What Risk Managers Need to Know about Concussions

The following article was written by Robin Bowman. Robin is a certified athletic trainer and risk manager with nearly 20 years experience in recreational and varsity athletics.

Concussions are arguably the biggest hot-button issue in sports today. As more research comes out on the complex and sometimes long-lasting effects of even a single concussion, those involved with sports and recreation at all levels are left with some difficult questions. Should children be participating in contact and collision sports? If so, at what age is it appropriate to begin? What should athletes, parents, coaches, officials, and administrators know about concussions? Who is responsible for recognizing and responding to a suspected concussion? How can we balance all the benefits of athletic participation with the very real risks?

Risk managers are tasked with weighing these questions and developing sensible concussion plans. These plans should include strategies for minimizing the number of concussions; a concussion education plan for athletes, coaches and parents; and a well-defined protocol to be followed whenever a concussion is suspected.

The New Standard of Care

Gone are the days of brushing off concussions as “getting your bell rung” and returning to play the same day as the injury. As Maya Angelou said, "I did then what I knew how to do. Now that I know better, I do better." As a society, we now know better, and those working in and around athletics are held to a higher standard of care than they once were. The expectation is that every team and every league have a plan in place for concussion education, recognition and response.

Concussions Can be Managed

While we still have much to learn, we know that concussions are serious injuries that can have long-lasting effects. While we can’t eliminate the injuries altogether, we can take measures to reduce the incidence and ensure all potential concussions are taken seriously and athletes are offered appropriate care.

In an ideal world, there would be an athletic trainer/athletic therapist on the sideline of every practice and competition to look after the wellbeing of the athletes, but this isn’t realistic for many youth sports leagues. Even without an AT on the sideline, every team should have access to someone trained in concussion recognition and response.

Concussions Must be Managed

Effective concussion management is going to take a change in the culture. Risk managers, athletic administrators, and coaches play a vital role in setting the tone for a team, an athletic department, or a league. Those in these roles share responsibility for making sure athletes look at concussions with proper perspective and help them understand the rest of their career and rest of their life is more important than any one game or any one season.

We need to replace any thoughts an athlete may have of playing through a concussion as a sign of “toughness” with an understanding of the seriousness and potentially life-altering effects of the injury. Hiding a concussion and playing through isn’t tough, it’s just a bad idea.

We need to instill in athletes the responsibility to care for oneself, one’s teammates, and one’s opponents. Sportsmanship and fair play are more than just positive character traits, they help reduce unnecessary injuries.

Risk managers have a duty to ensure there is a plan in place to educate athletes, coaches, and administrators on how to recognize concussions, and what to do when an athlete is suspected of having a concussion. When dealing with youth leagues, it is also important to educate the parents. Create a shared understanding that athlete safety is paramount and everyone associated with the league is expected to take concussion seriously and work together to care for the athletes.

Preventing Concussions

The physical nature of sports means that concussions are going to happen from time to time. This is a risk inherent with athletic participation. There are ways to minimize the incidence of concussions, though.

Provide safe playing facilities and equipment. Conduct a safety audit of all facilities used for practice and competition. Are there obstacles in the way? Is there equipment lying around that could cause a tripping hazard? Are there walls or posts that need to be padded? Are playing surfaces well-maintained and free of holes? (Even a poorly maintained grass field can increase the chance of concussion by being too hard or causing athletes to fall.)  What can be done to make the athletic facilities safer? Is the equipment being used in good repair, and do athletes have the appropriate and properly fitted safety equipment? Prioritize and address any issues uncovered in your safety audits.

Train athletes to use proper technique. From the earliest stages of sports participation, athletes should be trained to use good form and proper technique that does not put themselves or others at unnecessary risk of injury.

Insist on good sportsmanship. This is part of changing the culture of sports, but good sportsmanship is non-negotiable. Create a culture in which foul play is discouraged. (While a hockey player may get a concussion from falling on the ice, there is no excuse for getting one from engaging in a fight.) Have zero tolerance for dirty play.

Consider low- or no-contact versions of sports. For example, a league could play flag- or two-hand-touch football instead of tackle football. Limiting contact in practice is another option for lowering the risk of concussion. Even some NCAA Division I football programs have moved to eliminating tackling in practices.

