Le génie derrière

les performances

Changing the game with data

Concussion in High Performance Sport

Suzanne Leclerc MD, Ph.D.

CMO INS Québec

Sport-Related Concussion Guidelines for Canadian National and National Development High-Performance Athletes

2018

A Guideline endorsed by the Canadian Sport Institute (CSI) Chief Medical Officers (CMOs), Canadian Olympic Committee (COC) Medical Director, and Own the Podium

CONTRIBUTORS

• Dr. Brian Benson (CMO CSI Calgary)

• Dr. Suzanne Leclerc (CMO INS Québec)

• Dr. Doug Richards (CMO CSI Ontario)

• Dr. Paddy McCluskey (CMO CSI Pacific)

• Dr. Robert McCormack (COC Medical Director)

• Dr. Mike Wilkinson (Director, Own the Podium)

• Dr. Jon Kolb (ex Director, Sport Science, Innovation & Medicine, Own the Podium)

HIGH

PERFORMANCE

CONTRIBUTORS

•Extensive peer review (internal and external) of COPSI-N, COC, CPC, OTP, ONS team physicians, CASEM and Parachute Canada

•Revised annually and updated with new medical/scientific advances and experiences gained through its implementation

•Supports CSI/CSC research initiatives to advance the scientific and clinical management of athletes with sport-related concussion.

CONTENT

• Definition

• Policy and Education

• Pre-season (Healthy) Clinical Assessments

• Recognition and Removal

• Clinical Assessment & Management

• Return to Sport

• Persistent Symptoms

RecogniseRemoveRe-EvaluateRestRehabilitationReferRecoverReturn to sportReconsiderResidual effects & SequelaeRisk reduction

Berlin 2016Les 11 « R »

Sport concussion assessment tool - 5th edition. Br J Sports Med 2017;51:851-858

POLICY & EDUCATION

High Risk Olympic winter sports: Alpine Skiing, Freestyle Skiing, Ski Jumping, Snowboard, Speed Skating – Short and Long Track, Figure Skating, Ice Hockey, Bobsleigh, Skeleton, Luge

High Risk Olympic summer sports: Boxing, Wrestling, Football (Soccer), Rugby, Basketball, Cycling (track, road, BMX, mountain), Equestrian, Field Hockey, Gymnastics, Trampoline, Handball, Judo, Artistic Swimming, Taekwondo, Volleyball, Water Polo, Diving, Athletics – Pole Vault

High Risk Paralympic winter sports: Para-Alpine, Para-Snowboard, Sledge Hockey

High Risk Paralympic summer sports: Para-Cycling, Para-Equestrian, Judo, Sitting Volleyball, Soccer 7-A-Side, Wheelchair Basketball, Wheelchair Rugby, Goalball, Wheelchair Athletics

Why High-Performance guideline?

• Sport injury surveillance system

• Daily contact with athletes - need to know them

• Resource availability

• Therapist travelling by him/herself

• Performance focus• early identification • comprehensive understanding• prompt intervention

• Targeted-Individualized Rehab program (best possible, timely, individualized care)

• Neck strengthening program• Balance program• Vestibular-oculomotor rehab program• Vision rehab program

• Sport-specific rehab/return to sport• Supervised activation• Sport specific activities under supervision• Close monitoring of progression

Concussion Interdisciplinary Clinic

CIC - INS Québec

[8]

• Short Track Speed Skating accounted for the highest proportion of concussions of all INS sports from 2012-2018 (35%)

Epidemiology-Sport INS Québec (2012-2018)Matthew Kelly, PT MSc Biomechanics Candidate McGill UniversityTaylor Léger, MSc Biomechanics Candidate McGill UniversityDavid J. Pearsall Ph.D. Associate Professor Department of Kinesiology and Physical Education, McGill University

[9]

LENGTH OF CONCUSSION RECOVERY (seasons 2012-2018)Kelly M, Léger T, Pearsall DJ, Mc Gill University

Male and Female athletes appeared to have similar recovery times from concussion, though Males took on average 3 days less to recover

Male short track athletes recover in less time (57 days) than Female short track athletes (77 days)

[10]

• Medical

• Cervical

• Vestibular

• Neuro-optometry

• Sports vision

• Readiness to return to sport (SNA-VFC)

• Prevention / Research

Interdisciplinary evaluation

[11]

