Hey, gang. It’s Maria here from GoalieTrainingPro.com. Welcome to Goalie Training Pro TV episode 6!
We are doing a bottom up sequence. We started with the foot, then we talked about the ankle, then we talked about the knee last week, and so today naturally we’re going to talk about your head and concussions.
Maybe I was sick a couple days of anatomy class, or I went out the night before and I missed it or something, but no. No, it’s something that’s been on my mind, and I didn’t want to wait.
Don’t feel like reading? You can also check out the video for this post here! >> https://youtu.be/jGtEqBg2JSM
So it’s all about concussions, and about your head. I want to make it really clear that what I’m going to share with you this week, in this episode, isn’t about my personal opinion, or “These are experiences I’ve had.” It’s a consensus statement on concussion in sport. Again, not my personal opinion. I’m just trying to digest this for you, because it’s a pretty long article.
I did put a link to the article at the bottom of this, so you can go and grab a copy yourself and read it over. I think it’s definitely worth it, but that’s where we’re going to go through.
It’s from the Fifth International Conference on Concussion in Sport. That conference was held in October of 2016. This consensus statement was published in April of 2017. The people who put this together, they’re called the Concussion in Sport Group, that was founded by the IIHF, the FIFA, and the IOC.
It’s got doctors from all over the world on it, some of the ones that are sort of local to us or that you’ve probably heard, like on Hockey Night in Canada, Dr. Karen Johnston who is a neurosurgeon in the Toronto … Willem Meeuwisse who is the medical director for the NHL, Jamie Kissick out of Ottawa who is a sport med doc for the Sens and the CFL team.
Even what they are representing in this paper, isn’t again, their bias. It’s not that they are thinking concussion is bad or concussion doesn’t exist or whatever. They are just digesting, “Okay, what has been done research wise.” They are discussing it and then they are compiling it to say, “This is from science. This isn’t from bias or emotion.”
Everybody has their own beliefs on it, but they are looking at it saying, “What can we say is fact and what can we say we don’t know, we need to do some more research.”
Even probably some of the things I’m going to share with you today, you are going to be like, “That’s not true because I’ve had concussions and I had this different experience.” Really, what we are saying is, that there needs to be a lot more research in these areas. They make it clear that this isn’t a clinical practice guideline. It doesn’t represent a standard of care. It is just a discussion and a consensus of that group.
They use the term SRC which means Sport Related Concussion to differentiate it from a traumatic brain injury that might be acquired … or a concussion acquired by a motor vehicle accident or something like that. Basically, they define an SRC as, a traumatic brain injury induced by biomechanical forces caused by either a direct blow to the head, face, or neck, or elsewhere on the body with an impulsive force transmitted to the head.
This has been a long pet peeve of mine, and I’ve had athletes that we train who have been concussed, like clearly been concussed, but in some cases the family member or the coach is like, “No, he couldn’t have had a concussion, ’cause he hit his face. He didn’t bang his head. He hit is face so it’s not a concussion.”
It can be a direct or indirect blow. Typical results are rapid onset of short lived impairment of neurological function that results spontaneously, but in some cases can evolve over a number of minutes or hours. This is important too. You really want to watch someone in those first few hours after they have an initial incident. If you are seeing signs of deterioration, the symptoms are actually getting worse over that first few hours, that is not good. You should immediately go seek medical attention to get that looked at.
Usually it will be a transient thing. Someone might feel a little woozy, wobbly, weak in the knees, but then even within an hour or so, they are like, “No. I’m feeling okay.” Even sometimes within minutes they are like, “No, no. I feel okay now. I feel okay now,” which makes you tempted to be like, “Are you sure you’re okay?” “Oh yeah, yeah. I was just a little woozy for a second.” “Okay. Go back in,” which is totally the wrong thing to do, but if you see those symptoms getting worse, that’s a big, big time red flag.
Resolution typically follows a sequential course. However, in some cases it can be prolonged. Usually there’s a pattern. I think in the last consensus paper they had a statement that the average for a concussion to resolve is 10 days. One of the things they point out in this paper was that “Well, that might be somebody who resolves in one day, and somebody who resolves in 20 days, so, oh, most people resolve in 10 days.” An average is a little bit hard to say.
Sport Related Concussions is one of the most complex injuries in sports medicine to diagnose, assess, and manage. These are doctors saying it about doctors, assessing and managing. It’s not for us or you as coaches or parents or strength coaches, or even the team trainer to be able to definitively assess, “Oh yeah, this is a concussion, and this is what need to be done.” Even the medical professionals who specialize in sport medicine are saying, “This is one of the hardest things for us to diagnose and manage.”
