Health
Canadian researcher helps define new standards for diagnosing concussions
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Meg Kerekes had two concussions while playing amateur hockey as a high school student.HO/The Canadian Press
Remembering what happened after she hit her head on the ice while playing hockey is tough for Meg Kerekes, but she knows how that particular headache felt – “like a one-pound weight on the spot that got hit.”
“I forget if they took me out or if I finished the rest of the game. I think I might have finished the game,” she said of thesuspected concussion in September 2018 when she was playing amateur hockey during her high school years in Vancouver.
Her coach, who doubled as the person in charge of safety, suggested she stop playing and mentioned she may have a concussion.
“I didn’t go to a doctor or anything. They just didn’t let me play for two weeks,” said Kerekes, who suffered another hit to the head five months later when an opposing player slammed into her.
Her mother took her to hospital after the second incident on the coach’s orders, where a suspected concussion was confirmed and Kerekes was out of school for 10 days. She returned to “light” hockey practice, but no games, three weeks later.
Coaches and other volunteers in amateur sports need to be more aware of concussion risks, said Kerekes, who still gets a slight headache sometimes from just shaking her head while listening to music.
Recognizing and properly diagnosing concussions has also been an issue in clinical settings. A Canadian researcher hopes that will change with a new diagnostic standard he helped develop.
Noah Silverberg, associate psychology professor at the University of British Columbia, co-led an international panel’s efforts to replace “wildly inconsistent” definitions of concussion. The North American, European and Australian experts included clinician scientists such as emergency room doctors, neurosurgeons, pediatricians and those specializing in rehabilitation and sports medicine.
Silverberg’s paper outlining the new standardized criteria, co-authored by neuropsychologist Grant Iverson of the Harvard University-affiliated Spaulding Rehabilitation Hospital on behalf of the American Congress of Rehabilitation Medicine (ACRM), was published last week in Archives of Physical Medicine and Rehabilitation.
Silverberg said concussion has historically been minimized as a minor injury that does not need medical attention and is believed to get better on its own.
That often means people don’t seek medical treatment immediately, or at all, so a potential mild traumatic brain injury goes undetected, said Silverberg, who focuses on concussion recovery and treatment.
However, a concussion may not get diagnosed in an emergency room, where the focus is typically on ruling out catastrophic injuries rather than diagnosing a condition that could involve persistent symptoms and disability, he said.
There is also a long-standing concern about family doctors missing the signs and symptoms of a concussion because of little training in a field that has advanced quickly over the last few decades. There are inconsistencies in how the condition is diagnosed in specialty concussion clinics as well, Silverberg said.
A definition of mild traumatic brain injury published by the ACRM in 1993 is outdated, he said, and whether a patient is diagnosed with the condition depends on the particular criteria being used.
He said diagnosing concussions is tricky because symptoms can overlap with other conditions so health-care providers should determine how someone was injured, for example by being hit on the head while participating in a sport or in a crash.
Two or more symptoms, such as a headache and dizziness, would meet the criteria for diagnosing concussion but clinicians should also rely more heavily on observational signs such as a patient responding slowly to questions, being off balance or not knowing where they are, Silverberg said.
A clinical exam that tests for balance, memory, concentration and vision is also part of the new criteria, he said, adding a brain scan could also be ordered but does not always show signs of injury.
He pointed to a 2008 study in Australia that applied multiple sets of criteria for 12,000 children aged three to 16 and found the proportion of those diagnosed with a mild concussion ranged from seven per cent to 99 per cent. Silverberg saidsuch a wide range means there’s a huge barrier to harmonizing findings from studies that compare “apples and oranges.”
“I think there has been widespread discontent with the existing criteria among health-care providers of all kinds. Different settings all stand to benefit from getting on board with this unified, evidence-based, consensus-based criteria.”
The new criteria also emphasize the need for awareness about intimate partner violence.
“Being assaulted by your partner is an alarmingly common way to get hurt,” Silverberg said. “These are predominately women victims and predominantly not having a single injury but multiple injuries with repeated assaults over months to years. And they’ve been left out of the conversation around the brain injury research until pretty recently.”
Stacey Ashton, manager of shelter services and affordable housing at YW Calgary, said the facility that offers shelter space to women for 21 days recently started screening for mild traumatic brain injuries that could have occurred because of domestic violence.
“The big piece, too, is going to be around building awareness for women who are experiencing violence, that they could have a potential brain injury. I think that correlation is poorly understood by a lot of people,” Ashton said.
New criteria or clinical guidelines typically take several years to be universally adopted as awareness increases but that could happen more quickly in some cases if insurance companies require a verified diagnosis according to the latest definition of a condition before paying for a specific treatment, Silverberg said.
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A new report from the Heart and Stroke Foundation shows that women are more likely to suffer adverse mental health effects after a stroke, and that services and supports are lacking.