PMHConcussion history

• Symptoms: number, duration (> 10 days), severity

• Signs: PC> 1 min, amnesia

Temporal: frequency, interval, number concussion

Tolerance threshold: • concussion occurring with smaller impacts

• or progressively slower resolution of symptoms

Behavior: Dangerous playstyle

Equipment

PMH: facial trauma, maxilla, other head injury

PMH cervical trauma

PMH Migraine

PMH mental health

Sport concussion assessment tool - 5th edition. Br J Sports Med 2017;51:851-858

SCAT-5

Cervical Spine Function: ROM

13

I) Cervical Flexion-Rotation Test (Ogince 2006,

Schneider 2018)

IV) Palpation for Segmental Tenderness(Schneider 2013)

III) Manual Spine Examination (Schneider 2013)

II) Extension Rotation Test (Schneider 2013)

Positive test

<45 °,> 10 difference between the sides

or pain (scale 0-10 / 10)

Positive Test• Provocation cervical pain ≥3 / 10

Positive test• Pain ≥3 / 10

• Slight to marked resistance

Positive test

Pain ≥ 3/10

Cervical Spine Function: Strength

14

Timed test: / sec

Positive <20 sec

Negative> 40 sec

Objective: reach 30mmHg

1) Cervical Endurance Test (Olsen 2006, Schneider 2018) II) Cervical Extensor Endurance (Edmonston 2008)

III) Cervical Rotation Side-Flexion Test(Metcalfe 2006, Schneider 2018)

IV) Craniocervical Flexion Test (Jull 2008)

Average strength of 3 reps with 1 minute

rest between each repetition / pds

Vestibular system

• Vestibular system = one of the pillars of sensory integration and balance

• Frequent vestibular dysfunction after TBI• Central vs. peripheral

• Intrinsically linked to the visual system• Vestibulo-ocular reflex

• Often difficult to separate vestibular complaints from visual complaints• Multidisciplinarity

Review of Vestibular and Oculomotor Screening and Concussion Rehabilitation. Anthony P. Kontos, Jamie McAllister Deitrick, Michael W. Collins,

and Anne Mucha. Journal of Athletic Training 2017 52:3, 256-261

Visual / Vestibular Symptoms▪ Oculo-visual and / or vestibular involvement: 60-80%

▪ If not diagnosed: delayed recovery

Oculo-visual Vestibular

Blurred vision / eye fatigue x x

Dizziness x x

Nausea x x

Diplopia x

Difficulty following a moving object x

Difficulty reading / scanning x

Discomfort in a stimulus-laden environment,

i.e. shopping center, grocery store, school

environment

x x

Balance problem x

Nystagmoscope: (nystagmus, saccade)• Vestibulo-ocular reflex

• Head Shake

• Head thrust

Provocation tests• Dix-Halpike D / G

• Side tilt

• Maneuver specific to the horizontal channel

Vertical subjective visual• Vestibular and otoneurological function

Vestibulo-ocular assessmentFrance Lamoureux, Ostéopathe/physiothérapeute: franceosteophysio@gmail.com

[17]

Balance evaluation

[18]

BESS-errors• Hand leaving the iliac crest

• Hip displacement more than 30 °

• Forefoot or heel lift

• Eye opening

• Step, trip or fall

• Failure to maintain the assessment

position

• for more than 5 sec

1 point / error (max 10)

Duration: 20 sec / position

Oculovisual exam

Primary visual path

Standard optometric examination

Higher order visual path

Neuro-optometry examination

[19]

•Retina → visual cortex

•Rarely affected post CC•Susceptibility au DAI

(diffuse axonal injury)

• High energy-system

•Slowness and fatigue

of the visual system PC

Optometry laboratoryAnnabelle Charlebois, optométriste: anabelle.charlebois@umontreal.ca

[20]

Afferent visualpathways

• AV

• Pupilles

• Visual field

• Optic nerve

Oculomotor functions

• Ocularmotilities

• Fixation

• Pursuit

• Saccade

Eye alignment and fusion

• TE VL and VP

• Subjective alignment (Maddox)

• Concomitant Assessment (PRN)

• Fusion

• Stereoscopy

Vergence

• PRC

• Fusion reserves

• Flexibility

• (3BI/12BE)

Accommodation

• Amplitude

• VP test (convex acceptance and RNA / PRA)

