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Hundreds of thousands of Canadians get concussions each year — many don’t recover
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After Michelle Tobin-Forgrave fell and hit her head more than five years ago, she developed a constellation of symptoms that began to derail her day-to-day life.
The Miramichi, N.B., resident knew she had a concussion — her second one — and expected to have a quick recovery, just like her first experience years earlier. But this round felt different.
Tobin-Forgrave went back to her job in the education sector after taking two months off work, then realized she needed to take hourly breaks from her computer. Sometimes she’d just lay on a yoga mat in her office, wracked by fatigue. The busy mother of two also started experiencing insomnia, couldn’t remember basic words like the names of household appliances, and developed issues with her vision and depth perception.
“The symptoms just never, ever went away,” she said, “and got worse — much worse — over time.”
The latest available data suggests hundreds of thousands of Canadians get concussions every year, and federal guidance last updated in 2021 suggests while recovery times can vary, most people get better in “10 days to 4 weeks.”
Yet a growing body of research indicates that many take much longer to recover than previously thought — or don’t ever fully recover at all.
Many with concussions don’t recover quickly, if at all
A study published in the journal Brain in February found that almost half of people with concussions still show symptoms of brain injury six months later, likely due to damage in an area of the brain called the thalamus, which relays information from the senses.
Researchers analyzed the brain scans of 108 patients in Europe who had recently had a concussion to look for structural changes in the brain, and found a marked increase in the activity between the thalamus and the rest of the brain shortly after a concussion.
“It’s almost like they were doing more work than those areas normally do. They were trying to communicate harder,” said Emmanuel Stamatakis, lead author of the study and head of the Cognition and Consciousness Imaging Group at the University of Cambridge in England.
“We found that the more hyper-connected those areas were, the more likely it is that you will have one of the symptoms that are associated with concussion — such as headaches, fatigue and sleep disturbances.”
The researchers used a less-common type of scan called a resting-state functional MRI — which isn’t widely available to patients — to analyze structural changes in the brain. Stamatakis said he hoped the findings would better inform patient care in the future and potentially lead to new concussion treatments.
“What I hope this study will achieve is to have clinicians think twice or three times before they send somebody with a concussion home and tell them: ‘You’re healthy,'” he said.
Dr. Charles Tator, an internationally renowned neurosurgeon and head of the Canadian Concussion Centre at Toronto Western Hospital’s Krembil Brain Institute, said the study points to the thalamus as an important area for concussion research for the first time.
“We’ve always known that it’s a more or less waystation — it’s the Union Station for pain,” he said, referring to Toronto’s bustling downtown transit hub. “But what this paper has identified is that in concussion it’s also an important structure and we didn’t really know that beforehand.”
Lingering concussion symptoms can be life-altering
The long-term impacts of brain injuries — from concussions among the general population, to reports of chronic traumatic encephalopathy (CTE) among professional athletes who’ve sustained repeated hits to the head — has been a growing field of study, and concern, in recent decades.
The latest European study’s sample size was fairly small, noted Toronto-based neurologist Dr. Matthew Burke, the medical director of the Traumatic Brain Injury program at Sunnybrook Hospital Health Science Centre, and the number of patients experiencing lasting symptoms was higher than most previous estimates, which range from around 15 to 30 per cent.
But he agreed the paper shows a “strong signal” that concussions can directly cause an array of cognitive and emotional issues that “might persist longer than we anticipate.”
Those lingering impacts may also be broader, and more life-altering, than the acute injury itself.
Research on sports-related brain injuries has found links to degenerative brain disease that can manifest in major personality changes, or even early-onset dementia.
A new peer-reviewed Columbia University study on former National Hockey League players even showed being an enforcer, a role known for violent fights involving knocks to the head, was associated with dying approximately 10 years earlier — and more frequently of suicide and drug overdose — than control groups of other players who avoided fighting.
Researchers at Columbia University in New York conducted a study comparing former NHL enforcers to their peers and found the enforcers were dying a decade earlier and were more likely to die from suicide or drug overdose.
