Concussions

What is a Concussion and How does it Occur?

Concussions are brain injuries caused by the brain moving inside of the skull. The movement causes damage that changes how brain cells function, leading to symptoms that can be:

• physical (headaches, dizziness)
• cognitive (problems remembering or concentrating), and/or
• emotional (feeling depressed).

A concussion can result from any impact to the head, face or neck or a blow to the body which causes a sudden jolting of the head.

Because of the contact nature of hockey and the speed with which the game is played, the brain is vulnerable to injury. Trauma may occur through direct contact to the head or face or indirectly through a whiplash effect. Injuries to the brain are characterized by an altered state of mind. An altered state of mind is the key thing to look for with any head injury.

A concussion is a common injury, but since it cannot be detected on X-rays or CT scans, concussions have been difficult to fully investigate and understand. Fortunately, there have been many important advances in our knowledge of concussions, including how to identify, manage and recover from a concussion. Although concussions are often referred to as ‘mild traumatic brain injuries’ and often resolve uneventfully, ALL concussions have the potential for serious and long-lasting symptoms and so must be treated carefully and in consultation with a physician.

Children are more sensitive to the effects of a concussion and will need to have a longer period of rest prior to returning to activity and the sport.

The potential impact of a Concussion

In February 2012, during a hockey practice drill, Nathan Fraser, age 12, sustained a concussion. In the nine months following the incident, Nathan and his parents, Christine and Adam, learned about the symptoms of concussion, the steps to take if a concussion occurs, and how to play safe to minimize the likelihood of a concussion.

NATHAN’S STORY >

Hockey Alberta Resources:

Hockey Alberta has created a presentation available to all minor hockey associations. This two-hour interactive session is delivered by industry experts and is designed to increase knowledge about the identification, removal, and recovery from this injury.

Request Hockey Alberta’s Concussion Safety Presentation 

Hockey Canada Concussion Resources:

As the national body for our sport and a leader in creating a safe environment for sport, Hockey Canada has worked with numerous partners to develop a toolbox for all associations to use. Here local associations will find resources such as the Hockey Canada Concussion App, The Hockey Canada Concussion Card with the 6 steps for responsible return to play, as well as the Concussion Recognition Tool (CRT 5). 

HOCKEY CANADA CONCUSSION POLICY >

HOCKEY CANADA CONCUSSION TOOLBOX >

Hockey Canada Concussion App: FOR ANDROID > | FOR APPLE >

Berlin Consensus:

A consensus statement developed by the leading experts of concussions in sport that serves as the guiding principle for the development of the best practice in concussion prevention, diagnosis, and management.

BERLIN CONSENSUS >

Parachute Canada: 

A national leader in injury prevention and management has created many of the generally accepted best practice resources for the management of concussions from the perspectives of the athletes, coaches, parents, and educators.   

CONCUSSION GUIDELINES >

PARENT TIP SHEET >

GUIDELINES FOR PARENTS/CAREGIVERS >

GUIDELINES FOR ATHLETES >

Coaching Association of Canada

The standard for coaching in Canada through the National Coach Certification Program, the Coaching Association of Canada has also developed resources on concussions - including their award-winning online learning module “Making Headway”. 

Concussion Awareness Resources >

National Hockey League

A 13-minute video - produced by NHL Studios in conjunction with the National Hockey League and NHL Players’ Association - was created to help players, parents, coaches and team medical staff at all levels of hockey recognize the signs and symptoms of concussion and better understand how to proceed when a player is suspected to have suffered a concussion. There are appearances by current and former players who have experience with concussions, team and League medical professionals, and recognized experts in the field of concussion diagnosis and treatment. This is a must watch video for all hockey participants.  

NHL Concussion Video >

PREVENTION

The most important step in preventing concussions is RESPECT.

Coaches, team staff and parents/guardians play a big role in helping to develop an atmosphere of respect for the safety wand well-being of all participants in the game. You can make player safety a priority at your team meetings, talk about concussion prevention, and ensure that all players understand the consequences of violent actions and dangerous hits.

Respect for the players

• If you are a fellow player never check to the head, hit someone from behind, or attempt to injure a fellow player
• If you are a coach:
  • encourage safe competition and discourage reckless or malice behavior,
  • set expectations for behaviors and potential consequences, and
  • focus on proper skill development.
• If you are a parent:
  • be a positive influence,
  • encourage and celebrate positive behaviors like teamwork and skill development rather than negative behaviors like intimidation.

Respect for the rules

• Everyone should understand the rules and the reasons they are in place
• As a coach:
  • educate players on the techniques and game play,
  • ensure the players are playing within the rules, and
  • educate the players on why a penalty was assessed.
• As a parent:
  • gain an understanding of the rules,
  • support rule emphasis within the team environment, and
  • communicate to your child why certain rules are being emphasized.