• Flexibility

• MEM retinoscopy

Refraction and test lenses

• Do not neglect the small Rx

• Color test

Eye health

• PIO

• External examination and anterior segment

• Posterior segment with dilation

• OCT

Binocular vision

• Repeat certain measurements during the examination• Notice which tests are causing symptoms

Complete visual examination after concussion

Eye tracking results (RightEye)

Post

Concus-

sion

Within

norms

• Psycho-perceptuo-motorassessment

• Visual processing speed

• Peripheral attention

Sport vision

Kirschen & Laby, 2011

[23]

Sport visionThomas Romeas, tromeas@insquebec.org

Peripheral visual attention test Advanced visuomotor assessment

[24]

• Baseline testing:• Orthostatic test

• Post concussion:• Orthostatic test

• BCTT (Buffalo concussion treadmill test)

• Return to sport:• Heart rate variability monitoring

• temporal et spectral

Readiness to return to sport:ANS reactivity monitoringDavid Martin, kinésiologue: davidmartin303@gmail.com

[25]

Baseline Vs post concussion lyingdown position

Example: post concussion sympathetic dominance

lying down : standing:

[27]

HRV during BCTT while on treadmill

[28]

Last minutes of test: Return to calm-lying :

Variabilité du rythme cardiaque : une nouvelle approche pour améliorer le suivi post-commotionnel chez les athlètes de haut niveauChristian Soto candidat au Ph.D.David Martin, KinésiologueAlain Steve Comtois Ph.D. Professeur, Département des sciences de l'activité physique

[29]

NeuropsychologyJohnathan Deslauriers, neuropsychologue: jdeslauriers@cognisports.ca

Computerized neuropsychological test

• Selective and sustained attention

• Executive functions• Inhibition

• Flexibility & planning

• Working memory

• Long term memory

[30]

Vienna Test System NEURO

Évaluation des capacités cognitives d’athlètes de haut niveau en santé et suivant une commotion cérébraleMélissa Vona, candidate au doctorat en psychologie clinique – option neuropsychologie Thomas Romeas, INS Québec, Prof. associé Université de MontréalÉlaine De Guise, professeure agrégée, département de psychologie, Université de Montréal

Neuropsychological tests database - INS Quebec:• 350 top athletes (F & M), from more than 10 different sports

• >2800 tests/retest

• Post concussion evaluation

Goals:

1. What are the most important cognitive functions in athletes?

2. Which are the most susceptible to concussions?

3. Co-factors of interest: gender, expertise, history of concussion

[31]

• 48H: return to activity according to ANS data

• According to postconcussion evaluation• Cervical exercises

• Balance exercises

• Visual therapy

• Vestibular therapy

• NB: the priority of interventions will be based on the results of the postconcussion evaluation

• BE CAREFUL of the system OVERLOAD.

• After returning to baseline• Sport vision

• Neuropsychological re-evaluation-associated therapy

Interdisciplinary integrated rehabilitation

[32]

Le génie derrière

les performances

Prevention

Reducing Concussion Incidence in Short-track Speed Skating: Feasibility Study on the Impact of Improving Cervical & Sensorimotor ControlJulien Bernier BSc. pht, FCAMPT Master in rehabilitation science candidate at McGill Isabelle Gagnon PT, PhD, Associate Professor, School of Physical and Occupational Therapy, McGill University; Clinical scientist Montreal Children’s Hospital, McGill University Health Center

Group 1: Long sitting progressions Parameter

Week 1: CrV Flexion + reverse sit-ups (Metronome @ 40 BPM)

Week 2: CrV Flexion + reverse sit-ups + head rotation (M@ 40 BPM)

Week 4: CrV Flexion + reverse sit-ups + head rotation with TB resisted

(M@ 40 BPM)

Week 6: Week 5 progression with thoracic rotations added (M@ 40 BPM)

2 X 60 seconds

2 X 60 seconds

2 X 60 seconds

2 X 60 seconds

Groupe 2: Plank to Standing (Skating position)

Progressions

Week 1: Plank + CrV flexion and spinal axial extension (2X60”; 45”,15”;

2X30” or 4X15”)

Week 2 Plank + CrV flexion and spinal axial extension + rotation

(Metronome at 40 BPM)

Week 3: Week 2 position + alternate split squats + Neck extension

(M@40BPM)

Week 4: Week 2 position with Theraband resisted (M@40BPM)

Week 5: Week 3 progression with Theraband resisted (M@40BPM)

Total of 2 X 60 seconds

2 X 60 seconds

2 X 60 seconds

2 X 60 seconds

[34]

Short Track vs Hockey HelmetDaniel Aponte, Candidat Ph.D.McGill UniversityDavid J. Pearsall Ph.D. Associate Professor Department of Kinesiology and Physical Education, McGill University

SHORT TRACK& HOCKEY HELMET IMPACT COMPARISON: CAN STANDARDS IMPACT SAFETY?

