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The Number One Injury In Hockey
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Concussion Toronto Hockey Concussions have become the number one injury in contact hockey. While equipment manufacturers have made great strides to protect the other areas of the body, the head area still remains vulnerable to serious injury in contact hockey. Trainers for hockey teams are often confronted with the problem of concussions. Diagnosing hockey related head injuries can often be difficult. Although concussions can result from a wide variety of common, everyday activities the focus of this article will be sports related injury.

At the time of the injury, trainers must consider the issue of whether the hockey player can resume playing the game. If the player cannot resume play, there is the issue of when it is safe for the the hockey player to return to the game. Issues such as Post Concussion Syndrome and Second Impact Syndrome must be considered when making this decision. Making this decision is difficult as there are currently no universally accepted guidelines for the management of concussion in sports.1,2,3

Concussion has reached near epidemic proportions in contact hockey at both professional and amateur levels, with an estimated 300,000 concussions per year in contact sports in the United States alone. The effects of concussion can have a significant, negative impact on scholastic abilities and in some cases can be a career ending event for the hockey player.

To gather information for this review, I searched Doctorsns.com to find national and international guidelines, MDConsult for review articles and PubMed 1999 to 2002, using "concussion" as the search word.

Although there is some controversy about the definition of concussion, the Canadian Academy of Sport Medicine uses the Congress of Neurological Surgeons definition as "a clinical syndrome characterized by immediate and transient post traumatic impairment of neural function, such as alteration of consciousness, disturbance of vision and/or equilibrium due to brain stem involvement".4

Signs and Symptoms of Concussion:

According to the CASM guidelines the following are signs and symptoms of concussion. If any one of the following symptoms or problems is present, a head injury should be suspected and appropriate management provided. Note: A player does not need to have lost consciousness to have had a concussion!

1. Memory or Orientation Problems:

  • Unaware of time, date, place
  • Unaware of period, opposition, score of game
  • General confusion
2. Typical Symptoms
  • Headache
  • Dizziness
  • Feeling "dinged" or stunned
  • "Having my bell rung"
  • Feeling dazed
  • Seeing stars or flashing lights
  • Ringing in the ears
  • Sleepiness
  • Loss of field of vision
  • Double vision
  • Feeling "slow"
  • Nausea
3. Physical Signs
  • Poor coordination or balance
  • Vacant stare/glassy eyed
  • Vomiting
  • Slurred speech
  • Slow to answer questions or follow directions
  • Easily distracted, poor concentration
  • Displaying unusual or inappropriate emotions (e.g. laughing, crying)
  • Personality changes
  • Inappropriate playing behaviour (e.g. skating or running the wrong direction) Significantly decreased playing ability from earlier in the game/competition

Complications of Concussion:

Immediate complications of concussion include seizures and subdural or epidural hematomas. Delayed complications include Post Concussion Syndrome and Second Impact Syndrome.

Post Concussion Syndrome includes a constellation of symptoms including persistent headaches, fatigue, equilibrium disturbances, irritability, and impaired concentration. The etiology of this condition is unknown and it may persist for months or years and it tends to be refractory to any kind of treatment.

Second-impact syndrome is a rare but often fatal condition that may occur when an athlete returns to competition while still suffering from the effects of a concussion. The mechanism by which this syndrome occurs is thought to involve loss of the normal cerebral autoregulatory mechanisms, leading to vascular engorgement, brain edema, increased intracranial pressure, subsequent herniation, and death. The severity of the second impact which provokes this response may be minor.

There is evidence that the neurologic effects imparted by a concussive event are cumulative. and that individuals sustaining multiple concussions seem to process information more slowly during neuropsychologic testing and take longer to recover than patients concussed only once. These findings may have implications for individuals engaged in activities that place them at high risk for repeated concussions, such as contact sports.5,6

Return to Play:

There are several protocols available for deciding when an athlete can return to play. These include the Cantu Grading Scale For Concussion7, the Colorado Medical Society Sports Medicine Committee: Guidelines for the Management of Concussion8, and the American Academy of Neurology Guidelines.9 The problem is that none of these guidelines are based on prospective studies, and all offer only expert opinion and as such represent level 4 evidence. Moreover a recent study has questioned the validity of guidelines that use loss of consciousness as a marker of concussion severity for making return-to-play decisions, and several of the current guidelines use this marker.10

Nevertheless, these are the tools that we have to use at present. Here is a summary of their suggestions. I've highlighted the definitions that I find most useful:

  1. Mild (Grade 1) concussion is variously defined as no loss of consciousness, or concussion symptoms or mental status abnormalities on examination that resolve in less than 15 minutes.

    When assessing a player with a mild concussion with respect to return to play in the present contest it is necessary to obtain a thorough history and do a complete physical evaluation to rule out other injury (e.g. spinal cord damage). ANY symptom of concussion is cause to remove the player from play. If the examination is normal and there are no symptoms at rest or with exertion after a period of 15-30 minutes, return to play can be considered. Players with Grade 2 or 3 concussions should be withdrawn from play.

  2. Moderate (Grade 2) concussion is variously defined as loss of consciousness less than 5 minutes or post traumatic amnesia longer than 30 minutes, confusion with amnesia, or concussion symptoms or mental status abnormalities on examination that last more than 15 minutes.

    The guidelines would suggest that with Moderate concussion, athletes can return to play after 1 asymptomatic week. The patient must be asymptomatic at rest and with exertion. Players who sustain a second Moderate concussion should refrain from play for 1 month but then can return to play after being symptom free for 1 week.

  3. Severe or Grade 3 concussion is variously defined as loss of consciousness longer than 5 minutes or post traumatic amnesia longer than 24 hours, or any loss of consciousness, either brief (seconds) or prolonged (minutes).

Players with severe concussion may return after 1 month having been asymptomatic at rest and with exertion for at least 2 weeks. A second Severe concussion will terminate the season, but the athlete can return to play the following season if asymptomatic.

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