Even children aren’t immune to potential ripple effects on the brain, other Canadian research recently suggests. A population-based retrospective cohort study led by the Ottawa-based CHEO Research Institute, published in 2022 by JAMA Network Open, found young people who sustain a concussion are at a 40 per cent higher risk of mental health issues, psychiatric hospitalization, and self-harm compared to those who sustain an orthopedic injury like a broken bone.
Ongoing research is still needed, Burke added, to understand what drives lasting symptoms, and what puts some people more at risk than others — a key piece of the puzzle so medical teams can ensure patients get long-term supports.
“How can someone have all of these symptoms after this somewhat trivial head injury? Well, in a vulnerable brain, that can absolutely happen,” Burke said.
“If they’re already predisposed or at risk for mental health conditions, or already experiencing things like anxiety, depression or chronic headache or chronic pain disorders, those are known risk factors for having longer recovery periods after a concussion.”
Over 400,000 Canadians have concussions each year
As scientists strive to understand the full mechanisms behind post-injury health issues, basic data on the true number of Canadians actually affected by concussions in the first place remains hard to find.
One 2020 study in the Journal of Head Trauma Rehabilitation analyzed Ontario medical billing records and found close to 150,000 per year from 2008 to 2016 — or 1.2 per cent of the population.
Keith Yeates, head of the psychology department and Ward Chair in pediatric brain injury at the University of Calgary, said the number is likely an underestimate because the study is based on physician visits and many concussions don’t result in medical attention.
“The ‘real’ number is undoubtedly higher,” he said. “But we don’t know how much higher because we lack some of the surveillance systems that are in place in the U.S.”
Even so, the estimate amounts to more than 400,000 Canadians with concussions across the country each year.
“Which is just phenomenal when you think about it,” said the Canadian Concussion Centre’s Tator. “And they all don’t get better.”
Multiple clinicians and advocates who spoke to CBC News stressed that frontline medical teams may still not be aware of those long-term risks, leaving many patients struggling to get ongoing treatment and support after their initial injury.
“Brain injuries are happening far more often than I think anybody realizes, and I think the long term consequences of brain injuries are far more severe than anybody realizes,” said Tim Fleiszer, a former professional Canadian football player who is now the executive director of Concussion Legacy Foundation Canada.
“And the system is just not caught up with that yet.”
Health Canada concussion guidelines out of date
Health Canada’s latest guidelines, which state that most people recover from a concussion within a month, also note that Canadians who get a concussion should talk to their doctor or health-care provider about when to return to work, school and sports.
But Tator said that guidance is woefully out of date and the percentage of people who recover within a month can range from as low as five per cent to as high as 35 per cent — with a generally agreed upon estimate of about 25 per cent with persistent symptoms.
“I’m surprised that it hasn’t been brought up to date,” he said of the Health Canada guidelines. “That doesn’t give it the credibility that it’s a significant problem at all.”
In a statement to CBC News, Health Canada and Public Health Agency of Canada (PHAC) spokesperson Mark Johnson said PHAC regularly tracks scientific findings on traumatic brain injury, including concussion.
“New recommendations on sport-related concussion evaluation and management are expected to be released by summer 2023, based on findings from the 6th International Consensus Conference on Concussion in Sport,” he said. “These recommendations will be taken into consideration when updating Canada’s guidance on concussion.”
Tator said current Health Canada guidelines also fail to address the fact that many family physicians aren’t up to date on the evolving research on concussion treatments and protocols and don’t know how to help their patients.
“And it plays out in the fact that when the patient goes to their family doctor they are often not directed appropriately,” he added.
Community-based resources are also lacking, particularly since patients often experience such a broad range of symptoms that don’t fit neatly into one form of treatment. “If you have a non-sports concussion, and it’s been longer than, say, 12 months… there really is just no resources out there,” Fleiszer said.
‘I couldn’t find my old self’
That’s an experience Tobin-Forgrave understands well. As the years passed following her concussion, she bounced between more than a dozen specialists. None knew how to handle her full spectrum of symptoms. Some didn’t know how to treat a concussion at all.
Certain treatments did help more than others, she said, such as specialized glasses to help mitigate a communication breakdown between her eyes and her injured brain, allowing her to walk around more safely.
