Aug. 16, 2016

Sports-related concussions and brain injuries

With a focus on prevention, University of Calgary researchers look at all facets of youth sports injuries, from causes to symptoms to recovery.

The first concussion knocked 12-year-old elite hockey player Ash Kolstad out of school for a week. A concussion two weeks later – the result of a second, unexpected body check – pushed him onto a grim path that he continues to navigate today.

He’s not alone. Forty per cent of injuries in children aged 10 to 19 in Canada occur during sports activities. Hundreds of millions of public health dollars are spent every year on treating sports and recreation-related injuries (including concussions) to kids and teens.

Other costs can’t be added up in dollars. Painful headaches throb with no end. Sound and light seem to stab. Concentration disappears in a fog. Kolstad has suffered all of these debilitating symptoms and more with post-concussion syndrome, at times crying with his head in his hands in a dark room, adrift without hope.

Now 19, the University of Calgary undergraduate kinesiology student is dedicating his life to raising awareness about traumatic brain injury and concussions in sports – and to making them preventable.

"My life as I knew it was taken away in an instant.”

“People must realize that a concussion is not just a bump on the head, it is a brain injury,” says Kolstad. “I loved playing sports as a kid. My life as I knew it was taken away in an instant.”

His voice is one among many, as students, researchers and clinicians recognize that sport and recreational injuries in kids and teens are a major health problem in Canada.

Increasingly, UCalgary experts are leading the national and global discussion with insights and solutions. The benefits to the broader community in Calgary and beyond are significant.


Ash Kolstad was sidelined by consecutive concussions.

Giving back after treatment

The first big step toward easing the pain came in 2011, with physiotherapy treatments at what has become UCalgary’s Sport Medicine Centre, says Kolstad.

Besides introducing him to a medical pathway that serves the general public as well as elite athletes, it has led him toward his aim of becoming a clinical researcher working in injury prevention.

The centre has opened Calgary’s first sport concussion clinic to the public, providing care to anyone who may have suffered a concussion while participating in an athletic activity.

Physicians can refer their patients to the Acute Sports Concussion Clinic – a worldwide leader in sport and exercise medicine prevention and clinical services – for a wide range of sport-related injuries. Patients are assessed with the same protocols used by professional sports leagues. While adults are also treated at the clinic (and are a topic of research), researchers are primarily focused on sports-related injuries to children and teens.

Kolstad wants to ensure others won’t have to suffer the consequences he faced after being felled by two vicious body checks that he never saw coming. “The experiences that resulted from my injuries have changed me,” says Kolstad, who serves on a knowledge translation board associated with the Alberta Program in Youth Sport and Recreational Injury Prevention.

The program brings together interdisciplinary researchers, trainees and community partners to reduce the burden of sport and recreational injuries. It considers youth sports including hockey, soccer, basketball and snowboarding and targets common injuries – concussion, ankle and knee.

“I want to make a difference in my studies and my work," says Kolstad. "By speaking about what happened to me, I want to make sure other children don’t have to go through what I did.”

The benefits of reducing sports injuries

Collaborative research initiatives like the Alberta Program in Youth Sport and Recreational Injury Prevention, led by UCalgary researchers Carolyn Emery and Brent Hagel, are looking at how and where injuries occur and how targeted interventions can prevent them from happening in the first place.   

The goal is to reduce sports injuries by 20 per cent by 2020. Emery and Hagel, both PhDs, are working with a team of some 20 researchers in Alberta, across Canada and elsewhere in the world.

Their investigations have become go-to resources for sports organizations, as well as families seeking information they can turn into action for their kids.

image of a distress teenagers seats on the floor holding his head

Concussions cost the health-care system millions of dollars every year.

In soccer, for example, parents and coaches can encourage a neuromuscular training warm-up program that can cut the risk of injury by about 40 per cent. UCalgary kinesiology researchers have demonstrated cost savings of more than $2.7 million for Alberta youth soccer players alone.

A study by University of Calgary researchers, including Emery and lead author Deborah Marshall, PhD – both of the Cumming School of Medicine and members of the O'Brien Institute for Public Health – showed that a neuromuscular training prevention group in youth soccer had a 38 per cent rate of injury reduction. At the same time, health care costs were reduced by 43 per cent.

The study, published this year in the British Journal of Sports Medicine, included analysis of direct costs to the healthcare system, as well as out-of-pocket costs racked up by players and their families. Costs calculated from Alberta Health Services Calgary Zone included health-care professionals, specific treatments, services, quantities of supplies, and much more.

