Concussions in Ontario
Recent research has shed light on the risks associated with concussions. These injuries
are more common than previously thought, and improper management has been
linked to chronic brain disorders such as chronic traumatic encephalopathy (CTE). In
addition, the symptoms and proper recovery procedures are not widely recognized,
creating a gap between knowledge and practice. In Ontario, data examining the
prevalence of concussions has been limited. This report aims to use recent data to
provide a picture of concussion-related emergency room visits in Ontario, and identify
trends and conclusions that will assist health care practitioners working in injury
prevention and concussion management.
Definitions
Defining a concussion is not a simple task. As a
form of brain injury, concussions are the result
of a complex physiologic process.1 The world’s
leading researchers on the topic describe
concussions as brain injuries that result from a
transfer of energy to the body.1 Energy could be
transferred directly to the head, but this is not
always the case; any force hitting the body
causing a jarring motion could result in a
concussion.1 Symptoms usually appear shortly
after the incident occurs, but in some
individuals symptoms may not appear for 1 or 2
days. Furthermore, symptoms will present
differently in each individual, and while recovery
tends to be short term and sequential, some
cases will take longer. Lastly, unlike many brain
injuries that can be detected via neuroimaging,
concussions tend to involve functional
disturbances rather than visible structural
damage.1
Issue 1 Version 2
Spring 2013
Analysis and
discussion of injury
issues in the province
and demonstrates that ‘other unintentional’
were the main contributor to ER visits due to
concussions, accounting for 41% of all
concussion-related visits; the majority of these
injuries were classified as being ‘struck by or
against,’ which includes sports equipment,
falling objects or other people. The category of
falls was second to ‘other unintentional’
category, making up 38% of visits; the majority
of these injuries were classified as being ’other’.
Lastly, transport incidents made up 15% of
concussion ER visits in the unintentional
category. Motor vehicle crashes (MVTCs) were
the most common injury resulting in an ER visit,
with 7% of total incidents.
Ontario ERs for a concussion more often than
females. Specifically, concussion-related ER visits
in males tend to peak between the ages of 10
and 29. In terms of females, the data suggests a
slight increase in concussion related ER visits for
teens and young adults between the ages of 10
and 29. Lastly, relatively few ER visits for
concussions occur among the oldest adults
included in the analysis; this is an interesting
trend considering that falls account for the
majority of concussion ER visits (see Table 1)
and falls are prevalent among older adults.2
These observations differ from Canadian
concussion-related hospitalizations, which tend
to show an increase among older females.3
Age & Gender
Considering age differences in causes of
concussion injuries, as can be observed in Table 2,
more than 50% of ER visits classified in the struck
by/against category occurred among Ontario youth
Figure 1 illustrates trends related to age and
gender. It is apparent that males tend to visit
External Cause of Concussion
An analysis of the National Ambulatory Care
Reporting System (NACRS) database revealed
14,406 concussion-related injuries that were
treated in an Ontario emergency room (ER) in
the 2009-2010 fiscal year. Table 1 presents the
external causes of concussion related ER visits,
FIGURE 1. Treatment in Emergency Department for
concussions, by age and sex, NACRS 2009/10, all
ages, Ontario
Injury Counts Females
80+ yrs
65-79 yrs
50-64 yrs
40-49 yrs
30-39 yrs
20-29 yrs
15-19 yr
10-14 yr
5-9 yr
1-4 yr
< 1 yr
2,000 1,500 1,000 500
COMP SS
TABLE 1. Emergency Department visits associated with concussions, NACRS 2009/10, all ages, Ontario
Etiology
Injury Counts Males
Ontario Injury
0
500 1000 1500 2000
Unintentional Injuries
Transport
Transport - Pedestrian
Transport - Pedal cyclist
Transport - MVTC
Transport - ATV, snowmobile
Transport - Animal rider
Transport -Other
Falls
Falls - on same level
Falls - Stairs/ladders
Falls - Furniture
Falls - Skis/skates
Falls - other
Other Unintentional
Struck by/against
Bitten by animal
Other/Unspecified
Violence
Undetermined / Other / Missing
Complications / Sequelae
Total
Count
Percentage (%)
13493
2119
100
493
972
228
158
168
5507
1561
673
292
928
2053
5867
5388
57
422
884
17
12
14406
94%
15%
1%
3%
7%
2%
1%
1%
38%
11%
5%
2%
6%
14%
41%
37%
0%
3%
6%
0%
0%
100%
(10-19 years). Further, nearly 45% of transport
incidents causing concussion-related ER visits
occurred among those 15 to 29 years of age. In the
older adults, falls were the most common cause of
ER visits, accounting for 10% of all fall-related
concussion injuries presenting to an Ontario ER.
Discussion
Overall, injuries classified in the ‘struck by or
against’ category (which includes sports
equipment, falling objects or people), falls, and
transport incidents were the top contributors to
concussion-related ER visits in Ontario.
Although direct comparisons cannot be made
between Ontario and Canadian data, it is
important to note that observations have
revealed that transport related injuries may
account for a greater percentage of concussions
requiring hospitalizations (34% of
hospitalizations). 3 This demonstrates that
specific injury groups may differentially relate to
the severity levels of concussions, operating
under the assumption that concussions
requiring hospitalizations are more severe than
those treated in an ER only.