For us it’s just to get this athlete out of harm. The analogy I always use, it’s hard because … I think if I had a kid and I saw them get a knee on knee hit and they went down and they got up and they could kind of walk with a limp like, “I want to play, I want to play.” I’d be like, “No. I think you are going to have a seat and we are going to go see the doctor.” The limp makes it much clearer, but someone with concussion it’s kind of like, “Well, let’s just see what happens.”
That really can have some dire consequences.
The point is, it’s impossible to rule out a Sports Related Concussion when an injury event occurs, associated with a transient neurological symptom. What that means is if somebody is woozy or stands up and is a little bit dizzy, but then is like, “Oh, no, no. I’m fine.” We can’t rule out a concussion on the field like that. You need to remove them from the sport. In all cases, you need to remove them from the playing field, until they are assessed by somebody with better skill.
There are lots of sideline tests that are totally easily accessible. Again, I put a link for one, that’s a sport concussion assessment tool. They call it a SCAT. (Which I think is what bear poop is called. Is bear poop not called scat as well? A little something I think I learned tree planting.)
It’s the Fifth Edition. It’s the most up to date edition. If your child plays contact sports, if you are the coach, if you are on the sidelines (again not that you are going to be the medical professional) but you should read this over, because it also has some really good information.
Again, athletes with suspected concussion can evolve over time. It’s important to consider repeat evaluations. Any athlete with suspected concussion should be removed from play.
Athletes with suspected concussion should not drink alcohol, use recreational drugs. You see that sometimes in adult league sports. My husband used to play rugby. When I was in grad school he took up rugby. We were probably in our late 20s, early 30s. He’s like, “I’m going to play rugby with the boys from university.” Some of those guys would for sure be getting concussed and then be crashing beers.
Actually, too I had a question from a goalie coach who had a teenage athlete that had a concussion and some of his buddies said, “If you smoke pot, it makes your concussion heal.” It’s like, “No. No. Don’t do that.”
It also reminds you to don’t forget, if they’ve had some kind of a blow that’s maybe caused a transient injury to the brain, it’s maybe also done something to the c spine so don’t forget to protect the neck and make sure that’s all cleared before you start getting them up and moving them around.
Then it goes through, and I won’t go through the whole thing, but it’s like total red flags, neck pain or tenderness, double vision, weakness or tingling in arms or legs, headache, seizure, loss of consciousness, deteriorating conscious state, vomiting, increasing restlessness, agitated, combative.
I remember when I was the bench trainer for the women’s hockey team at Western University their first few seasons. We had a girl that she didn’t even get hit very hard, just kind of hit and she fell down. Then when she came back to the bench, she almost … she was just acting odder than normal. She almost seemed like she was drunk, like you would have thought. You know she wasn’t, but you would have thought, “Has she been drinking here before the game?” Just chatted with her and she was in la la cuckoo land. Sometimes those things happen so fast you don’t even realize it.
Then observable signs. Do they lay motionless at all? Is there balance or gate or motor coordination. You see those guys in hockey definitely that they can’t even find their way to the bench, they are in such trouble. Disorientation, confusion, that blank vacant look, any facial injury after trauma. Those are things you would observe.
Then you would just ask them, “Where are we playing this game? What half is it now or what period is it? Who scored last in this game? What was our last game against? Did we win the last game?” Things like that.
And then it goes on, even does the Glasgow Coma Scale. Symptom, like mild, medium, severe. Going through all sorts of things. You should read that over so you know what you are looking for and probably even take a copy with you.
Again, I put the link down there. You can just download it for free. That’s a great thing too, they make all this stuff really easily accessible ’cause they are serious about improving it.
So any symptoms count. If it’s only a headache, or only a little dizzy, that counts. It’s not like, “Oh, okay, well, then that’s probably fine or it’s only a headache, it’s not dizziness, that’s probably okay.” It’s just any sign, because everybody is different. Any sign counts.
It could be headache, foggy, loss of consciousness, a little amnesia, short term memory loss, neurological deficit, balance impairment, behavioural changes, cognitive impairment, trouble thinking, sleep disturbances, drowsiness, any of that stuff. Again monitor for any deterioration in the first few hours.
NOW… this is the interesting part. It’s something you are not going to like.
There is a graduated return to sport. The return to play progression takes a week. Even if you heal as fast as you can heal, you’ll be back to sport in a week. There’s no three day fast track of the progression, which I know some of you are not going to like very much at all.
Here’s how it works.
The first 24-48 hours are just rest. Try to limit your screen time, rest, probably not even school. Just make sure that you are symptom free for that 24 hours.
