Concussions: evaluating potential prevention and management solutionsPete Kissel
NHL star Sidney Crosby is on the verge of returning to play after a 10 month concussion hiatus. With all the attention brought to the issue of concussions in the wake of his absence, the question is has his injury sparked positive change?…or are we any closer to a solution that will either reduce the number of concussions sustained or changes that will improve the management of concussions?
Concussions are an ever increasing controversial topic. After decades of using loss of consciousness, memory difficulty and confusion as the primary criteria to determine the severity of a concussion these now make up a small component of our current diagnostic tools. As a team doctor for a junior hockey team we now rely on a large battery of symptoms, memory and cognition tests and balance tests to make a decision. Some leading experts may even have access to advanced imaging such as functional MRI to help in the diagnostic process. Although the diagnostic tools have evolved immensely the decision to label a player with a concussion is still (in most cases) highly subjective. This diagnostic subjectivity makes investigation and research into concussion prevention and management interventions highly problematic.
With a market for the next big concussion solution at an all time high let’s look at some of the ideas being tested right now and discuss their importance in the big picture.
Computerized Concussion baseline testing
There are several computerized testing platforms that are competing for market share (ImPACT, CogState etc). These tests take about 25 minutes and cost approximately 25 dollars per player for a preseason test. ImPACT has published dozens of studies to boost its scientific credibility to establish itself as the go to tool for helping determine when a player is ready to return to play. Is this potentially a piece of the puzzle? Maybe…especially at the junior and professional levels where return to play is particularly important for career development. In fact, Dr.Kissel and I implemented this baseline testing for our junior hockey players this year. But should the Greater Toronto Hockey League, with over 10,000 rep players age 9-20, be investing approximately 1/4 million dollars on this baseline testing? Current guidelines require a graded exertion progression prior to clearance for return to play, which still requires a trainer/physician…the computerized pre/post information does not replace this process. The GTHL has tabled a motion until 2012 to further discuss funding this baseline testing…but several other organizations have already broken the ice for what seems to be inevitable.
Role in the big picture? Theoretically improves timing of return to play and, again, may be a piece of the puzzle…but distracts us from the underlying more important issue of reducing the incidence of concussions in sport. In my opinion implementing these in minor hockey is unneccessary, cumbersome and a poor allocation of resources. Instead emphasis on concussion education for minor hockey players, such as this video produced by Think First, would be a better use of team time and effort (leaving a large chunk of change for a more productive long term solution…see video review below).
Red light lunacy: Battle Science impact indicator
Battle Science has created a football chinstrap with a LED indicator on the front that changes from green to red if a player sustains a hit that results in a threshold of G forces. If the indicator turns red the probability that the player has sustained a concussion is 50% or higher. I was unable to find a link from their site to substantiate the threshold magnitude…this theoritical point where insignificant contact suddenly becomes significant. For $149.99 you can order the chinstrap…and then what? Again the diagnosis and management is still up to the trainer/physician on the sidelines…but now trainers/physicians can read a book or catch up on some ZZZ’s on the sidelines during the game I suppose. And if you don’t want a chin strap that lights up…a mouth guard with similar technology may not be that far behind.
Role in the big picture? Negligible. Yes it’s an extra set of eyes, however we know that the magnitude of the impact is poorly correlated to the post concussive symptoms that a player experiences (Guskiewicz et al. Biomechanics of Sports Concussion: Quest for the Elusive Injury Threshold. Exercise and Sports Sciences Revews. January 2011.). If only the issue was black and white, or red and green as Battle Science seems to claim!
Neck constriction collar
Finally…a prevention oriented idea! Dr. Joseph Fisher, a University of Toronto anaesthesiologist, claims a simple neck collar that constricts the internal jugular veins is the cheap prevention solution we’ve been waiting for. The collar restricts just enough to top up the brain bathing fluids to help prevent excessive brain movement within the skull. Although the analogy of contents in a fluid filled container is captivating, the application to interrupting our normal cerebral cardiovascular flow is much more complex…I would assume more research (beyond that done in rats already) is to come before giving this theory any credibility.
Role in the big picture? Although I think the likelihood of this idea gaining momentum is about as likely as the Leafs finishing first overall in the East this season…let’s give Dr.Fisher credit for innovation in the prevention realm (quoting Apple’s think different campaign: the people who are crazy enough to think they can change the world are the ones who do).
Video Review of headchecks in the NHL
In my opinion, the most valuable change fueled by the Crosby concussion spotlight has come from the league itself: Sheriff Shanahan’s video review approach. Shanahan has brought transparency and clarity to the leagues decisions on suspensions for illegal checks. Many hockey purists (see Don Cherry) will argue that this will ruin the game, with players afraid to deliver a check in fear of accidentally hitting an opponent’s head etc. While this will inevitably tone down the aggression factor, holding players accountable for their actions is the only way to reduce or eliminate head checks. It will be interesting to see if the incidence of concussions in the NHL is affected by the video crack down on head checks/illegal checks.
Role in the big picture? If this accountability and greater respect for your opposition disseminates down the ranks to minor hockey imagine the widespread effect on preventing concussions. Think implementing video review outside of the NHL is financially unrealistic?…I believe the GTHL could implement a video review system for far less than a 1/4 million annually (instead of paying for computerized concussion baseline testing).
Side Note: a local concussion researcher and expert, Dr. Paul Echlin who has researched the incidence of concussions in junior hockey and has a particular interest in concussion prevention/education, stated that Hockey Canada has an annual budget in excess of 15 million/year (other sources say as much as 30 millon/year), of which they have never funded concussion research (prevention or other). Much like our current medical system…Hockey Canada (and their affiliates) seem to be sending a message that they are willing to spend money on reactive measures but not potentially proactive measures.
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