In terms of age differences, these data have
demonstrated that concussions resulting from
being struck by or against an object/person,
which includes sports equipment, may be of
particular concern for our Ontario youth,
especially those between the ages of 10 to 19.
Fall-related ER concussions in Ontario tend to
peak in adults between the ages of 50 and 64. An
interesting note here is that a great deal of fall
prevention research tends to focus on older
adults;2 this report suggests that there may be a
gap in prevention research for falls in middleaged adults. When looking at concussions caused
by transport incidents, these data show that
more than half of ER visits due to a concussion
sustained in a transport incident are experienced
by youth and young adults, aged 15 to 19. This
supports the notion that young drivers face an
increased risk of injury on our roads.4,5
There are a number of resources that describe
evidence-informed prevention strategies for these
top causes of concussion ER visits, such as:
• Consensus Statement on Concussion in
Sport1
• Pocket Concussion Recognition Tool6
• Concussion Clinical Toolkit7
• Ontario Regional Injury Data
Report2
TABLE 2. Concussion related Emergency Department visits, by age group and major external cause
grouping, NACRS 2009/10, by age group, Ontario
Age group
(years)
Transport
Falls
<1
*
36
1-4
13
5-9
86
10-14
Struck by/ Other Uninagainst
tentional
Violence
Other
*
*
*
*
461
69
13
*
*
537
385
14
8
*
224
831
1381
56
53
*
15-19
467
754
1613
100
261
5
20-29
467
645
791
98
323
8
30-39
276
438
468
65
123
8
40-49
294
559
361
55
71
*
50-64
226
673
251
51
42
*
65-79
53
388
57
19
*
*
80+
13
185
10
7
*
*
2119
5507
5388
479
884
29
14406
TOTALS
*Suppressed due to small number of cases or value of zero.
sports equipment, our report suggests a
potential link between these activities and
concussions in males, but more research is
needed to determine the role of gender.1
Overall, concussions are a widespread injury
issue within Ontario, with varying causes that
may extend beyond the commonly perceived
top issue of sports and recreation. This report
demonstrates the need for further research into
concussion related incidents within all of the
major injury categories, particularly falls,
transport and injuries where one is struck by or
against an object. With a more in-depth
understanding of the injury trends around
concussions, practitioners may become better
situated to prevent, educate and treat these
serious brain injuries.
Methodology
Emergency room data were obtained from the
National Ambulatory Care Reporting System (NACRS)
at the Canadian Institute for Health Information
(CIHI) for the 2009/10 fiscal year and were provided
by the Public Health Agency of Canada. ICD-10
codes S00-S09 were originally analyzed, with any
cases therein where concussions were present,
either as most responsible diagnosis (MRD) or in
addition to the MRD, being presented as
concussion injuries within this report.
TOTAL
Thank you to the Public Health Agency of Canada
for providing the data utilized within this report.
References
1
McCrory, P., Meeuwisse, W.H., Aubry, M. et al.(2013).
Consensus statement on concussion in sport: the
4th international conference on concussion in sport
held in Zurich, November 2012. British Journal of
Sports Medicine, 47, 250-258.
2
Ontario Injury Prevention Resource Centre (2013).
Ontario Regional Injury Data Report. Parachute:
Toronto, ON.
3
Morrish, J. & Carey, S. (2013). Concussions in
Canada, Canada Injury Compass, Spring 2013.
Parachute: Toronto, ON.
4
Groger, J.A. (2006). Youthfulness, inexperience and
sleep loss: the problems young drivers face and
those they pose for us. Injury Prevention, 12, i19-i24.
5
Harre, J., Brandt, T., & Dawe, M. (2000). The
development of risky driving in adolescence. Journal
of Safety Research, 31(4), 185-194.
6
Pocket Concussion Recognition Tool. http://
bjsm.bmj.com/content/47/5/267.full.pdf
7
Concussion Clinical Toolkit. Retrieved May 7, 2013,
from http://www.cattonline.com/
8
Scott,V. (2012). Fall Prevention Programming:
Designing, Implementing and Evaluating Fall
Prevention Programs for Older Adults.Raleigh, North
Carolina: Lulu Publishing
Acknowledgements
The Ontario Injury Prevention Resource Centre
(OIPRC), operated by Parachute, is a resource
centre of Public Health Ontario in the Health
Promotion, Chronic Disease and Injury Prevention
Department.
Suggested citation: Carey, S. & Morrish, J. (2013).
Concussions in Ontario. Ontario Injury Compass,
Spring 2013. Parachute: Toronto, ON
• Canadian Fall Prevention Curriculum8
Looking at gender differences, these data show
that males visit Ontario ERs for concussions
more often than females and given the increase
in ER visits, young males between the ages of
15 and 29 appear to experience unique risks.
Taken together with the information on struck
by or against concussion visits, which includes
Produced by the
Ontario Injury Prevention Resource Centre
Operated by Parachute
36 Eglinton Ave. W., Suite 704
Toronto, ON M4R 1A1
P: 647-776-5100 TF: 1-888-537-7777
[email protected]
www.oninjuryresources.ca
www.parachutecanada.org