Then you go to Stage One, which is symptom limited activities. Daily activities that don’t provoke the symptoms. Just gradual reintroduction of work or school or screens or whatever. As long as that doesn’t provoke symptoms, you get to go to Stage Two.
Stage Two is light aerobic exercise. Just walking or stationary cycling at a slow to medium pace, not jogging that’s going to bounce you around, or roller blading where you might fall and smash yourself. No resistance training where you are going to be holding your breath and straining. We are just trying to increase the heart rate a little bit, beyond resting level and see. Does that make you feel fine or do you feel worse? Do your symptoms come back?
Again, you are not going to like this. If your symptoms come back, even if it’s a little bit, you go back to Stage One. Which is 24 hours of regular activity. If you are symptom free, you can try to go back to Stage Two again, which is light aerobic exercise. You can’t just be like, “Wow, it’s just a little bit. I’ll keep going.”
Stage Three is sports specific exercise, so running or skating drills. No head impact activities. You can’t participate in practice, but you can go out and just skate or run just to add some more dynamic movement patterns. If that’s fine, you go to Stage Four. If that’s not fine, you go back to Stage Two. Then if you can do a day with light aerobic activity and it’s fine, then you get to try Stage Three again.
Stage Four, non contact training drills. Harder training drills, might be some passing drills, some shooting drills. You can start progressive resistance training. Here is where you can get back in the gym and do some progressive resistance training. Not just back to what you were doing, but a little bit lighter.
So you are working some exercise, some coordination, increased thinking.’Cause you are participating, “Okay, I’m in a passing drill. Where am I supposed to go? Who am I supposed to pass to?” If you can do that without any symptoms, even if it’s just little bitty, then you get to go on … you are getting the idea. You get to go on to level five, which is full contact practice.
Hopefully you are lucky enough (I live in London Ontario, Fowler Kennedy Sport Medicine Clinic does an amazing job with concussions), hopefully you can go see somebody who specializes in it. Sometimes your family doctor, unless they take a special interest in working with athletes, and especially helping athletes who have had concussion, they might not be up on this stuff, ’cause they’ve got so much other stuff to worry about.
So full contact, following medical clearance, participate in normal training activities. Again, we do this to restore your confidence to know, “Yeah, I’m okay. I feel good. I feel safe. I know what’s going on.” Assess your functional skills by the coaching staff. The coaching staff too can see, “Yeah, he looks good.” You are not out there with poor skill or poor judgment, things like that.
Then, Stage Six would be return to game. You should never be playing a game until you’ve done a full practice, even if it’s the biggest tournament of the year.
I remember actually I did have an e-mail from a parent once. Their child had been concussed and the doctor I think had told them they had to take a week off, didn’t really have a progression, but said they had to be away from sport from the week. The tournament started like tomorrow kind of thing and the parent was really mad and e-mailed to say, “My kid was so upset and they were in tears about it. What do you think? Do you think it’s okay for them to play in the tournament?” I was like, “Number one, I’m not a doctor. Number two, no.”
And again, somebody who has had a concussion isn’t in their right mind really, and they are going to be over emotional. Just ’cause they are crying … If the kid couldn’t walk on their knee you wouldn’t be like, “Yeah, I think you should go try and see how it goes.”
That’s your return to play criteria. That takes a week to follow each of those steps. Again, it has to be symptom free or else you go back.
Then there’s a return to school progression too.
The return to school progression, is again, maybe 24 hours off just for rest. Then, daily activities at home that don’t give symptoms. Typical activities your kid would do as long as they don’t increase symptoms. Some reading, even screen time. Starting with 5 to 15 minutes at a time and then building up. Just gradual return to typical kid activities (doing the Twitter or whatever).
If that’s good, you go to Level Two, which is school activities, which would be homework, reading, other cognitive activities, but outside the classroom. Just getting them thinking, using their brain, doing their homework.
Then the next would be returning to school part time. Back to reintroduction of schoolwork, but maybe a half day, or first period, third period, fifth period or something like that. Again, to be around lots of people and doing the school work.
And last, if that’s fine then back to school full time.
I know, crazy eh?
A couple of the current things, currently they are working on some advanced neuroimaging. They are working on fluid biomarkers and genetic testing to assess if there has been a concussion. I could do a blood test to see if there are these biomarkers in my blood that suggests that I actually had a concussion.
Also, that might suggest the degree or the length of recovery. They’ve even been looking at genetic predisposition. Are there some things that genetically predispose you to getting concussion or to having more severe concussion symptoms? Those are all in their infancy. So there isn’t such a thing, but those are some of the things they are working on to try and help.
