Exploring Concussions with Dr. Anne W. Hunt of the Concussion Centre at Holland Bloorview

On April 7th, BIST is hosting a FREE talk on Exploring Concussions:
Concussion Facts & Myths AND The latest Research Findings – featuring speakers Dr. Lesley Ruttan of Main St. Psychological Centre and Toronto Rehab; Dr. Carmela Tartaglia, Assistant Professor at the University of Toronto Tanz Centre for Research in Neurodegenerative Disease and Dr. Anne W. Hunt, Manager, On TRACK concussion program Concussion Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital.

Our writer Karolina Urban spoke to Dr. Hunt about her upcoming talk with BIST.

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KU:  What are some of the pieces of advice you have for those who have sustained a brain injury in terms of recovery?

AH:  Work as hard as your body and brain will let you; be open to doing things differently; keep in mind that recovery may continue for many years. I’ve seen survivors make significant changes many years after injury.

Dr. Anne W. Hunt

KU:  Can you tell me about the importance of time management and prioritization and how to best manage every day life? How important is goal setting? exercise? Doing the things you love?

AH: All of these things are important! It’s important for health and well-being in general to be engaged in activities every day that have purpose and meaning to each person.

Time management and prioritization are important skills that can help us to find time to do activities we need and want to do. Using calendars to schedule activities, using ‘to do’ lists, setting alarm reminders are strategies that may be helpful in managing time. Goal setting is helpful for some people, it is important to set goals that are specific, meaningful and relevant. Setting time frames for goal achievement can be tricky as sometimes following brain injury it can be challenging to know how long it might take to do something. Instead, think about what you might accomplish today and consider how you will accomplish that-make plans and then do it!

Exercise is good for health overall and contributes to optimal brain function. I encourage people with brain injury to participate in exercise that they enjoy, but to do this in a way that doesn’t make symptoms worse. This may mean doing the activity at a less intense level, for a shorter period of time or in a less stimulating environment.

KU: In terms of mental health and dealing with the accident itself, can you speak to some of the tips and/or advice you have for someone who is dealing with persistent issues?

AH: Good mental health is important for well-being. Following brain injury, people may feel more emotional, this may include feeling sad, anxious, scared, angry, overwhelmed, and less confident to name a few. It’s important to develop a support network to help you through difficult times. Consider who your network is-who can you turn to for support-this might be a professional (e.g. therapist), a family member, or friend. If you are uncertain, community organizations like BIST may be able to provide some direction.

KU: Dr. Hunt can you tell me about some of your current or recent research and outcomes?

AH: As an occupational therapist by profession, I’m most interested in developing interventions to enable individuals with brain injury to participate optimally in meaningful activities.

Recently, I’ve been studying how self-management problem solving interventions can help adults and youth with mild traumatic brain injuries. Results from our initial work are very positive. People like these interventions and they are useful in helping people get back to doing activities as well as improving their mood. Our work is in very early stages though so more research is needed.

I’ve also been investigating how vision is affected following brain injury. Visual issues are not uncommon following brain injury. We think that in some people visual issues may be contributing to symptoms like headache and fatigue. Currently we are focusing on understanding and identifying these visual changes in youth following concussion.

KU: Where do you see research fitting in to rehabilitation and assisting recovery or helping to get people back to their daily lives?

AH: Research is very important in brain injury rehabilitation. We need to develop evidence to help us understand what interventions work for specific individuals-no two people with brain injury are alike! Participating in research may have benefits for brain injury survivors. By participating in an intervention study for example, there is the potential to benefit from the intervention itself, plus research participants typically feel good about participating in general because they are contributing to research and ultimately helping others with brain injury.

Although intervention studies may be hard to find, I encourage anyone who may have an interest to contact their local hospital’s research program. Being a research participant can be a very rewarding experience.