“We know that when kids have a significant injury in their youth, their fitness levels go down and a proportion of them can have long-term effects such as osteoarthritis,” says Emery, who is with the Faculty of Kinesiology as associate dean, research, and associate professor, and is a member of the Hotchkiss Brain Institute (HBI) and Alberta Children’s Hospital Research Institute (ACHRI).

“It’s about keeping kids active and focusing on prevention, rather than management of injury and rehabilitation.”

Some 35 per cent of Alberta youth aged between 11 and 17 are expected to sustain a sport-related injury that will require medical attention this year. This includes concussions and musculoskeletal injuries.

Two out of three (66%) injuries among adolescents were linked to sports, according to Statistics Canada. In the United States, almost 175,000 children and adolescents are treated annually in emergency departments (EDs) for sport-related head injuries, according to the Centers for Disease Control and Prevention.

Parachute, a national, charitable organization dedicated to preventing injuries and saving lives, has acknowledged that there has been a lack of Canadian data focused on the issue of concussions, resulting in a gap between knowledge and practice. The organization considers concussions a significant injury risk to Canadians, particularly because they are often misunderstood in terms of diagnosis and recovery procedures.

Emery, Hagel and other University of Calgary researchers working on better understanding concussions, particularly related to sport and youth, are filling an important knowledge gap in Canada with their studies.

Both Emery and Hagel are on the Parachute Expert Advisory Committee.

Preventative measures for concussion

As Emery and Hagel raise awareness of sport-related injuries, their research consistently has real-world impact.

Emery has influenced youth ice-hockey policy changes in both Canada and the United States, reducing injury and concussion risks.

Her examination of injury and concussion rates in youth ice hockey led to a national ban in Canada on body-checking in Pee Wee ice hockey (ages 11 and 12) in 2013 – the same level that Kolstad was playing at when he suffered his two concussions. Kolstad now works as Emery’s research assistant at the university.

Hagel’s injury-prevention research on the effectiveness of helmets in skiing and snowboarding has supported mandatory helmet use policies in ski-area terrain parks and helmet legislation in Nova Scotia.

"The key is preventing the injury in the first place.”

Both Emery and Hagel worked on an investigation that found the rates of injury and concussion were three times greater in non-elite Pee Wee ice hockey players in leagues where body checking was permitted. The rates of injury and concussion did not differ between provinces in elite levels, where body checking was allowed.

“For me, the key is preventing the injury in the first place,” says Hagel, who is associate professor with the Cumming School of Medicine, with a joint appointment to the Faculty of Kinesiology; he’s also a member of ACHRI. “When there is a concussion, getting the proper rest and a break from your activities is very important.”

One of the public benefits of the Alberta Program in Youth Sport and Recreational Injury Prevention is collaborative research, which brings a range of skill sets to bear on the concussion issue.

“We have a truly interdisciplinary team of concussion researchers examining prevention, assessment and management,” says Hagel. “A rigorous and comprehensive scientific approach at the University of Calgary is a great strength and has dramatically improved our understanding of concussion.”

New treatments at concussion clinic

Kathryn Schneider is working with Emery to look at innovative new treatment protocols in the new Acute Sports Concussion Clinic.

“Ultimately, we want to prevent concussions,” says Schneider, PhD, assistant professor and clinician scientist in the Faculty of Kinesiology and a member of the HBI. “We want to be able to detect them as soon as possible and employ the best treatment to facilitate recovery and minimize any long-term effects.”

It was Schneider who treated and helped Kolstad along the road to recovery in the wake of his concussions. She has spearheaded bringing vanguard technology into the clinic that will provide new approaches to concussion treatment and management.

New balance-testing equipment, a computerized mat that looks at how people walk, a neck strength and movement testing machine, and more, are all being used to seek answers to concussion problems. A future trial will combine neck and balance treatment with exercise.

Schneider says that while most people with concussion can recover in seven to 10 days, up to 30 per cent might have symptoms that can cause considerable difficulties with their daily activities.

“With the collaborative research at the university, we can answer unique research questions that can inform clinical practice to improve the health of all Canadians,” says Schneider.

The Conversation: How to avoid, recognize and treat concussion in sports

Understanding the brain's response to concussion

Keith Yeates’ research aims to better understand the outcomes of childhood and youth brain injury and the influences on recovery, focusing on neural injury and repair. This research can inform more effective treatment and management.