While it’s unlikely we’ll completely eliminate concussions anytime soon, we can have an impact by proactively managing the risks we have control over.

Have a Plan

Since it is impossible to prevent all concussions, you must have a plan in place for how you will respond when an athlete is concussed. Don’t wait until an injury happens to think about how you’ll handle it. Have a well-thought-out plan in place long before a competitive season starts, and communicate this plan to everyone involved with the team, athletic department, or league. A plan can only work if people are aware of it. Make sure everyone knows what their role is in preventing, recognizing, and responding to concussions.

Maintain Proper Documentation

It’s hard to overstate the importance of thorough documentation. Risk managers should ensure that every team keeps thorough and up-to-date documentation of:

  • Facility and equipment inspections
  • Pre-participation physical exams
  • Concussion policies and protocols
  • Proof of concussion training
  • Waivers and releases
  • Injury reports with follow-up/progress notes
  • Proof of medical clearance to return to activity following a concussion

In the event of legal action, the judge will want to see both documentation of the organization’s concussion policies and protocols and proof that they were followed.

Putting it All Together

Concussions aren’t going away anytime soon, but neither are athletics. A risk manager should provide leadership on concussion education, prevention, and response efforts for their team or league. There are many proactive steps than can be taken to minimize risk, but it takes consistent effort and a team approach to make real change.

Reference

Br J Sports Med 2017 51: 838-847 originally published online April 26, 2017


AT Stories: Joey Garland - Windsor Spitfires

Joey Garland is completing his eleventh season as Athletic Therapist of the 2017 Memorial Cup Champion Windsor Spitfires. The Memorial Cup is awarded annually to the champions of the Canadian Hockey League.

 

A native of Newfoundland, Joey became interested in Athletic Therapy at a young age. In recent years he has also found success at the international level, winning Gold with Team Canada at the World U-18 Championships in Russia and representing his country again in 2014 at the U-20 Championships.

 

Garland graduated with a B.Sc. (Kinesiology) from Dalhousie University in 2002 and also obtained his Sports Injury Management Diploma from Sheridan College in 2005. In the midst of the whirlwind of Windsor hosting the Memorial Cup tournament, Joey took some time out of his busy schedule to chat with us about his passion.

 

 

You have had some success on a global scale with Team Canada and are now entering your 11th season with the Spitfires, why did you choose Athletic Therapy? 

 

Joey: I guess I chose athletic therapy because I have loved sports from a young age. I was never really good at anything but I knew the culture was something that I wanted to stay involved in. I have also always enjoyed watching athletes perform on TV and hated when players got hurt. Even my mom recalls stories from before I can remember of me as a kid watching first responders run out to assist an injured athlete during a televised game, and I always said, “I wanna do that.” So uhh (laughs) I think it was just in me to do.

 

What is your favourite part about your job?

 

Joey: My favourite part of my job is just seeing the boys perform. At this level and when they advance. Our league is very much developmental. Namely, it is trying to produce elite athletes, professional hockey players, but even more than that just good people. I keep track as they move to other endeavours and from time to time I get an email from a former player looking to get into Athletic Therapy, Kinesiology, or strength and conditioning. They appreciated what I did for them, and are now also looking to move into the same role as professionals. It is a special feeling.

 

What are the top 3 most common injuries you handle on a day-to-day basis?

 

Joey: AC sprains, MCL sprains, and concussions

 

In your position with the Spitfires, how do you handle player concussions?

 

Joey: We have a league protocol. Additionally, the OHL has a neuropsych consultant that our team works with. We get a baseline done for each of the boys at the beginning of the season via impact testing. Starting next year we will also be using HeadCheck to help with data collection, storing, and sharing of protocols. Once an incident occurs athletes are re-tested and that along with their symptoms will be examined to determine whether they are cleared or initiate a return-to-play protocol.

 

 

How do you treat concussions on a personal level? Undoubtedly, it is a daunting injury for a young player. How do you provide both physiological and psychosocial support for your athletes?

 

Joey: In this regard there has actually been a bit of a swing since I joined the profession over a decade ago. Concussions have become slightly easier to treat due to players, parents, agents, and coaches being more informed about the realities of the injury. Particularly with the publicity surrounding players like Sidney Crosby, concussions have been given much more emphasis and legitimacy at the highest level. There is a greater understanding of the long-term ramifications that head injuries can have on one’s career and even quality of life as a human being. That being said, telling a kid that they are going to miss any length of time is really difficult. Nobody wants to sit out.