Find out more about BIST’s Exploring Concussions Speaker Series HERE

Register by March 31st at info@bist.ca

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 Karolina Urban is a former University of Toronto and Canadian Women’s Hockey League player. Currently she is a PhD student at the Concussion Centre in Holland Bloorview Kids Rehab Hospital. 

What my personal experience with concussion has taught me

BY: KAROLINA URBAN

Summer is here and with it comes the inevitable concern for safety and injury prevention. From organized sports such as soccer and rugby, to recreational activities such as wakeboarding, tubing, biking or your friendly match of volleyball, there is always a risk of a concussion.

Concussions are not limited to a direct hit to the head. They can also be the result of a large biomechanical force, known as a acceleration-deceleration injury, which causes the brain to move within the skull.

The rate of concussions occur in 754 per 100 000 for boys and 440 per 100 000 for girls. Nearly one-third of these injuries are the result of falls, while skating and hockey account for the greatest number of sports related concussions in Canada.

photo credit: UPEI Panthers at Saint Mary’s Huskies (Nov 27 2010, Halifax NS) via photopin (license)

The difficulty with assessing or recognizing a concussion is the wide range of symptoms that vary as a result of the heterogeneity of injury. These symptoms can range from being physical in nature (i.e. headaches or dizziness), to cognitive (i.e. difficulty concentrating), to behavioral (i.e. depression, anxiety) or sleep-related (i.e. difficulty falling asleep or sleeping too much.)

80  per cent of adults recover from a concussion within two weeks. For children, the recovery process tends to be slower, but despite the longer recovery period, it has been shown that most of the pediatric population does not continue to have long-term difficulties. However, around 14 per cent of the children who sustain a concussion continue to have symptoms beyond three months after injury. As a parent, guardian, coach or friend it is critical to recognize the impact of concussions, know how to prevent them and how to promote recovery.

Throughout my hockey career I always had this willingness to do whatever it took to win. In the face of injury I would shrug off the pain and continue to compete. In my second year of hockey at the University of Toronto I sustained a concussion in the last season game. From what I recall, the puck came out of a scrum in the neutral zone and the next thing I can remember is sitting on the bench feeling ‘out of it.’ My line-mate asked whether I was okay and I simply responded, “Oh yeah, lets go.”

Rowan Stringer; Image via Facebook

Luckily there were only few minutes left in the game as I continued to play. That evening I began to feel worse, more anxious, dizzy and fatigued. But as I had always done, I continued on until the next evening, I went to class, wrote an exam (which I did horribly on) and continued onto practice. As we began to do skating drills, I began to feel nauseous and dizzy and finally agreed to get an official diagnosis. Although I took this step, I quickly got cleared to play again as game one of playoffs was eight days later.

It was quite evident I was no were near ready to return to play. I missed the puck several times, my reaction times were slower, my head was hurting and I was dizzy every time I turned. To be honest I probably hurt my team more than helped. I was, however, extremely lucky to have not sustained another hit to my head. This is called ‘second impact syndrome’ where you undergo another hit to the head when you haven’t given your brain time to recover from the first injury. Impact to the brain during this vulnerable period may result in devastating consequences, such as with the recent death of high school rugby player Rowan Stringer.

If you or someone you know has sustained a concussion, there are return-to-life and play guidelines to help. The Ontario Neurotrauma Foundation has produced pediatric concussion guidelines and has information on persistent concussion symptoms. Parachute has return-to-play guidelines which are also a valuable guide for concerned parents and athletes.

