Knocking out concussions in sport que es la anoxia

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• beyond the immediate impact of an injury such as pain and inability to participate in regular activities, there are a lot of other consequences. Those who suffer an injury as a kid are more likely to have lower subsequent participation in sport other physical activity–participation among injured youth drops by 8% each year. CLICK also, kids who are hurt may have to miss school or certain classes because of medical appointments, or because they are unable to participate CLICK looking ahead, injury can result in lower participation in physical activity throughout their lifetime, which we know is linked with increased risk of becoming overweight or obese CLICK furthermore, those who suffer lower extremity injuries are known to have up to 4x the risk of developing early onset osteoarthritis in their joints as a result.Que es la anoxia

CLICK other consequences include long-term psychological and even psychosocial sequelae, including depression and implications for learning, such as the timing of returning to school after an injury like a concussion we also cannot forget about the financial consequences of money spent on health care, and indirect costs (e.G., parents missing work).

• modifyable vs nonmodifyable

• first three are tested with and without a puck, the last test, 6-repeat is tested without a puck only

• cervical flexor endurance test: the CFE test has demonstrated interrater reliability of 0.83-0.88 and intrarater reliability of 0.78-0.93 olson et al, 2006; kumbhare differences between wad and controls cervical flexion rotation test: this test has also been reported to have high sensitivity, specificity and diagnostic accuracy in the diagnosis of C1/2 related cervicogenic headache cervical rotation side flexion test: head perturbation test: joint position error test: clinical DVA computerized DVA: abnormal computerized DVA testing has demonstrated high positive predictive value (96%), negative predictive value of 93%, sensitivity of 95% and specificity of 95% in individuals with vestibular disorders (based on positive caloric, vertical axis rotary chair and/or vestibular autorotation tests head thrust test: when the HTT is performed in this way, sensitivity has been reported to be 71% in individuals with unilateral vestibular hypofunction (UVH) of various degrees and 88% in individuals with total UVH specificity has been reported to be 95%-100% to identify lateral canal pathology in individuals with unilateral vestibular hypofunction [25].Que es la anoxia the positive predictive value of the HTT is increased to 80% when combined with head shaking tests (looking for nystagmus induced from rapid head motion) functional gait assessment: this 10 item gait assessment is based on the dynamic gait index (DGI) and has demonstrated an intrarater reliability of 0.83, interrater reliability of 0.84, internal consistency of 0.79 and concurrent validity (r=0.80) with the DGI in individuals with vestibular disorders WWT test: tasks of divided attention have been used as predictors of falls in elderly patients and in individuals who have had a stroke

• eight weeks is consistent with current literature sport medicine physician is blinded to treatment group and determines the outcome of interest orthopaedic physiotherapy: neuromotor retraining, sensorimotor retraining (cervicocephalic kinesthetic awareness, smooth pursuit, etc), manual therapy, soft tissue techniques as warranted vestibular rehabilitation; gaze stabilization, standing balance, dynamic balance, habituation, canalith repositioning maneouvers, substitution

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Knocking out concussions in sport


Knocking out concussion in sports

Carolyn emery

Professor, faculty of kinesiology

Brent hagel

Associate professor, cumming school of medicine

October 20, 2016



 webinar series by university of calgary scholars

 information presented is a summary of the

Scholars’ research

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Carolyn emery

Faculty of kinesiology

 physiotherapist and epidemiologist

 professor, faculty of kinesiology and cumming

School of medicine

 chair, sport injury prevention research centre

 chair in pediatric rehabilitation

 phd from the university of alberta; msc from

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The university of calgary; bscpt from queen’s


 research focused on injury prevention in

Youth sport and recreation and the prevention

Of consequences of injury

• in particular: a focus on concussion and joint

Injuries and their consequences in youth


Brent hagel

Cumming school of medicine

 injury epidemiologist

 associate professor, pediatrics and

Community health sciences, cumming

School of medicine

 adjunct professor, faculty of kinesiology

 phd mcgill university; msc university of

Calgary; BPE university of calgary

 research focused on injury prevention in

Youth sport and recreation



 to understand the public health impact of

Concussion in youth sport and recreation

 to be exposed to evidence-informed

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Examples evaluating concussion risk and