 

If you could hold your own workshop, what is your thing? What fuels your fire/what are you the BEST at?

 

Joey: I would say incorporating strength and conditioning with athletic therapy to minimize injury, and reduce the time missed. I am passionate about integrating strength and conditioning with the therapy aspect of training. I love the blend of “prehab” exercises with rehabilitation and still staying active with the team even if it is in a limited capacity. But when speaking of the strength and conditioning aspect of my job there is a lot of psychology that comes into play. Not every player reacts the same way to the same exercises or rehab protocols so it is important to consistently adapt to the individual. It can be challenging because players get advice from different people or have heard the “key to success” or the best way to make it to the NHL from agents, parents, and other athletes. What I want most is to get each of them performing at their full potential while explaining that there are many ways to find success in hockey. Buying into the system part of it is crucial, and is often the difference maker between good teams and champions.

 

What's the most challenging part of your job?

 

Joey: Well (laughs) probably pretty much the same thing. It is dealing with all of the outside sources and getting a player to buy in to what we’re doing and why what we are doing is going to be best for them. The information they are getting from other sources may not be wrong, but it is just not how we do it here.

 

 

Unfortunately, you guys were eliminated in the first round of playoffs, how did you help ensure that Windsor would be ready to host the Memorial Cup tournament?

 

Joey: The coaches and I sat down, looked at our calendar, and realized that we had 44 days to peak. We could have viewed this period as a long lay off where we could get rusty and slow, but instead we chose to see it as an advantage. We had a unique opportunity to get healthy and into excellent shape. In coordination with the RMT, I also brought in a yoga instructor and consulted with a few other strength coaches. We created a 6-week program to peak for May 19th. The guys bought in. All the credit goes to the players. They could have sat on their thumbs and waited or only given a half effort at the gym but they never once wavered. I think it showed with our results.

 

How do you communicate and coordinate with ATs and rehabilitation staff from other teams?

 

Joey: There was a generalized medical meeting at the beginning of the tournament. Basically an explanation of the protocols, relevant contacts, and resources teams can access while they are here. More personally, we all talk and communicate professionally. The relationships between support staff are very open and casual. We have our league meetings and that is really where we share. This is where we help each other to get better individually and as a group.

 

What is your favourite part about the hockey community?

 

Joey: My favourite part of the hockey community is…how do I explain this…it is a small world. I’ll be in a random airport and I will run into someone that played here 6 years ago. For example, one year at the World Junior tournament I was in Malmo, Sweden and I got a random knock on my hotel room door. It was a former Spitfires player that happened to be playing professionally there. It is a very interconnected community and you would be hard pressed to find more than two degrees of separation no matter where you go. I think it is pretty neat. I grew up and lived in Newfoundland for most of my life and we are pretty isolated (laughs). Elite trainers, NHL players, the best hockey brains in the world; I always looked up to them as a kid and now to be integrated into the same circles is such an exciting privilege for me.

 

What would you most like to see progress in hockey safety?

 

Joey: Well, this answer is something that I have become extremely focused on in the last couple of years. I will be finishing my masters this summer and much of my research has focused on early specialization in youth sports. Kids are playing hockey and only hockey at a very young age at the expense of trying other sports or activities. In my scope, this is where overuse injuries really come into play. Surgeries, sports hernias, labral tears, or conditions like FAI developing in 16 or 17 year-olds. In reality, these types of conditions or injuries should never occur so young. They are more commonly seen in the 25-30 year old athlete age range, if ever. Additionally, these kids do not have the same athleticism coming in and I find are more prone to even minor ailments. One of my goals in my job here and as an athlete therapist overall is to get the message out there to young talent to broaden their base. I think that all children under 12 should seek balance and compete in a variety of sports.

 


 

 

After being eliminated in the first round of the 2017 OHL playoffs, Windsor completed an intense 6-week training program led by Garland in order to prepare for the Memorial Cup tournament. The Spitfires opened strong, and swept the competition in round robin play - finishing with a 3-0 record. This was enough to clinch a spot in the final. Windsor faced the Erie Otters in a fast-paced and physical game, emerging as the 2017 Memorial Cup Champions with a 4-3 victory.