These guidelines are the most up to date and based on research. However, I would like to impart some of the things I have learned throughout my career and the few concussions I have had:

1. Remove yourself from the activity you are doing. I know this is hard but you are probably putting yourself at risk for a longer or more complicated injury. If you want to get back out there as quickly as possible and avoid more serious injuries, it is critical to stop what you are doing. 
2. Give yourself time to rest – some of the symptoms of concussion can develop up to 24-36 hours after the injury occurred. So jumping right back into a high risk activity can put you at more risk.
3. If something doesn’t feel good, stop. If you hurt a muscle and felt the pain when you began running you would stop, so don’t treat your brain any differently. I think this is particularly important when you are trying to get back to your life and sport. Monitoring how your brain feels when you are beginning to re-integrate yourself into all your activities is key.
4. Be patient – For me this was the most difficult one. Some days you begin to feel better and think that you have recovered and then the next you feel worse again. This can be extremely frustrating, especially if you want to get back to school or back to what you love doing. As long as you are aware that it’s not going to be a straight forward recovery, then maybe you can lower that frustration.
5. Rest, but don’t sleep all day. Previously it was thought that it was important to completely isolate yourself, stay in a dark room until you felt better and your symptoms were gone. However more recent research has shown that full rest can have a negative effect on brain health and recovery. After the suggested 24-hour rest period, begin to get back into what you are doing, slowly. Go for a walk or try cooking dinner, but whatever it is, make sure you’re moving in small steps.
6. Define your priorities. One common symptom for  people is fatigue and difficulty to concentrate. If you overwhelm yourself you could hinder your recovery.
7. This so-called ‘invisible injury’ is nothing to hide, nothing to be ashamed of and it is okay to not feel comfortable doing something that everyone else is. All that matters is taking care of your brain and you need to do whatever it takes to take the appropriate steps.

 Karolina Urban is a former University of Toronto and Canadian Women’s Hockey League player. Currently she is a PhD student at the Concussion Centre in Holland Bloorview Kids Rehab Hospital. 

Women and brain injury: What you need to know

BY: ALISON

Men are more likely to acquire a brain injury than women, and are three-times more likely to die from a brain injury. Perhaps because of this, the media tends to pay more attention to men and brain injury. For instance, name a person in Canada who didn’t know about NHL player Sidney Crosby’s struggle with concussions from 2011 to 2012.

But there’s a lot about women and brain injury which needs to be understood. How many people know about award-winning women’s hockey Olympian Meghan Duggan’s struggle with concussion? Or about hockey player Katie Weatherston, who lost her spot in the 2006 Olympics due to concussion symptoms? Or, more recently, Nicole Setterlund, who left professional sports due to TBI?

photo: Kevin Healy via flickr

Given recent evidence that females are more susceptible to concussions and have greater difficulties with recovery than men, it stands to reason the focus of attention should be shared between men and women equally.  But further research is required to understand how men and women respond to and recover from TBI differently.

Male and female brains: different but equal

Despite decades of jokes on the subject, male and female brains are, infact, different.

In general, male brains are larger than female brains, while female brains have thicker, more convoluted cortexes with more tightly packed neurons (brain cells).

Functionally, male and female brains rely more heavily on different sides of their brains when performing various tasks. Male brains have a higher proportion of gray matter whereas female brains have a higher proportion of white matter. Gray matter is made up of more active neurons which process information. White matter networks information between different areas of the brain and allows thoughts to be intergrated from gray matter, assisting with complex skills such as language.

This suggests that women’s brains are more complex, even though men and women are equally intelligent. Evidence also suggests that the percentage of gray and white matter regions involved in cognition, which are located in the frontal lobes, is drastically larger in women than that in men. Taking into account the specific location of trauma to the brain, this could explain why frontal lobe injuries can be more devasting to females than males.

Concussions Rates for Men and Women

Although the majority of people who sustain a TBI are male, recent studies indicate that women are actually more susceptible to concussions and experience poorer outcomes than men. Despite the fact that more men play contact sports than women, women suffer significantly higher rates of concussions than men in these sports. Where men have a higher percentage of concussions resulting from player-to-player contact, women have a higher percentage of concussions resulting from player-surface contact and player-equipment contact. A higher incidence rate of sports-related concussions (SRCs) has been documented in females in high school sports (soccer and basketball) and college-level sports (soccer, basketball, and ice hockey). Furthermore, high school girls are more likely to have recurrent concussions than boys.