But given her host of cognitive issues, Tobin-Forgrave — who is now 51-years-old — is no longer able to work, and has no clear roadmap to a full recovery. Until the medical system catches up with how to treat long-term concussion impacts, she’s had to come to peace with her challenging new reality. That process, like everything else now in her day-to-day life, hasn’t been easy.
“There was grief,” she said, “because I couldn’t find my old self.”
News
How 'severe and unusual' smoke from Canadian wildfires is spreading and what it means for your health – CBC.ca
Vast portions of eastern Canada and the United States are covered in smoke and haze, as wildfires continue to rage out of control in Quebec and other provinces.
The smoke has prompted air quality warnings in many cities and towns in Quebec, Ontario and beyond in Canada, and resulted in hazy, apocalyptic skies and warnings in places like New York City and Washington, D.C.
- Have a question or something to say? Email: ask@cbc.ca or join us live in the comments now.
CBC News spoke to experts and consulted recent studies to show the potential health impacts of the smoke in the air — and the extent to which it has spread across North America.
“The levels of air pollution that we’re seeing today are severe and unusual in Canada and in parts of the U.S.,” said Rebecca Saari, an air quality expert and associate professor in the department of civil and environmental engineering at the University of Waterloo.
“These are poor air quality days, especially in certain areas, where people should be aware and protecting themselves.”
She says such events are likely to be more common as climate change intensifies and prolongs the hot, dry conditions that wildfires need to thrive.
For June, the fire risk is considered well above average in almost every province and territory. In Newfoundland and Labrador, the risk is considered average. In P.E.I., the risk is low across the island.
Overall, people across Canada are facing an especially difficult wildfire season, and federal government officials have said their modelling shows increased wildfire risk in most of the country through August.
Roughly 130 forest fires are currently burning in Quebec, with just under 100 of them considered out of control.
A storm system off the eastern coast of Nova Scotia has pushed the smoke from those fires toward Ontario and to the U.S., with poor visibility as far south as North Carolina and into the Midwest.
It has also spread further east, and officials as far as Norway warned the smoke could affect air quality there on Thursday.
The air quality improved early Thursday in Ontario and Quebec, but was forecast to get worse in many parts of Ontario again later in the day and through the weekend.
How bad is the haze?
Different countries use different indexes to measure air quality.
While the Air Quality Health Index (AQHI) used in Canada reflects current knowledge of the health effects associated with air pollution and measures on a scale of 10, the Air Quality Index (AQI) used in the U.S. is based on air quality standards and is measured on a scale of 0 to 500. The higher the value, the greater the level of air pollution.
The Associated Press reported Wednesday that the AQI exceeded a staggering 400 at times in Syracuse, New York City and Pennsylvania’s Lehigh Valley. A level of 50 or under is considered good; anything over 300 is considered “hazardous.”
Meanwhile, the air quality in Toronto ranked among the worst in the world for much of Wednesday, near the level of Delhi, India, and Dhaka, Bangladesh, according to IQair, an online service that monitors and tracks air quality using the AQI.
The levels in Kingston and points further east in Ontario were considerably worse on both scales.
Those areas had among the highest levels of particulate matter — known as PM2.5 levels — in the country.
Those particles are so small — 30 times smaller than the diameter of a human hair — that they can go into the lungs and into the bloodstream, said Dr. Samir Gupta, a respirologist and an associate professor of medicine at the University of Toronto.
“So you can imagine the havoc that they wreak in the lungs themselves,” he said. “That’s the most sensitive organ to all of this in terms of breathing symptoms, particularly people who have underlying lung conditions like asthma.”
With wildfire smoke enveloping major parts of Ontario and Quebec, we look at some ways you can protect yourself — including masking up. Plus, a Q&A from viewers with respirologist Dr. Samir Gupta.
Air quality in terms of cigarettes
A recent Stanford University study quantified what breathing in that particulate matter would mean in terms of cigarettes.
According to the study, an AQI measurement of 20 is equivalent to smoking one cigarette a day.
The study noted that exposure to wildfire smoke causing an AQI of 150 for several days would be equivalent to smoking about seven cigarettes a day if someone were outside the whole time.
By that calculation, Kingston residents who spent eight hours outside Wednesday smoked the equivalent of nine cigarettes.