 

Joey Garland is yet another example of the integral role rehabilitation science plays in athletic success, individually and on a team level. Joey facilitates the harmony of strength training, sport psychology, and athletic therapy. This approach has helped him to excel in his field. Garland's message of balance incorporates encouraging young athletes to try lots of different types of activity, nutritional and physical education, and ensuring continuous psychological and performance-oriented support. Although he loves to win and see each of his players perform, Joey also aims to nurture healthy, intelligent, and hard-working human beings, prepared for all of life's future endeavours.

(Photo Credits: www.windsorspitfires.com)


Sarah Allison

BHK – Clinical Exercise Physiology

BSN-PB Student – Nursing (RN)


AT Stories: Kate Trippier, Head Athletic Therapist - SAIT Trojans

Athletic Therapy is a unique discipline that encompasses both clinical and field practice. It is one of the few rehabilitation professions wherein one is required to manage an athletic injury at both ends of the continuum: from initial trauma to return to play. ATs work cohesively and collaboratively with other healthcare professionals and must fulfill a broad spectrum of competencies on any given day. Athletic therapists are elite caregivers that provide on-site treatment in the management of sport-related injuries. In many cases, the profession requires one to adopt emergency care protocols for injured athletes using adaptations of existing medical and paramedical standards.

 

The Competencies in Athletic Therapy are divided into five domains:

  1. Prevention
  2. Assessment
  3. Intervention
  4. Practice Management
  5. Professional Responsibility

An Athletic Therapist is an extraordinarily valuable friend and colleague to have in any stage of life and athletics. Today we will gain insight on what makes the profession so special.

(Photos courtesy of saittrojans.com)

Kate Trippier Interview

March is National Athletic Trainers Month so it is only fitting to begin with an extremely knowledgeable and insightful individual. Kate Trippier is the Head Athletic Therapist at the Southern Alberta Institute of Technology (SAIT) in Calgary. She completed her Kinesiology degree and AT certification through the partner program at the University of Calgary and Mount Royal University. After graduation, Kate worked in a private clinic until she was hired to work with the Trojans in 2016.

 

Why did you decide to become an Athletic Therapist?

 

Kate: I was born and raised in a small town in northwestern Ontario without any qualified rehabilitation professionals. I played a handful of sports growing up, primarily hockey, and at one point I fractured a vertebrae in my neck. Getting access to care and a proper plan for recovery was really challenging. It was a lengthy and often frustrating process but the experience allowed me to do a lot of research. It sparked a passion to learn about the human body and musculoskeletal world in a hands-on way.

 

What is your favourite part about working with young, elite athletes; the most challenging aspect?

 

Kate: I love how entertaining they are. Every day at work I have a great time and it is hard to go even an hour without sharing some chuckles. Athletes are highly motivated and hard working people, but they are also intelligent and hilarious.

 

The most challenging part of my job is trying to foster the understanding that there is life after the Alberta Colleges Athletic Conference (ACAC). Many athletes struggle to understand or are frustrated by why they are being held out of games or practices when they feel they could play. As you grow older, you come to understand just how much of life there is to see, and how many important and exciting experiences are waiting beyond college athletics. It is my job to keep them healthy for life, not just the season.

 

What do you currently do when you suspect an athlete could have sustained a concussion?

 

Kate: SAIT is really fortunate to have access to practicum students who are assigned to each of our varsity teams. If an injury or suspected concussion occurs during training or competition, they are immediately assessed by whoever is on site. If the athlete reveals signs or symptoms of a concussion they are immediately removed from play. The next business day the athlete will check in with our clinic and myself for a comprehensive exam. We do a full SCAT 3 and compare their results to the baseline testing conducted on all athletes prior to the beginning of each season. Depending on the results, we follow protocols from here.

 

The athlete will continue to check in daily until asymptomatic, at this point we can proceed with the return to learn protocol. If every step of this is successfully completed, we move on to the return to play protocol. This process has become quite universal and much more streamlined in recent years. By scraping the old school grading system and implementing a specific 5-stage protocol, it allows us to be more consistent and thorough across the board.

 

 At SAIT, there are numerous varsity teams and over a hundred athletes representing the Trojans. What resources do you feel best equip you to do your job? 