The gender-specific rates of sports-related concussions have been explained by the fact that women have less neck strength than men. Neck strength is needed to protect the brain from sudden acceleration-deceleration forces. In fact, it is already well-documented that women are more susceptible to whiplash injuries due to sudden acceleration-deceleration. TBI and whiplash are often experienced concurrently and can cause similar symptoms. Besides having stronger neck and back muscles, men also have more cartilage in the facet joints of the spine, resulting in better protection from injury.

A person’s body mass index (BMI) may play a role in transmitting force and contribute to the severity of an injury, since young girls tend to have higher BMIs than boys.

photo: Tayor Mackenzie via flickr

Here’s what some of the research has found:

• Women who experienced worse outcomes than men following a TBI also had higher BMIs than men
• In a study comparing men and women with mild TBIs, women experienced worse symptoms than men three-months post injury, especially women in their childbearing years
• Three-years after their injuries, women with mild TBIs had worse outcomes than men in terms of symptoms and disability.
• Post-concussion female soccer athletes have significantly slower reaction times and perform more poorly on visual memory tests compared to their male equivalents.
• Female TBI survivors tend to outperform male survivors on tests of verbal memory and executive functions, including planning, initiating, and problem solving.
• Women are less likely to have a caregiver and are particularly vulnerable to isolation, disempowerment and abuse.
• Male survivors are more likely to be successfully employed, receive vocational rehabilitation services, and less likely to have vocational services prematurely terminated than women.

Hormonal Changes After TBI

Hormones fluctuate more drastically in women, making women particularly susceptible to migraines and reproductive changes after a TBI. Fluctuations in estradiol are a cause of migraines in women of childbearing ages. Concussed female soccer players report double the rate of migraines compared to the males.

One study followed 104 women with moderate to severe TBI and observed that 46 per cent of those women had amenorrhea (the absence of menstruation) lasting up to 60 months and 68 per cent of them developed irregular menstrual cycles including more skipped menses. The women also reported worsened premenstrual syndrome (PMS) and menopausal symptoms after TBI. Although the study did not see an effect of TBI on fertility, it noted that fewer female TBI survivors had live births than the controls and that those that did had more difficulties in the postpartum period.

Given the anatomical, hormonal, and psychosocial differences between men and women, it lends to reason that sex should be a factor when planning treatment, support, and return to school/sports/work for TBI survivors. However, further research is needed before sex-specific treatments can be developed and new medical management guidelines established.

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 Alison suffered a concussion in 2013 that damaged her mind and body. The injury shook her spirit, but it didn’t take her determination or ultimately her happiness. In fact, she’s certain that she never would have found love, had it not been for her concussion. Although she went from being a workaholic to a homemaker (and a poor one at that), an extrovert to an introvert, and a partier to a hermit, she set new priorities, accomplished new goals, and found new hobbies. Some things haven’t changed about Alison; she still loves dogs, cooking, and helping others. She’s hopeful that she will one day reconnect with her love for traveling. In the meantime, she hopes to help brain injury survivors and their caregivers by sharing her experience and spreading awareness. 

 

New pediatric concussion guidelines – what you need to know

By: RICHARD HASKELL

Whoever said, “Youth is wasted on the young,” was probably envious of all their energy and exuberance!

Indeed, these attributes are ones that children and adolescents seem to have in abundance, clearly demonstrated by the myriad of physical activities and contact sports they enjoy both on and off the playground. As healthy as these activities are – and they should most definitely be encouraged – there is always the danger of injuries, including broken bones, sprained ligaments or tendons, and, probably the most serious of all, trauma to the head.

photo credit: stevendepolo via photopin cc

What we’ve known up to now

Head injuries fall into two categories, external and internal. While an external injury may appear more frightening, it is actually considerably less dangerous than an internal injury. There may be heavy bleeding followed by a ‘goose bump’, which eventually disappears within a few days or a week.