“The goal of my research is to examine factors that predict the outcomes after childhood Traumatic Brain Injury (TBI), and to identify those that are modifiable – and can therefore be a target for new interventions that are then subject to clinical trials,” he says. “For instance, if we find that certain psychological characteristics of the child, such as resilience, predict better outcomes after mild TBI/concussion, then we can try to develop interventions that foster resilience, and test those in randomized clinical trials, to see if we can improve outcomes therapeutically.”

“Sports-related injuries and concussions are preventable.”

Yeates, PhD, a pediatric neuropsychologist in the Faculty of Arts, the Ronald and Irene Ward Chair in Pediatric Brain Injury and member of ACHRI and the HBI, leads the UCalgary Integrated Concussion Research Program. He brings considerable perspective as the Traumatic Brain Injury NeuroTeam leader. The team draws researchers from the faculties of Arts and Kinesiology, the Cumming School of Medicine, ACHRI and the HBI.

While the titles and organizations may appear daunting, there is a practical payoff for the broader community.

“People sometimes think of research happening in an ivory tower, but health-related research means kids in the local community are the first ones getting the cutting-edge work,” says Yeates. “Almost all of our investigators, including me, are clinicians who work with patients and families. So we take our research back into the clinic.”

He observes that the severe concussion effects Kolstad experienced are not the norm, though a small percentage of kids and adults do have persistent difficulties.

“We have a pretty good reason to think your kid will recover well and we are getting better at knowing which kids are low-risk,” Yeates says. “The data suggests the majority of kids and adults with concussion recover reasonably quickly and pretty much fully.”

Even so, he says, there is a long way to go in understanding the brain’s response to concussion and traumatic brain injury. For anyone who has a concussion, even a month of disruption can seem like a horribly long time.

“As we get better at providing diagnosis and treatment that is more informed by evidence, we will have a lot more hope to offer,” Yeates says.

For Kolstad, who hears on Facebook now and again from kids who have undergone a concussion or traumatic brain injury, seeking advice or thanking him for speaking out, new research spurs encouragement.

He still gets throbbing headaches, but he foresees a welcoming future.

“Sports-related injuries and concussions are preventable,” says Kolstad as he readies to speak about his experiences at the Canadian Academy of Sport and Exercise Medicine national conference. “I get excited knowing there is a huge shift coming in awareness.”

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Dr. Carolyn Emery, PhD, is the associate dean of research and an associate professor for the University of Calgary’s Faculty of Kinesiology. She also holds a joint appointment a professor in the Departments of Paediatrics and Community Health Sciences, Cummings School of Medicine. She is a member of Hotchkiss Brain Institute, Alberta Children’s Hospital Research Institute, McCaig Institute for Bone and Joint Health and O’Brien Institute for Public Health. Her research fields include sport injury epidemiology, sport injury prevention, and rehabilitation outcome measurements in sport medicine. Find out more about Carolyn’s research here.

Dr. Kathryn Schneider, PhD, is an assistant professor and clinician scientist in the Faculty of Kinesiology at the University of Calgary. She is a member of Alberta Children’s Hospital Research Institute and Hotchkiss Brain Institute. Her research focuses on the assessment and treatment of individuals with dizziness, neck pain and headaches following concussion. More information on Kathryn’s research can be found here.

Dr. Brent Hagel, PhD, is an associate professor in the Departments of Paediatrics and Community Health Sciences at the University of Calgary’s Cumming School of Medicine, and an adjunct associate professor in the Faculty of Kinesiology. He is also a member of Alberta Children’s Hospital Research Institute and O’Brien Institute for Public Health. His current research interests include evaluation of the effects of protective equipment use and injury prevention policies, with particular interest in child and adolescent sport and recreational injury prevention. Learn more about Brent here.

Dr. Keith Yeates, PhD, is a professor in the Department of Psychology and Ronald and Irene Ward Chair in Pediatric Brain Injury at the University of Calgary’s Faculty of Arts. He is also a member of Alberta Children’s Hospital Research Institute and Hotchkiss Brain Institute. He aims to better understand the outcomes of childhood brain injury and influences on recovery in order to foster more effective treatment and management. His current research projects focus on concussion and mild traumatic brain injury (TBI).   Find a list of Keith’s academic papers here.

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