Prevention strategies in youth sport and

Recreation (i.E. Hockey)

 to discuss the relevance and impact of

Evidence in concussion prevention in youth

Sport in practice and policy considerations

 to consider secondary prevention of

Consequences of concussion in sport



 “concussion is a brain injury and is defined as a

Complex pathophysiological process affecting the

Brain, induced by biomechanical forces.”

• direct blow to head or other part of body with force

Transmission to head

• rapid onset of short lived neurological symptoms

• functional disturbance rather than structural injury

• may not involve loss of consciousness

McCrory et al. Consensus statement on concussion in sport: the 4th international conference on concussion

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In sport held in zurich, november 2012. Br J sports med 2013;47:250–258


Societal burden of concussion

 sport injuries requiring medical attention

• 15-18 years: 40 injuries/100 students/year

• 11-14 years: 30 injuries/100 students/year

• (emery CA, tyreman H. Paediatr child health, 2009; emery et al. Clin J sport med.


 sport related head injuries in the ED

• 10 days (benson et al


NIH 2007, emery et al 200,2010,2012, 2013


Youth vs adult ice hockey

Concussion rates

Emery meeuwisse (2006, 2010, 2011, 2013)

atom (9-10): 0.24/1000 player hours

pee wee (11-12): 1.47/1000 player hours

bantam (13-14): 1.3/1000 player hours

midget (15-17): 1.3/1000 player hours

Agel harvey (2010)

NCAA males: 0.72/1000 athlete exposures

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NCAA females: 0.82/1000 athlete exposures

Benson et al (2011)

NHL: 1.8/1000 player hours over 7 seasons


National hockey league

Pee wee (11 and 12 years old)


A dynamic, recursive model of

Etiology in sport injury meeuwisse et al 2007





Body checkingbody checking


Contact sportscontact sports

Dizziness, neck pain,

Headaches at baseline

Dizziness, neck pain,

Headaches at baseline

Smaller sizesmaller size









Injury prevention

Specific strategies used to prevent injuries:

 rule changes

 body checking policy

 head contact rule enforcement 2011

 STOP program

 fair play


Alberta (BC) vs. Quebec (no BC)

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Pee wee game injury rates



Injury concussion injury1week time loss concussion10days

Alberta quebec

Game-related injury rates in pee wee (age 11-12 years)

All injury: IRR = 3.26 (95% CI; 2.31 – 4.60)

Concussion: IRR = 3.88 (95% CI; 1.91 – 7.89)

Injury (7 days time loss): IRR = 3.30 (95% CI; 1.77 – 6.17)

Concussion (10 days time loss): IRR = 3.61 (95% CI; 1.16 – 11.23)


Bantam game injury rates

By province



Injury concussion injury1week time loss concussion10days time loss

Alberta quebec

Game-related injury rates in bantam (age 13-14 years)

All injury: no difference IRR = 0.85 (95% CI; 0.63 – 1.16)

Concussion: no difference IRR = 0.84 (95% CI; 0.48 – 1.48)

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Injury 7 days time loss: IRR = 0.67 (95% CI; 0.46 – 0.99)

Concussion 10 days time loss: no difference IRR = 0.6 (95% CI; 0.26

– 1.41)


Alberta (BC) vs. Ontario (no BC)

Non-elite pee wee injury rates

Injury: IRR = 2.97 (95% CI; 1.33 – 6.61)*

Severe injury(7 days): IRR = 1.76 (95% CI; 0.77 – 4.04)

Concussion: IRR = 2.83 (95% CI; 1.09 – 7.31)*

Severe concussion (10 days): IRR = 2.08 (95% CI; 0.62 – 6.94)