 

Kate: In addition to what we have already mentioned with our practicum students and certain protocols, having access to the sports medicine clinic in Calgary is invaluable. We are able to get our athletes in with Sports Medicine as soon as next day if urgent. We are fortunate to have the option to get athletes in with Dr. Brian Benson at Winsport. He is one of the leaders in concussion research. He is able to have athletes complete further testing, such as robotics, to aid in the safe return to play of anyone referred.

 

Looking to the future, how would you like to see the field of concussion science develop?

 

Kate: I am glad you asked this. The technology is progressing at a fairly rapid pace which is great to see, however there is still a long way to go. It would be great if we could get onsite testing that is more in depth that what we currently have available through the basic SCAT3. There are some technologies available at this time, but athletes can still ‘’throw the testing’’ at baseline or become accustomed to the assessment allowing them to appear to be better than they are. It’s definitely a lot to ask to have something available at our finger tips that is in depth, accurate, and without loop holes and that’s likely why it isn’t available yet.

 

Hopefully, as technology continues to advance it won’t be long before this is available for all Athletic Therapists’ to utilize. From a return to play perspective, I would love to see a more psychological aspect be added to the current model. It is known that there are psychological effects associated with concussions from frustration due to inability to participate to feeling isolated from the team. Although athletes are always advised of options on where to seek help for this aspect of health it is often not sought out.

 

"Your neck is your head's safety belt. Keep your neck muscles strong to help reduce risk for concussion." - Kate Trippier

 


 

Athletes in every field are bigger, faster and stronger. There have been advances to equipment in several sports, and training, nutrition and preparation have never been better. Once lagging behind, the scientific and medical knowledge of brain trauma is now determined to keep pace. From elite athletes to the general public, our community is growing and there have been steady increases in curiosity and understanding of concussion science. At HeadCheck, we support professionals to provide concussion testing and management for their athletes.

 


Sarah Allison

BHK - Clinical Exercise Physiology

BSN-PB Student - Nursing (RN)


A Close Inspection: Heading the Ball

In recent years, research has raised awareness in both amateur and professional sports by demonstrating the link between collisions, blows to the head, and concussions. While it is believed that 80-90% of concussions will resolve without therapeutic or pharmaceutical intervention in 7-10 days, it is suspected that repetitive impact exposure may lead to permanent damage. Sub-concussive injuries are an emerging and under-recognized phenomenon resulting from low magnitude head impacts. It is suggested that these injuries are not severe enough to result in clinically observable deficits, but may have the potential to cause significant long-term neurological changes. As a result, the effects of soccer heading on the brain has become a popular area of study, particularly due to the exposure of head impacts to young children.

 

Soccer is the world’s most popular sport with 240 million participants. In soccer, concussions are suspected to occur not only during head-to-head collisions, but also during head-to-ball. Recent studies on the topic of soccer heading suggest a wide range of changes to the central nervous system such as white matter microstructural and cognitive abnormalities (Lipton et al. 2013), vestibular deficits (Hwang et al. 2016), and improper pituitary function (Greco et al. 2013). Last year in the Emirates FA Cup, Andy Wilkinson suffered a concussion after a volley to his temple reduced his peripheral vision on his right side. Over the following 6 months, Wilkinson struggled with his recovery, often getting ill after practice. Wilkinson retired from soccer in February at the age of 31.

 

It isn’t professional athletes that are most susceptible to these changes to the nervous system. In fact, research is showing that youth are the most at risk. Perhaps most alarming for youth soccer players, damage to the pituitary gland following concussive and sub-concussive blows could result in altered brain development due to this structure’s role in the release of developmental hormones (e.g. growth hormone).

 

Fortunately these research findings appear to be a strong reason behind the US Soccer Federation’s move to eliminate heading for children 10 and under, and limit heading in practice for children between the ages of 11 and 13. Other coaching methods are being used as well, including increased focus on foot fundamentals and heading technique lessons using inflatable beach balls. Concussion experts estimate that delaying the introduction of heading until high school will result in the prevention of 100,000 concussions among middle school soccer players in the US every three years. Certainly a move in the right direction.

 

The Men’s FA Cup final will be underway tomorrow (at 9:30am PST). We’ll be watching and like Andy Wilkinson, we’ll be hoping that the game will be incident free.


