.

For those of you who are interested, here is the entire paper.  Definitely worth a read – http://www.thinkfirst.ca/downloads/concussion/consensus-statement-2013.pdf

It is your brain, take care of it please.
Cheers,
Maria

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Maria Mountain

Maria Mountain is a Fitness Coach and the owner of Revolution Conditioning in London, Ontario. She helps hockey players from AAA to professionals compete at their highest level while reducing their risk of injury. Dedicated to athletes who want to work hard, but train smart.

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