Objectives:

1. Test ST and IH helmet models at different impact velocities and locations, measuring both linear and rotational forces;

2. Compare the peak resultant linear and rotational accelerations between ST and IH helmets, as well as calculated injury criteria

Conclusion This series of impact tests suggests that these IH helmets are better at attenuating both impact velocities at all locations

than the ST helmets. Interestingly, results were most differentiated in the low-velocity impacts

SHORT TRACK& HOCKEY HELMET: A COMPARISON OFF INITE ELEMENT HEAD MODELING OF IMPACTS

Objectives:

1. Maximum Principal Strain (MPS)

2. Cumulative Strain Damage Measure (CSDM)

Conclusion The primary finding of these simulations is that, when looking at CSDM15, and MPS99.9, ST helmets outperform IH

helmets in most impact conditions. The somewhat contrary results of the impact study and FEA study indicate that each helmet type

has features which are better at mitigating certain types of forces than the other

[35]

Fall and Head Impact Acceleration Monitoring of ST Speed SkatersAïda Valevicius postdoc McGill UniversityDavid J. Pearsall Ph.D. Associate Professor Department of Kinesiology and Physical Education, McGill University

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Methods

Prevent Biometrics head impact monitoring mouthguard (IMM)

Accelerometer based technology (3200 Hz sampling rate, 5% impact detection accuracy,

99% false positive filtering)

Impact metrics (linear acceleration, angular acceleration, location & direction, impact

count, collision workload)

Outcome measure(s)

Head impact metrics (from IMM)

Head impact outcomes (concussion/no concussion)

Athlete health and concussion history

Analytical plan

Investigate associations between head impact data, head impact outcomes, and athlete

health history

Background

Short track (ST) speed skating is a fast-paced, pack-style skating sport where crashes are commonplace

Head impact monitoring in ST athletes is essential to:

Better understand mechanism of head injury

Inform coaching practices and helmet design

• Perceptual-cognitive training strategies using virtual reality to enhance performance in elite boxers. Thomas Romeas, INS Québec, Prof. associé Université de Montréal

• Development of a 3D virtual reality boxing simulator using artificial intelligence for elite training Thomas Romeas, INS Québec, Prof. associé Université de MontréalDavid Labbé, Prof., École de technologie supérieureSheldon Andrews, Prof., École de technologie supérieureJocelyn Faubert, Prof., Université de MontréalHossein Feiz, candidat au PhD, École de technologie supérieure

Sport Vision

[37]

• Effect of "ecological" perceptual-cognitive training on theperformance of water polo goaltenders Thomas Romeas, INSQuebec, Associate Professor Université de Montréal;Véronique Richard, Mental Performance Consultant, INSQuebec

• Improving fatigue resistance of sport-specific decision-making in water polo: Gap #1: The effects of exercise intensity and cognitive task specificity on dual-task performance among elite female and male water polo playersNicolas Berryman, Prof., Université du Québec à Montréal, INS QuébecThomas Romeas, INS Québec, Prof. associé Université de MontréalLily Dong, candidate au doctorat, Université du Québec à Montréal

Sport Vision

[38]

Sport vision

• Bourse Bishop’s U 2020-2022 : Investigating the benefits of virtual reality on perceptual-cognitive processesMaxime Trempe, Prof., Université Bishop’sThomas Romeas, INS Québec, Prof. associé Université de Montréal

• La périodisation cognitive au Football : méthodologie d’entraînement basée sur l’entraînement des habiletés perceptivo-cognitivesThomas Romeas, INS Québec, Prof. associé Université de MontréalDavid Labbé, Prof., École de technologie supérieure Jocelyn Faubert, Prof., Université de MontréalBasil More-Chevalier, candidat au doctorat, Université de Montréal

[39]

Le génie derrière

les performances

MERCI!

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