Respect for the officials

All participants should avoid setting a negative example when a penalty is called and be patient with officials as they refine game management techniques to make the game safer and more exciting for the players.

Hockey Canada has passed a zero tolerance rule to any contact above the shoulders. This rule - combined with education awareness, strong player development and respect for the game - will reduce injuries like concussions and help to keep the game fun for all. The keys to preventing concussions from occurring are:

• Reducing violence in the game.
• Reducing head contact.
• Reducing hitting from behind.
• Educating all participants on prevention and recognition of head injuries and responsible return to play.
• Encouraging respect and fair play.

HOCKEY CANADA RULE BOOK > 

EDUCATION

Equipment

Players, parents, and coaches should ensure that proper equipment is worn at all times. This includes ensuring the equipment is the proper size and used in the manner it was intended.

It is important to remember that no study has yet to show that any equipment - including helmets and mouth guards - prevents a concussion. However, helmets and mouth guards provide protection against localized injuries such as skull fractures and dental/oral damage.  Therefore, it is important to think first and keep respect in the game.

PARACHUTE CANADA VIDEO > | HOCKEY CANADA EQUIPMENT VIDEO >

Skill Development

Another important factor in preventing concussions is skill development, especially in checking. Checking should not be confused with body checking.

Checking is a 4-step progression starting at the novice and atom levels focusing on skating, positioning, and angling and progressing as the players develop and mature to initiating body contact, confidence in body contact, and finally body checking.

Teaching players the proper skills will give them confidence on the ice to move around in a safe manner, will create awareness for them to avoid dangerous situations, and ensure they reduce the potential to injure another participant.

HOCKEY CANADA CHECKING SKILLS PROGRAM > | HOCKEY ALBERTA CHECKING SKILLS COURSE > 

Avoiding unnecessary behaviour

Players should avoid activities that result in direct impacts to the head such as fighting or “locker boxing” regardless if a helmet or face mask is worn.

Coaches and team leaders need to work to eliminate this type of behavior both in the dressing room and in areas where this behaviour can potentially occur by implementing prevention plans and team rules against locker boxing and fighting, and by clearly defining these to all players, coaches, team managers, safety people and parents throughout the season. When combined with player and parent education with respect to concussions, this will help to eliminate this type of behavior.

TEAM MEETING CHECKLIST >

RECOGNITION

Recognizing when a player has suffered a concussion is a major factor to improving the long-term recovery of that player. However, symptoms or signs may have a delayed onset.

As well, concussions do not necessarily occur because of a massive impact or a direct blow to the head.

Therefore understanding what signs and symptoms can be concussion related are of importance.

Observing Symptoms/Signs of Concussion

Participants are observed for symptoms and signs of a concussion using the Hockey Canada Concussion Card or the current Sport Concussion Recognition Tool. Even though symptoms may not be present or they come and go, the participant is removed from play the day of the injury, does not return that day and sees a physician as soon as possible.

CONCUSSION CARD > | CONCUSSION RECOGNITION TOOL >

Red Flags: If ANY of the following are observed or complaints reported by a participant following an injury, initiate your Emergency Action Plan. Immediate assessment by a physician is required.

• Neck pain or tenderness
• Double vision
• Weakness or tingling/burning in arms or legs
• Severe or increasing headache
• Seizure or convulsion
• Loss of consciousness
• Deteriorating conscious state
• Vomiting
• Increasingly restless, agitated or combative

Consult the Red Flags section of CONCUSSION RECOGNITION TOOL. If no licensed health care professional is available, call an ambulance for urgent medical assessment.

Every team should have an Emergency Action Plan in place. When concussion symptoms or signs are identified, the Emergency Action Plan should be implemented. All injuries, including concussions must be documented and reported. If the player is a child or adolescent, also report to the parents/guardians. All concussions and suspected concussions must be referred to a physician as soon as possible.

EMERGENCY ACTION PLAN FLOWCHART >

If no Red Flags exist, the following can be used to help determine if a possible concussion may have occurred:

Observable signs and visual clues:

• Lying motionless on the playing surface
• Slow to get up after a direct or indirect hit to the head
• Disorientation or confusion, or an inability to respond appropriately to questions
• Blank or vacant look
• Balance, gait difficulties, lack of motor coordination, stumbling, slow movements
• Facial injury after head trauma

Symptoms:

• Headache or “pressure in head”
• Balance problems
• Nausea or vomiting
• Drowsiness
• Dizziness
• Blurred vision
• Sensitivity to light or noise
• Fatigue or low energy
• “Don’t feel right”
• More emotional or irritable, feeling sad, nervous or anxious
• Neck Pain
• Difficulty concentrating or remembering
• Feeling slowed down or “in a fog“

Memory Assessments (for players over the age of 12) where failure to answer any of the following questions correctly may suggest a concussion

• What venue are we at today?
• Which period is it now?
• Who scored last in this game?
• What team did we play last week/game?
• Did we win the last game?