Gender Differences in Concussion

The lack of attention to gender differences has been a problem in the medical field. This difference needs be taken into consideration when working with athletes recovering from traumatic brain injury because of physiological and chemical differences which impacts how you should manage concussions. Improper management of concussion may result in serious long-term or lifelong disability, risk of coma, or in extreme cases death.

 

Traumatic brain injury (TBI) commonly occurs in high-contact sports for both male and female athletes. However, when comparing the research between male and female athletes, female athletes suffer more concussions than men. Even in sports where the rules are the same for both sexes, such as basketball or soccer, female athletes experience or report a greater number and severity of symptoms and a longer duration of recovery than male athletes. A 2007 study of college athletic injuries shows that female softball players experience concussions at twice the rate of their male baseball counterparts. In some sports, such as women’s hockey where intentional body checking is prohibited for women, they still experience more concussions.

 

Screen Shot 2016-04-07 at 1.37.51 PM
Game concussion rate by gender. The figure compares game concussion injury rates in basketball and soccer (similar rules and equipment) and ice hockey (similar equipment but different rules—no body checking allowed in women’s game). In all three activities, the women’s sports showed absolute rate values that were higher than their male counterparts and in two cases, (basketball and soccer), these rates were statistically higher.

 

At first this difference was attributed to women being more honest or forthcoming about their injuries to their medical staff. However, view of female athletes being more culturally accepting of injury is slowly being reconsidered as studies prove that women are not just more vocal about their pain, but are being injured in sports at higher rates than men. Based on research, there are two reasons for this occurrence:

    1. Biomechanical Differences: Differences in the musculature in the cervical spine and less developed neck muscles. Studies have shown that neck size and strength may play a role in determining concussion rates and the comparatively weaker neck muscles in women may be causing less head stability in females during an impact of fall.
    2. Physiological Differences:Hormonal differences in women and men. Studies have shown that estrogen appears to be a protective factor in male, but it exacerbates the injury in female. Moreover,  the menstrual cycle is a predictor of the outcomes after a concussion. Women who are injured during the luteal phase, the last two weeks of the cycle, are more vulnerable to concussions and have worse symptoms than women who are injured during the follicular phase.

Although female athletes may face more concussions than male athletes, there are simple things that can be done to help reduce the rates of concussion. Pre-season testing and erring on the side of caution both after an impact and during return to play will help reduce second impact syndrome. Strength training, especially focused on the neck muscles may contribute to reducing the forces experienced by the head. With proper concussion management, an athlete can recover from a concussion and be able to return to play and life functions.


Managing Assessment Variances Within Sports Medicine Teams

Athletic Therapists (ATs) are commonly the first medical providers or health care professionals available onsite to evaluate any injuries that may occur during a competition or practice. They are not only crucial during competition, but also post competition during the injury management and return-to-play decision-making process. Athletic Therapists work closely with the Team Physician in order to provide the most effective therapeutic interventions and rehabilitation of injuries. Their goal is to return an athlete to competition as quickly and as safely as possible. Not only do they play a key role in injury identification, evaluation, and management, but are also critical at the sideline for screening for concussions to mitigate the risk of permanent brain damage.

 

One of the challenges faced by an Athletic Therapist is determining whether an athlete should be removed from activity for further evaluation after a suspected hit to the head. Although even a decade ago it was acceptable to “shake it off” and return to play, new legislations in Canada and the US and standard guidelines require athletes to be removed from competition or practice if a concussion is suspected. To properly determine the risk an Athletic Therapist should complete a post-injury assessment and compare it to a test done on the same athlete at the beginning of the season. In some sports leagues, there are multiple Athletic Therapists tending to multiple teams. A reality is that a post-injury test may not be completed by the same person who did the pre-season assessment. It is important for sports medicine teams to try to manage assessment variances in order to provide the best possible information for making return-to-play decisions.

 

Managing variability through diversification 

The post-injury assessment includes a series of questionnaires, checklists, and physical testing that is identical to the pre-season test. A concussion can impact brain function in a variety of ways and because of the nature and physical demands of a sporting event an evaluation of concussion-related symptoms can be challenging. For example, an athlete may show concussion-like symptoms if they are dehydrated or have performed a strenuous activity, however this does not mean that the athlete will also demonstrate balance or neurocognitive impairments. Therefore it is important that an Athletic Therapist, his/her team and the team physician are all using a comprehensive battery of tests to assess brain function. Relying on any one type of test for the monitoring and decision making regarding return to play for an athlete provides an incomplete picture of the severity and breadth of the brain injury.