Internal injuries can include a fractured skull, torn blood vessels, or damage to the brain. They are considerably more serious and can lead to a brain injury or a loss of life. Concussions are the most common type of internal head injury. Derived from the Latin concutere (to shake violently), the word concussion is defined as “a traumatic brain injury which may alter the way the brain functions.”

Concussions can be caused by any blow to the head, face, neck or anywhere the body that results in a sudden jarring of the head. A person doesn’t need to be knocked out or lose consciousness to have had a concussion. Immediate symptoms may include headaches, difficulty falling or staying asleep, nausea, dizziness, confusion, issues with concentration, memory and problems with balance and coordination. These symptoms can last anywhere from a few minutes to several weeks after the injury.

photo credit: Paul L Dineen via photopin cc

According to Dr. Sherilyn Driscoll, a physician with the Mayo Clinic in Boston, concussions in children and adolescents can lead to serious health risks, particularly if the symptoms aren’t noticed immediately after the injury.

The risk magnifies if a person returns to physical activity too soon after the injury before the trauma has had time to heal. Worse, a second incident of head trauma shortly after the first may result in brain swelling, a condition known as Second Impact Syndrome (SIS). Once a child has suffered an initial concussion, he or she has a much higher risk of sustaining another, and the effects of multiple concussions over the years can be cumulative. There can be dire consequences. Rowan Stringer, an Ottawa high school rugby player died as a result of SIS shortly after a game in May of 2013.

Recent Findings

In June, 2014, Dr. Roger Zemek, a scientist at Ottawa’s Children’s Hospital in Eastern Ontario, presented the first guidelines on the effects of concussions on children and adolescents. Zemek teamed up with the Ontario Neurotrauma Foundation and chaired a 30-member panel, which reviewed 4000 papers with the latest evidence about concussions in children.

photo credit: cellar8 via photopin cc

Stemming from Zemek’s conclusions were three recommendations for children suffering from concussions:

• longer rest periods
• no physical activity for up to 30-days
• a limited amount of time devoted to cognitive brain activity with limited or no recreational time spent on television or computer games.

The guidelines recommend that if a player demonstrates a concussion-like symptom such as vomiting or a failed memory test, he or she should be removed from the game immediately.  Another discovery: researchers found that in addition to the usual physical symptoms, young people also frequently experienced signs of irritability, sadness and anxiety following a concussion.

Zemek wrote in an email to BIST:

In my opinion, concussion has only been recognized as potentially serious in the recent past since there was so little concussion research even just five-years ago.  When we looked at all of the published literature, there was extremely limited high quality concussion research in children and teenagers more than 5 and 10 years back. Like in so many other illnesses, children are not just little adults.  

10-year-old Sam Barton became one of the 900 children and teens who show up with a concussion at the Children’s Hospital of Eastern Ontario emergency room last year after he banged his head on the floor during gym class. Without any signs of brusing or nausea, Sam’s parents took him to the ER after he complained of a headache.

Tests soon confirmed that Sam had a conscussion. The knock had also affected Sam’s ability to concentrate. Sam was lucky. Zemek’s findings show that only one in four medical practitioners are using concussion tools to measure the severity of injuries and to track recovery.

Zemek writes:

For parents, caregivers, teachers and coaches, the guidelines provide a ‘one-stop shop‘ in order to best monitor and manage ongoing symptom management, specifically the stepwise ‘return-to-learn’ and ‘return-to-play’ tools.  

For parents, the guidelines offer suggested alternative activities since their child may be unable to play sports while recovering, and also offer step-wise advice on how to return to school.

For teachers, the guidelines include templates letters that could be used to implement doctor-school communication describing recommended level of activities to facilitate communication with the school.   

For coaches and schools, the guidelines provide resources in order to improve the whole community response to concussion recognition and management, and offer tools to track recovery and to ensure safe removal from play in the event of a suspected concussion. 

The guidelines include a pocket Concussion Recognition Tool for use in schools by coaches and parents. The toolkit outlines various symptoms (such as loss of consciousness, convulsions, problems with balance or headaches) and which steps to take following an injury (such as removing the player from the game, checking his or her memory, or calling an ambulance).