Emery et al 2014


National policy change; alberta before

And after pee wee policy change

Multivariable poisson regression

Game injury: IRR = 0.50 (95% CI; 0.33 – 0.75)*

Severe injury(7 days): IRR = 0.40 (95% CI; 0.24 – 0.68)

Concussion: IRR = 0.34 (95% CI; 0.21 – 0.56)*

Severe concussion (10 days): IRR = 0.52 (95% CI; 0.29 – 0.92)

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*adjusted for cluster, year of play, previous injury/concussion, level of play,

Position, attitudes toward body checking, player size, exposure hours offset

Estimated reduction of 1000 injuries

(400 concussions) in pee W

Ee players

In alberta – evidence-informed


Pee wee hockey

Bruce #15 – 11 years old

Elite + previous hx

Alberta 2012/13

John #5 – 11 years old

Elite + previous hx

Alberta 2013/14

Concussion 26%

Concussion 6%


What has happened?

 USA hockey board (june 2011) – policy change

 ontario hockey (may 2011) and BC hockey (june 2012) –

Eliminate body checking non-elite levels (ages 11-17 – 70%)

 hockey canada board (june 2013) – national policy change

 hockey calgary/edmonton (june 2015) – eliminate body

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Checking non-elite levels bantam (ages 13-14 – 70%)




What about other rules and


Did “zero tolerance for head contact” rule enforcement in 2011 change the

Risk of game related concussions in youth ice hockey players?


Did “zero tolerance for head contact” rule enforcement

↓ risk of game related concussions in youth ice hockey


Maciek krolikowski msc


Concussion risk pre- and post- 2011

Zero tolerance head contact rule change

Head contact mechanism?

Referral bias?

M krolikowski

Head contact policy change

Not evidence-informed


Injury prevention

Early detection of concussion and

Prevention of progression,

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Complications, and disability

 pre-season examination

identify risk factors

(i.E. Previous concussion, symptoms,

Clinical measures)

 pre-season training

modify risk factors related to symptoms,

Strength, balance, other clinical


2. Secondary


“safe to play”

A longitudinal research program to

Establish best practice in the

Prevention, early diagnosis, and

Management of sport-related

Concussion in youth ice hockey players


Safe to play


Safe-to-play MR study B goodyear, R frayne

 diffusion tensor imaging (DTI)

• investigates the integrity of the

Functional connections of the brain

 resting-state fmri

• measures the diffusion (random motion)

Of water molecules in tissue

 perfusion MRI

• provides whole-brain images of cerebral

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Blood flow


Hockey canada skills test

• forward agility weave

 forward/backward

Speed skate

 transition agility

 6-repeat endurance



Cervical and vestibular measuresk schneider

Cervical flexor endurance test

Cervical flexion rotation test

Cervical rotation side flexion


Head perturbation test

Clinical dynamic visual acuity

Computerized dynamic visual


Functional gait assessment

Walk while talk test

SCAT3: BES and tandem gait


Management and rehabilitation


Primary outcome:

# days to medical clearance RTP

Treatment group

 education

 general range of motion


 orthopaedic physiotherapy

 vestibular rehabilitation

Control group

 education

 general range of motion


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Physiotherapy management

Schneider et al 2012



The participants in the treatment group were 10X more likely to be

Medically cleared to return to sport than the participants in the control

Group at 8 weeks


Education – RCT


Future directions?

Thinking outside the bubble!

• focus shifting from elite to recreational youth hockey

Where public health impact will be the greatest

• build research capacity through interdisciplinary

Opportunity (basic science, clinical, population health)

• continue to develop, implement and evaluate injury

Prevention strategies (primary, secondary,


• continue to validate measures of risk – extrinsic and


• develop standard of practice in concussion

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Prevention, evaluation and management

• continue emphasis on knowledge translation




Www.Sportmed.Ucalgary.Ca (acute injury clinics)



IOC research centre



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