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BC School Sports Association Presidents Meeting North Surrey Secondary School October 23, 2010. Dr. Shelina Babul-Wellar Associate Director / Sports Injury Specialist BC Injury Research & Prevention Unit Clinical Assistant Professor Department of Pediatrics, UBC. Agenda. Concussion in sport

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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

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  • Concussion in sport

  • ThinkFirst BC

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  • 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

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Nature of the Game – New awareness sport

  • "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)

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The Scope of the Problem sport

  • 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

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Points to Ponder… sport

  • Misnomer that a concussion = loss of consciousness


  • Concussions misunderstood until recently

    • media attention (football, hockey, snow sports, soccer)

  • Vary from person to person

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  • Falls sport

  • Motor Vehicle

  • Unintentional struck by/against object

  • Assault

  • Sports

Leading Causes of mTBIs (Emerg. Dept.)

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Groups at highest risk for mTBI

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Sports sport

  • 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

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Sports sport

  • 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?

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Multiple Concussions

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  • Player size sport

  • Speed of the game

  • Increased agression

  • Violence

What Contributes?

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What is the Key?

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Definition sport

  • 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



  • Duration variable: several minutes to days, weeks, months and longer

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Signs and Symptoms sport

  • 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

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Return to Play Guidelines sport

  • 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

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  • REST sport

  • 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

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Lystedt Law sport

  • 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

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Lystedt Law sport

  • 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.

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  • Chronic Traumatic Encephalopathy (CTE) sport

  • 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)

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Protective Equipment sport

  • Wear protective equipment (i.e. helmets)

  • Follow the safety rules

  • Good sportsmanship

  • Education

    • Coaches

    • Trainers

    • Parents

    • Players/participants

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  • 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.

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Helmets of crashes.

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Wipeout of crashes.

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.

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  • 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

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Concussion Management Card to concussion/brain injuries

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Whistler to concussion/brain injuries

  • 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.

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ThinkFirst BC to concussion/brain injuries

  • 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.

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ThinkFirst Elementary School Program to concussion/brain injuries

  • 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).

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  • What is the brain and what does it do? to concussion/brain injuries

  • 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


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What Needs to Be Done! to concussion/brain injuries

  • 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


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THANK YOU! to concussion/brain injuries

Thank You

Dr. Shelina Babul-Wellar


[email protected]

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Overview of Unintentional Injuries to concussion/brain injuries

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Injury is the fastest growing and least to concussion/brain injuries

researched of all modern epidemics

World Bank, 2008

Canada’s Invisible Epidemic

SMARTRISK Foundation, 2005

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Accidents! to concussion/brain injuries

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

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n = 9,505 to concussion/brain injuries

The Scope of the Problem

Unintentional Injury Deaths in Canada

Source: SMARTRISK (2009)

The Economic Burden of Injury In Canada. SMARTRISK, Toronto, ON

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n = 194,268 to concussion/brain injuries

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

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The Scope of the Problem to concussion/brain injuries

  • 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

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The Scope of the Problem to concussion/brain injuries

  • 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

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The Current Problem – British Columbia to concussion/brain injuries

  • Over 400,000 residents of BC are injured each year

  • On average, 2,000 British Columbians die and over 50,000 are hospitalized each year

  • Every hour of every day, 48 British Columbians are unintentionally injured

  • Each day, 31 people in BC are either killed or permanently disabled as a result of preventable injuries

  • Between 2000 and 2004, unintentional injuries accounted for 6,696 deaths in BC, or 5% of all deaths

  • More children die from injuries than all other causes combined

  • Source: The Economic Burden of Unintentional Injury in British Columbia, 2001

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Economic Burden of Injury in BC to concussion/brain injuries(Projected Direct and Indirect Costs of Unintentional Injury in BC to 2020)


Assuming a 5% annual increase in direct costs and 2% annual increase in CPI applied to indirect costs between 1998 and 2020

$ 4.4 billion


$ 2.6 billion


$ 2.1 billion

$ 2.5 billion

$ 1.9 billion

$ 1.4 billion

$ 1.2 billion

$ 1.2 billion

$ 850 million