DR. ROGER ZEMEK;  photo credit ERROL MCGIHON via OTTAWA SUN

 

 

 

 

 

 

 

 

What to do if your child has a head injury

There are a number of steps you should follow should you think your child has suffered a concussion. If he or she has any of the following symptoms, call 911:

• unconsciousness for more than a few minutes
• abnormal breathing
• obvious serious wound
• bleeding or clear fluid from the nose, ear, or mouth
• disturbance of speech or vision
• pupils of unequal size
• weakness or paralysis
• neck pain or stiffness
• seizure

If your child is unconscious:

• do not try to move your child in case there is a neck or spine injury
• call for help

If your child is conscious:

• do your best to keep your child calm and still
• if there’s bleeding, apply a clean or sterile bandage
• do not attempt to cleanse the wound, which may aggravate bleeding and/or cause serious complications if the skull is fractured
• do not apply direct pressure to the wound if you suspect the skull is fractured
• do not remove any object that’s stuck in the wound

Finally …

Concussions are serious matters, not to be taken lightly. If you suspect a child, colleague, or player has suffered a head injury, insist he or she seek medical attention immediately. Rest – both physical and mental – is crucial. If not treated, concussions can lead to much more serious issues such as SIS or acquired brain injuries.

The brain is a complex and marvellous organ, we human beings can’t exist without it, and young brains are particularly vulnerable. So let’s give it the respect it deserves. Indeed, concussions are more than “just a bump on the head.”

How Western University aims to reduce sports-related concussions

Despite the celebrity-association with sports-related concussions (cue Sidney Crosby, Eric Lindros) there continues to be a lot of misunderstanding about the injury.

photo credit: clydeorama via photopin cc

In fact, of the 100,000 concussions which occur in Canada each year, more than half happen while people are playing sports. In the U.S., concussion rates among high school students doubled from 2005 to 2012.

Now Western University, which has long been a leader in concussion research and awareness through its See the Line initiative, has joined forces with the Sports Legacy Institute in the U.S.. Their partnership aims to further enhance research and programs to reduce the “concussion crisis” in sports.

According to CHCH, new programs will include advanced concussion training and a ‘brain and brawn’ camp for athletes. An existing program out of Wilfred Laurier University, where athletes educate others in the community about concussion, will continue.

Former CFL player Tim Fleiszer, now the executive director of  the Sports Legacy Institute Canada, told am980, “… This is a big step towards solving the concussion crisis in Canada.”

photo credit: Michi Moore Images via photopin cc

The timing couldn’t be better. New research shows that concussions happen across the board in sports, not just in the seemingly accident-prone hockey, football and boxing the injury is associated with. In particular, there are high rates of concussions in competitive cheerleading (imagine what happens when you’re being thrown 20-feet in the air by your teammates), women’s soccer and lacrosse – the fastest growing high school sport in the States.

According to Dr. Robert Harbaugh, director of the Penn State Institute of the Neurosciences and chair of the department of neurosurgery, research shows that concussions are the result of a rotation of the head on the neck. Because of this, injuries are more likely to occur when players run into each other as opposed to when they are hit on the head by a ball.

According to Dr. Harbaugh and reported in PennLive.com, concussions are more frequent in women’s soccer, especially amongst children and teenagers, because men and boys have more neck muscle than women and girls.

photo credit: Alana Holmberg via photopin cc

As Crosby told the Globe and Mail in 2013,  “Concussions are still kind of a mysterious thing. We do know a lot more now, but there are still things that we can learn and hopefully ways and methods we can learn to either heal or to find out more about the actual extent of the injuries.”

Hopefully this new partnership will solve some of the concussion mystery, and crisis.

See the Line

London Health Sciences Foundation

519.685.8433, info@seetheline.ca

Sources: CHCH + Pennlive.com