It’s cool ’cause a lot of really smart people are working on this.
Beyond the rest for the acute phase of 28-48 hours is warranted as long as gradual return to activity doesn’t trigger any symptoms. That is to say beyond the first 24-48 hours, that absolute rest isn’t warranted unless we start to reintroduce activity and our symptoms come back and then we have to step back.
They also talked about, don’t forget rehabbing other injuries. So you know, if I’ve taken a significant blow that’s given me a concussion, maybe I’ve also jarred my neck or my shoulder, that actually needs rehabilitation too. We want to look after those things as well.
We are not just stepping back on the sporting field or on the ice like ready to go, but we still have our shoulder that’s not working right or our alignment is out. Don’t forget about rehabbing and assessing those other injuries. That also has to stay below thresholds, so you need to be working with a therapist who understands the concussion protocol and is going to help you do that without bringing on your symptoms.
The expected timeframes of recovery, 10 to 14 days in adults and somewhere under four weeks for children. So children take longer.
Prolonged symptoms for an adult would be lasting more than 10 to 14 days, prolonged symptoms for a child would be lasting more than a month or four weeks. I know, I was actually surprised by that too. I thought, “Wow. That’s a long time.”
If the symptoms persist, individualized treatment plan should include symptom limited aerobic exercise. So this is like, “My symptoms are persisting beyond the expected recovery time” so we are going to do some specific programmed aerobic activity with you, even though there are still some intermittent symptoms, but that don’t increase the symptoms. Again, guided by professionals and experts in the area. Some cognitive and behavioural therapy and any physical therapy to address other injuries.
This cognitive and behavioural therapy is really important. I think it gets missed a lot. I’ve seen it in other athletes that I train who played sports where they are getting chronically hit and some hockey players who have played long careers. You can see those guys that have had chronic concussion issues. You can see their personality does change over time. I don’t know why exactly that is, if it’s a structural change or just I don’t know why, but you see that.
I’ve heard presentations by sport med doctors who specialize in working with athletes who have had concussions. And if you are a parent, they kind of do this on purpose, but they’ll often try to get mom or dad out of the room so that they can have a really frank discussion with the athlete, especially a teenage athlete. Because sometimes athletes are hesitant to say things in front of their mom or their dad.
Like, before the injury this kid is happy go lucky, no problems, and then when they get a chance to talk to the doctor just in private, this kid is breaking down in tears and is suffering with depression and having thoughts of suicide and things like that.
It’s very scary and we all think, “Oh, that wouldn’t happen to my kid,” but again something is going on with the brain and the body is trying to respond to it. Those things can happen, so don’t neglect or think they are just kind of blue because they can’t play hockey for a while. It can be more than that. I’m not trying to scare you that it’s, “Oh my gosh. Every kid has those thoughts,” but it can happen.
Oh, and then they talked a little bit about pharmaceutical therapy, like taking meds to help with your symptoms. It sounded like that can sort of help with symptoms at times, but the bottom line was that you shouldn’t be returning to play if you are taking medicines to help control your symptoms.
Risk factors for sports related concussion is surprise, surprise, past sport related concussion. Multiple past sports related concussion are associated with more symptoms. If you’ve had ones before, you’re probably going to have more symptoms with subsequent ones.
The single biggest predictor of slower recovery is the severity of a person’s initial symptoms in the first day or initial few days. So the worse it is in the first day, it’s probably going to be longer recovery.
Individuals with preexisting mental health, or history of migraine headaches, may be more prone to have prolonged symptoms. Again, that wasn’t really, “Yeah, we did a research study and it was statistically significant,” but it was just like, “Yeah, there’s enough there to make us think that maybe that will prolong symptoms.”
Those with ADHD and other learning disabilities might require more attention and planning during the return to school phase, but don’t seem to be at increased risk of prolonged symptoms. It’s more just already being in that environment is a challenge so you might take a little bit more planning or a little more gradual transition back.
There is a greater risk for girls than boys for having prolonged symptoms as a teenager, which I thought was interesting and they didn’t say why, but it was just like, “Oh, that’s interesting.”
Then they talked about sort of a problem, because an athlete may show as clinically recovered. So like “Not having any symptoms, I can lift weights, I can do full practice, I’m good,” but they don’t know that that means they are physiologically recovered so that whatever actually did happen in their brain, that that’s repaired and that they are fine.
I thought of it almost as like if I had turf burn or something like that and I had a scab there. I’m fine. It feels fine and I can play, but I’m vulnerable if I get hit there again. I’m vulnerable to open up that injury. I thought that was an interesting point.