Most of Western Canada had a break from the smoky air after struggling with poor quality last month, though some regions, including Vancouver, were designated as “moderate risk.”
If an area has been designated as “very high risk,” Environment Canada advises the general population to reduce or reschedule strenuous outdoor activities.
It recommended that at-risk populations, such as young children, seniors and those with chronic conditions, to avoid strenuous activities altogether.
Many of the tips people picked up during the pandemic are useful now, said Scott Weichenthal, an associate professor in the department of epidemiology, biostatistics and occupational health at McGill University in Montreal.
“If you have to work outside, wear a mask, a proper mask that filters out the small particles, like an N95 mask,” he said.
“If you don’t need to be outside when it’s very polluted, don’t be.”
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Environment Canada has increased the air quality risk level for Toronto on Wednesday, up from Tuesday, as forest fire smoke continues to blanket the city.
A special air quality statement remained in place for the city on Wednesday night, saying high levels of pollution had developed due to the wildfires in Quebec and northeastern Ontario.
The federal weather agency predicts Toronto will reach a risk level of nine on the Air Quality Health Index (AQHI) on Thursday. The index measures air quality based on how it will impact health. That number indicates high risk during the day and means people may want to consider cancelling outdoor activities.
“There’s a ridge over Ontario right now, so it means these winds are consistently bringing in poor air quality,” said Trudy Kidd, an operational metrologist with Environment Canada.
On Tuesday, the city was at moderate risk and on a level five on the scale of one to ten.
Moderate risk levels mean the general population need not cancel “usual activities” unless you start to experience symptoms like throat or cough irritation. For at-risk populations at that risk level, people are urged to consider rescheduling outdoor activities if symptoms are present, according to Environment Canada.
Those with lung disease, such as asthma, people with heart disease, older people, children, pregnant people and those who work outside are at higher risk of experiencing health effects, the agency said.
Don’t light campfires, premier says
Premier Doug Ford commented on the wildfires and poor conditions on Wednesday during question period, urging the public refrain from lighting campfires.
Ford said half of the forest fires in Ontario were started by lightning strikes and the other half were caused by human activity, such as campfires not being properly extinguished.
Environment Canada issued an air quality alert for Toronto on Wednesday as the city faced smoky, hazy conditions from wildfires in Quebec and parts of Ontario.
When the index indicates a high level of risk, the general population should consider rescheduling or reducing outdoor activities if symptoms are experienced. At-risk populations should reschedule outdoor activities, according to Environment Canada.
“Stop those outdoor activities and contact a health-care provider, if you or someone in your care experiences shortness of breath or wheezing, asthma attacks, cough, dizziness or chest pains,” Kidd said.
“Poor air quality will persist into the weekend,” Environment Canada said. The agency’s most recent statement was firmer than Tuesday, as the agency previously said there were hopes the conditions would ease by the weekend. A low pressure system that could bring in cleaner air may arrive by Sunday, Kidd said.
“Wildfire smoke can be harmful to everyone’s health even at low concentrations. Continue to take actions to protect your health and reduce exposure to smoke,” Environment Canada said.
Air quality and visibility due to the wildfire smoke can fluctuate over short distances and can vary considerably from hour to hour. But wildfire smoke can be harmful even at low concentrations, it said.
Wear a mask if outside, Environment Canada suggests
If you must spend time outdoors, Environment Canada recommends wearing a well-fitted respirator type mask, such as an N95, to help reduce exposure to fine particles in smoke.
“These fine particles generally pose the greatest risk to health. However, respirators do not reduce exposure to the gases in wildfire smoke,” the federal weather agency said.
Air quality risks are ‘off the charts’ in Ottawa as smoke and haze cover large sections of central Canada. Toronto, Kingston, Ont., and Montreal are also feeling the effects as Environment Canada warns the air could be dangerous to human health for most of the week.
Environment Canada recommends the following:
- If you or someone in your care experiences shortness of breath, wheezing, severe cough, dizziness or chest pains, stop outdoor activities and contact your health care provider.
- If you are feeling unwell and experiencing symptoms, stay inside.
- Keep your indoor air clean.
- Keep your doors and windows closed if the temperature in your home is comfortable.
- Take a break from the smoke by temporarily relocating or finding a place in your community with clean, cool air such as a library, shopping mall or community centre.
- If you must spend time outdoors, a well-fitted respirator type mask that does not allow air to pass through small openings between the mask and your face can help reduce your exposure to fine particles in smoke.
- Be sure to check on people in your care and those who may be more susceptible to smoke.
- Evacuate if told to do so.
- Review your wildfire smoke plan and make sure you have enough medical supplies if the smoke continues to be an issue.
Toronto-area school board moves recess indoors
Due to the air quality warning for the Toronto area, one school board in the region has opted to move recess inside for safety, while others say they are monitoring the situation.
The York Catholic District School Board said in a statement on Tuesday evening that indoor recess would be held indoors all day on Wednesday due to poor air quality.
The Peel District School Board said Tuesday that “strenuous outdoor activities” scheduled for Wednesday and Thursday would be cancelled, including athletic events. While outdoor recess is allowed to continue, it encouraged students to “avoid strenuous activity” and stay inside if they chose.
The Toronto District School Board made the same changes and issued the same guidance as Peel. Further, it said “TDSB schools will also ensure that HEPA air filters are continuing to be used,” and it will monitor the situation. The Toronto Catholic District School Board left the choice up to schools, stating that it recommends indoor recess be considered along with possibly rescheduling activities.
The Dufferin Catholic District School Board said it will also keep an eye on the air quality on Wednesday and that it would be going ahead with field trips due to difficulties in rescheduling.
Schools aren’t the only thing in the city that’s affected — in an e-mail sent to CBC News, Toronto Blue Jays spokesperson Madeleine Davidson said that due to poor air quality, the dome is closed for Wednesday night’s baseball game.
On Wednesday night, the Toronto Zoo said it would limit its hours from 9:30 a.m. to 3 p.m. on Thursday due to poor air quality from the smoke and provide protective masks to staff and volunteers required to work outdoors.
The zoo said it would also limit access to the outdoors for some animals as well as limit the amount of time that staff and volunteers work outside.
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More than 400 wildfires are burning thousands of hectares of forest and land across Canada in an “unprecedented” start to wildfire season.
Ken McMullen, president of the Canadian Association of Fire Chiefs says, in his career, he’s never seen such an early and devastating start to the wildfires season marked by large fires in regions countrywide.
“We’re seeing fires like we’ve never seen before, at an earlier stage in the month of May than we’ve ever seen,” McMullen told CTV’s Your Morning on Wednesday.
Volunteers comprise the majority of Canada’s firefighting capacity, putting aside their day jobs when they are called. McMullen estimates, of the 126,000 firefighters countrywide, between 80,000 and 90,000 are volunteers.
“It’s unbelievable,” he said, suggesting most Canadians have no idea. “The volunteer system has been around for centuries, and it works most of the time. What it isn’t designed for is for the long, sustained, drawn-out events similar to what we’re seeing in the wildfires.”
Given the current needs, and the expectation they will not be reduced in the future, McMullen says there needs to be more incentive for people to become volunteer firefighters.
“Right now our volunteers get a tax incentive of up to $3,000,” he said. “I know we use the term volunteer, but the fact of the matter is there is some form of remuneration given to these volunteers in our communities and we’ve asked the government to increase that tax incentive from $3,000 to $10,000 annually.”
On June 8, 2022, six fires were burning out of control , among active wildfires covering 30, 575 hectares.
The latest data available, according to records from the National Wildland Fire Situation Report, as of May 31, 2023, 45 fires were uncontrolled and 2.7 million hectares of land had been burned.
Given the extreme season, McMullen says fire crews are “absolutely exhausted.”
“But they continue to do what they do every single day, which is to go out and give every effort that they possibly can to keep ourselves in our community safe,” he said.
McMullen says training for more firefighters, including Indigenous fire crews, would also help.
“Indigenous communities just have a very different understanding of fire,” he said. “They use it differently, they respect it differently, they’ve lived on the land for such a long time that they understand what the fire risk is in their city…They also protect their communities in a very different matter than us.”
To watch the full interview click the video at the top of this article.
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