 

Managing variability through calibration meetings 

Assessment variances also happen when training and communication is limited between therapy teams. It is possible to estimate and to some degree calibrate inter-rater (tester 1 vs. tester 2) reliability. For example, when testing balance at the beginning of the season, teams can grade athlete balance errors individually and after the test is complete they can compare scores. While this provides a crude measurement, it will provide insight into how much agreement exists and provides an opportunity for coaching and education. Weekly “calibration” meetings may also help - short dedicated discussions can happen and ATs can discuss why they chose the specific values they did. Where disagreements appear, the collective unit can help form some rules to help ensure calibration in the future.

 

Managing variability with routine 

Variability can also appear as a result of intra-rater (tester 1 vs tester 1) reliability issues. For example, grading a balance video in the morning, and then watching and grading the same video in a different setting in the afternoon can generate some significant variances. With the challenges and pressures that Athletic Therapists face during a sporting event combined with subjective concussion testing, a consistent routine and method can help improve intra-rater reliability. To begin, the trainer needs the support needed from his/her therapy team to focus exclusively on the concussion assessment at hand instead of  attempting to split his/her attention between the test and the active game. Reducing situational interference (distractions from the surrounding environment) and following a consistent testing structure or methodology every time can also help.

 

Managing variability with objectivity 

Technology has enabled us to collect objective measurements where subjective grading used to take place. In his Sensorimotor Physiology lab at UBC, PhD candidate Harrison Brown developed a way to use technology to reduce variances in balance testing. He specifically looked at the balance test done in concussion assessments. By analyzing the movement of athletes performing the test and by introducing motion sensors, he was able to develop an algorithm which can objectively score an athlete's balance. “Now it doesn’t matter whether my grandma is doing the test, my favourite doctor is or both; they’re both going to get the same score.” His technology has increased the test-retest reliability of the concussion gold-standard balance test from between 40-60% reliability to over 91% reliability.



Concussion Basics

What is a Concussion?

The occurrence of concussion, a type of traumatic brain injury (TBI), has risen dramatically over the past 10 years and is nowadays considered a major cause of disability in Canada and the US. This type of brain injury is caused by a direct bump, blow, or jolt to the head or an indirect blow to the body that causes the brain to rapidly move back and forth within the skull. Concussions can occur during a fall, accident, household or work mishaps and commonly in high-contact sports such as football, rugby, hockey, and soccer. Indications of a concussion usually reflect a functional disturbance to the brain and may include physical (e.g. headaches, nausea), cognitive (e.g. difficulty with concentration or memory), emotional (e.g. irritability, sadness), and ‘maintenance’ (e.g. sleep disturbances, changes in appetite or energy levels) symptoms. Standing balance is also a common indicator of concussion, whereby concussed individuals suffer from a distinct lack of postural stability. Improper diagnosis of these indicators and management of concussion may result in serious long-term or lifelong disability, risk of coma, or in extreme cases death.

What Should I Do If I Have a Concussion?

Never ignore a collision to the head - it is always better to miss one game than the whole season and to be safe than sorry. If you believe you have a concussion, informing your coach or athletic therapist/trainer is the first step in order to evaluate whether or not you have a concussion. If a more severe injury is suspected, they will send you to the hospital for further examination and diagnosis to understand the severity of the brain injury. Even though there are currently no validated medical treatments for concussions, the recommended recovery method is by giving your brain a rest, both physically and mentally. Rest includes limiting exercise and activities that require thinking or mental concentration such as schoolwork, reading, and using a computer or mobile device. Before returning to play, it’s crucial to receive a clearance from a medical professional even if you no longer feel the symptoms of a concussion anymore. Returning to sport too soon will increase the risk of having a second concussion that could lead to permanent or fatal brain damage.

How Do I Prevent a Concussion?

Do what you love and love what you love. If participating in sport is an activity that you enjoy, don’t let the increased chance of receiving a concussion prevent you from doing something that you enjoy. Concussion risk can be reduced by playing by the rules, wearing the proper equipment for the sport and wearing the equipment properly, learn and use the proper techniques of your sport, and practicing good sportsmanship.