They said management should be same for elite or non elite athletes. I think if you watch any NHL games … I’m suspicious. You see a guy that’s like, “Oh, he’s going to the quiet room. Oh, he’s back on the bench, he must have been fine.” It’s just like, “What?” They are saying there should be no difference.
Then they talk about chronic traumatic encephalopathy, the CTE, which some of the high profile hockey players who have unfortunately passed away, they donated their brains to research this and they look and they see that they have this CTE. There hasn’t been a cause and effect relationship established yet between CTE and sport related concussions. That doesn’t mean there isn’t one, it just means there isn’t enough scientific research. There’s anecdotal research, but again this is coming from science, not from common sense or what we think. There hasn’t been enough scientific research to make that connection. It doesn’t mean there isn’t one, it’s just there isn’t one yet.
Then they were looking at helmets. So in hockey and football and things like that, we usually say helmets prevent scull fractures and lacerations, they don’t prevent concussions. It’s hard to say whether they reduce the risk of concussion or not, because everybody wears one. It’s not like you have somebody who is out playing football or hockey that doesn’t wear a helmet, so you can say, “Oh, yeah, of the guys that don’t wear helmets, they are 90% more likely to get a concussion.” Everybody is wearing a helmet so it’s a bit of a moot point.
They looked at downhill skiing where some people do and some people don’t. And they said, “Yeah, there’s probably enough there to say that yes, wearing a helmet when you ski is warranted. That that should be mandatory.”
Then they did a meta analysis of mouth guards. A meta analysis is you go back and look at research that all these other people have done and you, not steal, but you take all the data and then you put it together as if it’s one data set, as if it’s one research project. Then you run that through a statistical analysis and see if there is a statistical significance.
So when they run all that through they say that there is a non significant trend to support the use of mouth guards. That means that it’s not statistically significant, but if you look at a trend of the raw data, that kinda looks like if you are wearing a mouth guard there’s a little slighter risk. That too is kind of new.
What I had learned is mouth guards protect your chicklets and that’s about it. They are like, “Well maybe there’s a trend to suggest that it might a little bit help.” It’s not going to prevent them, but …
They said that the strongest and most consistent evidence for reducing the risk of concussion in hockey was taking out body checking under the age of 13. That had a protective effect. Really there isn’t any equipment that is proven to have a protective effect. Even some of the programs, good sportsmanship and things like that, they don’t work. Taking checking out under the age of 13 does reduce the risk of concussion. It opens another can of worms, but it does reduce the risk of concussion.
I’ve shared you guys the Top Spin 360 before, but I want to talk about it again. I am on the Advisory Board (but I don’t get money from them, just so you know). It looks crazy, but you put it on like a helmet. Then you are going to motion your head/neck to spin the little “whirly bird” that is on top of it. It’s actually really hard and it takes a lot of coordination of your neck, which we don’t really have that much of. And it comes with an app so that you know we are getting how many reps and it measures your velocity and all that stuff.
What we are trying to do is make your neck stronger, but really mostly make it smarter so that you really know how to control your head in space. The idea is that if you can take a hit, and instead of your head flying back or all around, you’ll have more strength and control and there’s going to be a lot less sloshing of my brain inside my cranium. Which will cause less damage. That is the philosophy or the hypothesis behind it.
There’s some really interesting video on it. Again, it’s hard because it’s comparing a high school athlete to a university football player. But the high school quarterback gets tackled and he comes back and he smashes his head off the turf. The university player who trains using this, he gets tackled in a very similar way and probably by a guy that weighs maybe a 100 pounds more than the other guy. He comes and he gets knocked back, but he can stop his head and it never even touches the turf.
It’s pretty compelling. It’s compelling enough that we started using it in the gym here. It’s something that we can do to hopefully reduce the risk or the magnitude of concussions in the future. More research is going on with that, but that’s what we’ve been doing here at RevCon to work on it.
So that’s a wrap gang. We’ll be back next week. We’ll get back on a regular routine. We’ll be up in the hip and the pelvis. That’ll be a barn burner. There’ll be tons on that.
Thanks for tuning in! Episode number 6. Goalie Training Pro T.V.
This Maria from Goalie Training Pro. If you like this, give me a thumbs up, give me a like, give me a happy face. Give me a “ha ha ha” face. That will be great. Share it, whatever you do. Bye. Bye, bye, bye.
Links:
There are two big references that you should check out – the first is the actual Consensus Statement, you can get it here — http://bjsm.bmj.com/content/early/2017/04/28/bjsports-2017-097699
The second is the Sport Concussion Assessment Tool (SCAT5). You can get it for FREE here – – http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf