Pan Am Clinic is taking a lead
role in the research, diagnosis and treatment of concussions
BY BOB ARMSTRONG
Winnipeg Health Region
Wave, September / October 2012
It's hard to keep a young athlete away from a
game she loves.
Just ask Sara Vis.
A couple of the years ago, Vis, then
in Grade 10, was playing in a hockey
tournament in Regina when she was
cross-checked into the boards. It was
a classic dirty hit, one that left the
Winnipeg teenager with a brief loss of
consciousness and a concussion.
"I don't remember anything from the
time of the hit until the ambulance ride,"
But she does remember the common
concussion symptoms that followed:
muddled memories of what happened,
nausea for the first few days, difficulty
reading or watching screens, and
"massive headaches" when she did an
activity that raised her pulse rate. In the
aftermath of the hit, she missed one week
of school and the symptoms lingered for
about three weeks.
Still, her love of hockey prompted her
to return to the ice just two months later at
a tournament in Brandon where she very
nearly suffered another concussion when
a collision with the boards gave her a
"My doctor was not happy with me
when I saw him and told him I went
back," she says.
That should not come as a surprise.
Recent studies suggest children with
concussions appear to be more susceptible
to second-impact syndrome, in which
even a minor second injury can lead to
serious results. And another study suggests
that girls are more at risk of serious
consequences from concussions, and may
take longer to recover.
Fortunately, Vis has had no lingering
effects from her head injuries. But her
experiences with concussions have taught
her that they are not to be taken lightly.
"I definitely wouldn't have been so quick
to go back to that tournament, but if you
really love something like I loved playing
hockey, you don't want to stop."
Vis, now 18, out of hockey and beginning studies at the University of
Manitoba, is sharing her experiences
with concussions as concern grows over
the potential impact of head injuries,
especially on young athletes.
Her story illustrates several of the
research, treatment and prevention
challenges facing both the health-care
sector and the sports community. Among
those challenges: better understanding of
what kind of impact causes a concussion,
developing a protocol for deciding
when an athlete can return to sport, and
educating players, coaches and parents
so that all concussions result in medical
Sara Vis has received treatment from the staff at the Pan Am Clinic for two concussions.
Dr. Wayne Hildahl, Chief Executive
Officer of the Winnipeg Health Region's
Pan Am Clinic, which specializes in
sports medicine, says the growing interest
in head injuries is a good thing.
A former football player with the
University of Manitoba Bisons in the
1970s, Hildahl says concussions were not
always taken seriously. As he explains,
players and coaches alike used to shrug
off "having your bell rung" as a part of
the game. "You'd go back in the next play
and have no idea what you were doing."
That started to change in the last
decade or so as it became clear that
concussions were a serious health issue,
and new research confirmed that head
injuries could have lingering effects.
Dr. Peter MacDonald, Head of
Orthopedics with Pan Am Clinic and
Leader of Orthopedics for the Winnipeg
Health Region, says the new research
underscores the fact that concussions are
not just a temporary injury and that there
is much more to learn about how they
affect the brain.
"With concussions," explains
MacDonald, "we're injuring the chemical
pathways of the brain. You're shaking
those neurons to the point that they're not
Compounding the problem is the
fact that the damage is taking place at
a microscopic level, making it virtually
impossible to say how long someone
might take to recover. "Nobody in the
world is able to say, 'You're going to be
out for two days and you're going to be
out for two months,'" MacDonald says.
In response to the growing concern
about head injuries, Hildahl says the
Pan Am Clinic is taking action to better
understand the causes and prevalence
of concussions and ensure that the
Winnipeg Health Region is following the
best practices for diagnosing and treating
"As the research gives us more answers,
I want to be able to evolve our treatment
protocols," he says. Indeed, Hildahl
would like to see Winnipeg become
a world leader in research, diagnosis
and treatment of concussions. To that
end, the Pan Am Clinic team is building
research collaborations across disciplines,
involving neurosurgeons, neurologists,
sports medicine physicians, primary care
physicians and athletic therapists. They're
also collaborating across the border with
a colleague from the Mayo Clinic in
Minnesota, Dr. Mike Stuart, who serves
as medical director of USA Hockey and
whose son, Mark Stuart, plays for the
One of the first steps in the effort to
learn more about concussions was taken
in July when the clinic sent surveys to more than 15,000 amateur hockey
players, parents and coaches to get
a better handle on the prevalence of
concussions and how they were being
treated within the health-care system.
With support from the Winnipeg Jets
Foundation, the Clinic surveyed 7,443
Manitoba hockey players aged 13 to 21,
6,627 hockey parents and 1,392 coaches.
So far, preliminary data from the first 700
responses shows 46 per cent of those
who responded to the survey suffered
concussions last season. Twenty-six per
cent went to an Emergency Department,
35 per cent sought treatment in their
doctor's office, while 23 per cent went to
a sports medicine clinic.
"What we've seen is it's definitely
higher than what's reported in the
(scientific) literature," says Dr. Jeff Leiter,
Albrechtsen Research Chair at the Pan
Am Clinic and Executive Director of the
Pan Am Clinic Foundation.
Previous research done elsewhere
between 2007 and 2011 turned up a wide
range of incidence rates for concussions,
from less than one concussion per 1,000
player-hours to more than 21 per 1,000
player-hours. The number of player-hours
refers to the number of players on the ice,
times the length of the game or practice.