The report, Stroke and Mental Health: The Invisible and Inequitable Effects on Women, was released on Thursday.
Dr. Clair Barefoot, clinical psychologist at the Nova Scotia Rehabilitation Centre, says recovering from a stroke can take a big toll on people.
That, coupled with the additional roles women often take on—such as caring for children, can cause additional strain and force them to leave rehab early.
Barefoot says supports and services are generally lacking across Canada.
She says it is quite difficult and expensive for people to find personalized care, so she would like to see more psychologists in hospitals and more funding for the private sector so that people can access more of those services after they’re discharged.
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Cancer test maker Grail Inc said on Friday that its telemedicine vendor erroneously sent letters to about 400 patients suggesting they may have developed cancer.
Grail’s flagship cancer detection blood test Galleri is designed to detect more than 50 types of cancer before symptoms appear.
The company, owned by Illumina Inc, ILMN-Q said the letters were mistakenly sent by PWNHealth due to a software issue and that it “was in no way related to or caused by an incorrect Galleri test result”.
Grail said it had reached out to the patients immediately after the issue, adding that no patient health information has been disclosed or breached due to this.
The software issue being faced by PWNHealth has now been resolved, it said.
Illumina is currently appealing regulatory orders in the U.S. and EU, which are asking the gene sequencing company to divest Grail after it jumped regulators to close its acquisition of the cancer test maker.
Unprotected sex with more than one partner in a six month period is the biggest risk factor behind a recent rise in syphilis cases in Waterloo region, according to a report on infectious disease trends from Region of Waterloo Public Health.
The annual infectious diseases surveillance report gathers and analyzes information on the infectious diseases that physicians, laboratories and hospitals are required to report to the region’s public health unit in line with Ontario Public Health Standards.
Infectious diseases are illnesses caused by microorganisms such as bacteria, viruses, and parasites that have the potential to cause serious illness and outbreaks.
There were 116 reports of infectious syphilis in the region last year, a rate of 17.8 per 100,000 population compared to 23.1 across the province. The number is down from a high of 143 reported cases in 2021, and a rate of 22.2 per 100,000 that was higher than the provincial average of 20.6.
The report says rates of syphilis, while lower than the province, have increased substantially in recent years, especially among females. This trend has also been observed in the province, which suggests a shift in epidemiology and sexual health practices.
The most common sexually transmitted infections in Waterloo Region continue to be chlamydia and gonorrhea.
There were 1,388 cases of chlamydia reported across the region last year, a rate of 192.8 per 100,000 population compared to 255.9 provincially. That’s down slightly from the age-standardized rate of 196.9 per 100,000 reported in 2021.
Gonorrhea case counts continued to spike across the province in 2022, while experiencing a slight decline in the rate of infection in Waterloo region.
Waterloo region reported 266 cases last year, a rate of 38.2 per 100,000. That’s compared to 77.5 per 100,000 province-wide.
Across the board, the demographic with the highest number of cases of sexually transmitted infections locally and across the province is the 20 to 29 age group.
Mpox, previously known as monkeypox, was declared a disease of global public health concern and became a newly reportable disease in Ontario in 2022.
There were only four local cases of mpox last year. Public Health says it has been monitoring the situation, working with health care providers to provide up-todate treatment guidance, and providing mpox vaccines to high-risk individuals.
The mpox virus is most commonly spread to people through close, physical contact with an infected person.
Campylobacter enteritis and salmonellosis were the most common enteric diseases in Waterloo Region in 2022. The local rates for enteric diseases were similar to or lower than those of the province.
Risk factors for enteric illnesses such as Campylobacter enteritis and salmonellosis include consuming undercooked meats and unpasteurized dairy products, ingesting contaminated food or water, and contact with infected persons.
Rates of vaccine preventable diseases in Waterloo Region were similar to those of the province. The most common vaccine preventable diseases in Waterloo Region were pneumococcal disease and pertussis (whooping cough).
In 2022, as we returned to normal activities, we saw a return of circulating respiratory viruses including pertussis with rates higher than had been seen during the first two years of the pandemic.
Public Health says immunization is the best way to prevent whooping cough. Pneumococcal vaccine is also recommended for infants, older adults 65 years and older, and those at high risk from the infection.
Region of Waterloo Public Health undertakes a number of activities to prevent or reduce the burden of infectious diseases in the community.
Programs and services include case management, contacts and exposures for diseases of public health significance; inspections, investigations and outbreak management, including community outbreaks and those in institutions; health promotion activities and services for primary care providers, emergency service workers, childcare providers, and other community groups; and clinic-based services for sexual health, immunization, and tuberculosis screening and management.
Region of Waterloo Public Health says it will provide highlights of respiratory disease trends, including influenza, in a report to council this fall.
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