Canada advances concussion education

One of the priorities in the 2015 ministerial mandate letter to the Canadian Minister of Health was to raise awareness about the treatment of concussions.[1] The Public Health Agency of Canada was given a 2-year budget of $1.4 million to raise awareness about and develop a comprehensive approach to the prevention and management of concussions in Canada. The approach taken for these Canadian guidelines is based on recommendations from the 5th International Consensus Conference on Concussion in Sport (2016).[2] Key recommendations from the publications that came from this meeting are discussed below. 

Concussion signs and symptoms can develop over several hours; therefore, recognition of a potential concussion should be considered with any significant head injury. At the time of injury, short-lived impairment of neurological function often occurs. This may present as a stunned effect, loss of attention, or loss of consciousness. The Concussion Recognition Tool 5 is a useful tool for parents and coaches to help identify signs and symptoms to prompt removal from field of play and when further assessment is required.[3] The general mantra is, “When in doubt, sit them out.” 

The Sport Concussion Assessment Tool 5th Edition (SCAT5) is a freely available battery of tests that can be administered at the sideline.[4] If there are ongoing concerns about a suspected concussion, players should be removed to a distraction-free environment (e.g., locker room) for a more thorough evaluation. The SCAT5 is most useful in differentiating concussed from nonconcussed players immediately after an injury. The effectiveness of this tool diminishes 3 to 5 days after injury, although the concussion symptom checklist portion can still be used to help track recovery. 

Although rest plays an important role in the recovery from concussions, it can also prolong symptoms and delay overall return to sport, school, and work. The new recommendations call for a 24- to 48-hour rest period of reduced cognitive and physical activity. Afterward, patients should be encouraged to gradually and progressively become more active in their daily activities. Accommodations need to be in place at school and work to allow patients to stay below thresholds that may bring on or worsen symptoms. Early introduction of physical activities with low risk of head injury, such as jogging or stationary cycling, may be encouraged in a symptom-limited manner. Avoiding vigorous activity and cognitively intense situations (e.g., tests, exams) is reasonable, as patients would not be expected to perform at their best during this time. 

Rehabilitation should be directed toward the individual symptoms a patient is suffering. Many symptoms will resolve spontaneously over 10 to 14 days in adults and 3 to 4 weeks in children. Evidence supports cervical and vestibular rehabilitation. Psychological support can also be very helpful if needed. There is growing evidence that supervised, active rehabilitation programs, which allow for gradually increasing intensity of exercise to maintain patients below their symptom thresholds, can facilitate recovery. 

Current measures of clinical recovery may precede physiological recovery, but the significance of this difference is not yet fully understood. This is one reason to implement a gradual, stepwise approach to returning to school/work and then returning to sport. The Concussion Awareness Training Tool (www.cattonline.com) is an excellent British Columbia–developed online educational resource that has information detailing these steps for players, parents, coaches, teachers, and health care professionals.[5]

The greatest risk for having a concussion is a history of previous concussions. The use of helmets reduces the risk of overall head injuries, but their role in specifically preventing concussions in high-risk sports is less clear. Nonsignificant trends of reduced risk have been shown in a meta-analysis of the use of mouth guards in collision sports. The greatest risk reduction has been achieved with rule changes, particularly in youth ice hockey, by delaying body checking under the age of 13. 

We need to persist in building awareness and education about the importance of recognizing and appropriately managing head injuries in athletes. The latest consensus guidelines continue to cut back on recommendations of complete rest to instead focus on gradual and stepwise return to work/learning and sport. Fortunately, the majority of concussions seem to resolve within 1 month if treated appropriately.
—Tommy Gerschman, MD, FRCPC, MSc
Athletics and Recreation Committee

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This article is the opinion of the Athletics and Recreation Committee, a subcommittee of Doctors of BC’s Council on Health Promotion, and is not necessarily the opinion of Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.


References

1. Prime Minister of Canada. Minister of Health Mandate Letter. 2015. Accessed 10 July 2017. pm.gc.ca/eng/minister-health-mandate-letter.
2. McCrory P, Meeuwisse W, Dvorák J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847.
3. Echemendia RJ, Meeuwisse W, McCrory P, et al. The concussion recognition tool 5th edition (CTR5). Br J Sports Med 2017;51:872.
4. Echemendia RJ, Meeuwisse W, McCrory P, et al. Sport concussion assessment tool – 5th edition. Br J Sports Med 2017;51:851-858.
5. CATT Online. Concussion Awareness Training Tool. 2017. Accessed 10 July 2017. www.cattonline.com.

Tommy Gerschman, MD, FRCPC, MSc. Canada advances concussion education. BCMJ, Vol. 59, No. 7, September, 2017, Page(s) 325-355 - COHP.



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