REMOVE

When a participant is suspected of having a concussion, the participant is immediately removed from play. Regardless of whether the concussion occurs on or off the ice, the participant is not permitted to return to play that day. If there are doubts, assume that a concussion has occurred.

• The participant is referred to a physician for diagnosis as soon as possible.
• Do not leave the participant alone and ensure the player is continuously monitored for signs and symptoms.
• Do not administer medication and ensure no consumption of alcohol.
• If the participant experiences loss of consciousness assume a neck injury - call Emergency Services.
• If there is a significant loss of awareness and/or orientation, direct the participant to an emergency room at the nearest hospital.
• If unsure err on the side of caution and call Emergency Services.
• Inform the coach, parent, or guardian about the injury.
• The participant should be evaluated by a medical doctor as soon as possible
• The participant must not return to the activity until the 6-step return to play protocol is completed and the player has received medical clearance by a physician.
• Once a participant, who is experiencing concussion-like symptoms, is diagnosed with a concussion or concussion-like symptoms, s/he is not permitted to return to play or practice/training until all of the return to play requirements are met. 
• Written clearance from a physician is required as outlined in the return to play strategy prior to returning to activity. Copy of this documentation is maintained as per Member/Minor Hockey Association policy and procedures. 

NOTE: Second impact syndrome, although rare, can occur in players who return to activity with ongoing symptoms. Monitoring of return to play is essential. Always err on the side of caution.

RESPONSIBLE RETURN TO PLAY

No member of the hockey community in Alberta - including coaches, safety personnel, and parents/guardians - is to pressure the participant to return to play until s/he has completed the six‐step return to play strategy and is medically cleared by a physician.

Once a concussion has been diagnosed recovery is key to prevent the worsening of initial injury and potentially future concussions. Recovery has been identified as six steps that are a gradual return to regular activities. Signs and symptoms can last from 10 days to months and the time required to progress through each step can vary depending on the significance of the concussion and the person. Progression through the steps should be guided by the treating physician. 

Only when a player does not experience signs or symptoms should that player move to the next step, signs and symptoms may not appear during the activity but rather later. If any signs or symptoms return then the player should return to step 2 and be reevaluated by a physician.

These steps must be applied to all physical activity not just hockey. The priority in the recovery of a concussion is first returning to daily activities, followed by returning to school, and finally returning to hockey.

Prior to beginning the process

Following a concussion, a brief period of physical and mental rest is recommended. Typically, this period is between 24 and 48 hours, and resting does not mean during the entire time. Throughout the recovery process, appropriate activities can be done in moderation as long as the activity does not aggravate signs or symptoms. 

6 Step Return to Play Process

The six steps are a general progression designed to gradually increase tolerance to stimuli. Only progress to the next step when sign or symptom free. Progression through each step should take a minimum of 24 hours, however progression can vary and the key to proper recovery is not to rush through each step. If signs or symptoms return, then the participant must go back to the previous step. 

The first two steps focus on preparing the participant to return to school and general activities. The final four steps focus on preparing the participant to a full participation in school and sport.

1. Light activities of daily living which do not aggravate symptoms or make symptoms worse. Once tolerating Step 1 without symptoms and signs, proceed to Step 2 as directed by your physician.
2. Light aerobic exercise, such as walking or stationary cycling. Monitor for symptoms and signs. No resistance training or weight lifting.
3. A reintegration to school and sport specific activities and training (e.g. skating).
4. A full return to school and drills without body contact. May add light resistance training and progress to heavier weights. The time needed to progress from non-contact to contact exercise will vary with the severity of the concussion and the player. Go to Step 5 after medical clearance (reassessment and written note).
5. Begin drills with body contact. This step should not begin until the player has returned to full school participation.
6. Game play. (The earliest a concussed participant should return to play is one week.)

CONCUSSION CARD > | CONCUSSION RECOGNITION TOOL > | HOCKEY CANADA FOLLOWUP CHECKLIST >

IMPORTANT NOTE: A second sustained concussion on top of the first sustained concussion can lead to substantially more damage than one concussion alone. The effect of concussions are cumulative and the end result of several concussions could be ongoing symptoms. If not properly managed the result could be the end of the individual’s participation in sport and affect other aspects of his/her life. Sufficient time between the concussion and return to play is critical. If there are previous concussions, it is important to report this to the physician. Children are more sensitive to the effects of a concussion and will need to have a longer period before returning to sport. Use symptoms rather than a set time frame when assessing return to play. Always follow the advice of a physician.

Hockey Alberta determines and administers discipline for any club, team or individual who knowingly disregards their responsibility of requiring a physician’s written permission permitting a player to return to play following a concussion.