One team generates six player-hours in a
one-hour game and 18 player-hours in a
one-hour practice. At the Midget level (15
to 17 years of age) alone, Manitoba has
110 teams generating a total of 89,000
player-hours in games and practices in a
Dr. Wayne Hildahl (centre) holds a scale, which is used in conjunction with the hockey helmets held by Drs. Peter MacDonald (left) and Jeff Leiter, to test the neck strength of young athletes.
Leiter cautions that the numbers aren't
complete enough to provide an estimate
of the concussion rate among players.
It's likely that players (or parents of
players) affected by concussions would
be much more likely to respond to a
survey than those who weren't injured.
But even so, the early response indicates
that concussions affect a large number
of young athletes - and the health-care
system needs to prepare for a growing
number of patients as awareness of
concussions increases. In fact, Hildahl
believes the health-care system will
experience a "tsunami" of new patients in
the years to come.
Leiter says data gathered through
the clinic's survey will help the Region
prepare for the surge in new patients.
"If we're going to set up a concussion
treatment program, how many people are
we going to expect to see?" asks Leiter,
who played university and minor league
hockey before getting his Master's in sport
biomechanics and PhD in anatomy.
Of course, the survey has other
goals beyond quantifying the problem.
The project also examines the level
of knowledge about concussions
among players and coaches and the
administrative systems in place regarding
return to play, such as team or league
policies regarding players receiving
medical approval before coming back.
Players were asked if they were
familiar with the ThinkFirst Smart Hockey
concussion education program, which
includes a video aimed at young players
about causes, symptoms, prevention and
follow-up after a concussion. Few players
knew about the program, says Leiter,
suggesting that more needs to be done to
educate young players.
The Pan Am research also looks
into the impact of concussions, asking
participants how long it took them to
return to play, if they missed school as a
result of their concussion and how much
school they missed.
While the majority of people with
concussions are back to normal in seven
to 10 days, says Leiter, some of the
respondents to the survey indicated that
they missed entire seasons of hockey.
That variation in recovery time is another
mystery to researchers. Why, they
want to know, do some people recover
more quickly? Are some people more
predisposed to concussion?
"About almost every aspect of
concussion we have lots to learn," says
Dr. Anthony Kaufman, a neurosurgeon
who practises at the Health Sciences
Centre and has worked with the
Part of the challenge for medical
science is that the damage in a concussion is at a microscopic level.
Then there's the complexity of the brain.
"The connections between neurons are
so complex," says Kaufman. "It's like the
spreading of roots of a tree.
"It's apparent that an injury in a
concussion is a reversible injury, so
it's not the destruction of nerve cells.
It may be that the connections can be
restructured," he says.
Knowing when a player like Vis can
return to sport - or to other activities - is
one of the big mysteries of concussions.
Pan Am staff members hope their research
will help them get a better handle on
both recovery times and predicting which
kinds of impacts are most likely to cause
Leiter also intends to launch a research
project to help better understand the
causes of concussion. He plans to place
cameras at the MTS Iceplex hockey
complex in order to record games. Then,
when there's a report of a player suffering
a concussion, he will be able to analyze
the hit that caused it.
Outside of professional hockey, where
television cameras capture every check
and collision, there's seldom any way
of examining the impact that led to a
concussion, notes Leiter. Equipping the
Iceplex with cameras will allow for hits to
be examined in detail.
Leiter also plans to use accelerometers
- instruments that measure acceleration
- attached to players' helmets in order
to obtain more data on the hits. Other
research with accelerometers has shown
that impacts involving 50 to 120 times
the force of gravity (G force) cause
concussions. "But some players hit with
100+ Gs don't get concussions, while
some do with 50 Gs," he says.
Blindside hits are particularly likely
to cause concussions, perhaps because
the person being hit is unable to brace
for impact. As well, hits involving
rotational movement seem more likely
to cause concussion than straight-on
hits. Part of that is basic physics. When
there's a rotating movement, shear forces
are created in the brain that may tear
connections in the brain loose. Data from
the accelerometers will help to clarify the
Of course, MacDonald, who also serves
as Medical Director with the Winnipeg
Jets, and before that for all 15 seasons of
the Manitoba Moose, has a pretty good
idea of at least one reason for the recent
rise in concussions, especially at the
professional level: bigger players colliding
at higher speeds. "Before, you might see
one or two concussions a year (with a
professional team)," he says. "Now you
see one or two a month."
And then there is the equipment,
especially what he calls "Robocop" style
shoulder and elbow pads that allow
players to check each other much harder.
"You look at the old Wayne Gretzky-style
shoulder pads and they were paper thin,"
he says. The new armour-style equipment
and the hard-hitting play it allows have
made their way into youth hockey as
In addition to understanding how to
better diagnose and treat concussions,
MacDonald believes research will
also lead to changes in the game at
the youth level, and may influence the
current debate on the age at which body
checking is allowed in hockey.
Part of the problem in youth hockey,
he says, is the large differential in size
and speed among children who are the
same age. As well, he says, growing
understanding may lead to new rules
for penalizing all contact to the head -
accidental as well as intentional.
While the discussion in Canada focuses
largely on hockey, concussions are a
concern in many other sports, including
football and soccer. In soccer, one of
the concerns is with deliberate impact
to the head when players head the ball.
MacDonald recalls spending three or four
days feeling not quite right as a youth
after a concussion in a flag football game.
Leiter plans to send the concussion
survey to football players, parents and
coaches following this year's season in
order to get a better idea of the problem
in that sport as well.
Bob Armstrong is a Winnipeg writer.
Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.
Read the September / October 2012 issue of Wave