Brian Bleich, President of the Pelham Panthers Basketball Association, has a unique and personal knowledge of youth concussion.
“I’ve only dealt with five concussions this year out of all the players we have,” he says, “my son right now being one of them. So I’m going through it as a father too.”
Bleich continues talking about his son, a Grade 9 student playing basketball in a Pelham tournament at the MCC.
“He went up, came down on the floor. A player came down on top of him, knocking his head to the hardwood. It was observed, [he was] taken off, signs of a possible concussion, stayed out, and then I followed the protocols, the 48 hours no light, no screens, dark room at home.”
At that point, Bleich took his son to a local physiotherapy practice, where he was diagnosed with a concussion.
Bleich’s son missed four weeks of school, until February 1, as a result of the concussion, and did not return to play with his school’s team. He is fully recovered now, and began skills practice with the Pelham Panthers August 1.
Observing concussion protocol is the most important factor in successfully dealing with youth concussion. Bleich’s experience and knowledge as a coach, player and PPBA administrator equipped him to provide an appropriate response to his son’s injury.
Rowan’s Law, Ontario legislation being phased in between July 1, 2019 and July 1, 2020, has been enacted to guide all parents of athletes under 18 years of age, athletes themselves, coaches, team trainers and officials in following concussion Codes of Conduct and enhancing their concussion awareness. Sports organizations, municipalities, and educational institutions are also mandated to follow Rowan’s Law protocols when dealing with youth concussion.
It is hoped that Rowan’s Law will be the first step in a cultural change surrounding youth concussion in Ontario. The legislation is named in memory of Ottawa student Rowan Stringer, who passed away from Second Concussion Syndrome after sustaining multiple concussions while playing for her high school rugby team.
On September 25, it was announced that Ontario, the first province to tackle youth concussion with legislation, will lead a discussion on the development of a National Concussion Awareness Strategy at an upcoming meeting of Provincial and Federal Ministers Responsible for Sport.
In a statement, Lisa MacLeod, Minister of Heritage, Sport, Tourism and Culture Industries for Ontario said, "We have made real, impactful progress towards improving the safety of athletes and addressing the culture of amateur sports in this province...It is now time to take this approach across Canada."
As the parent of an active child or teenager, or a young athlete in Pelham, you need to review and understand the Concussion Awareness Resources provided by Rowan’s Law legislation. You will want to know how compliant the Town of Pelham and our local Sports Organizations are, and what concussion-related questions you should ask while enrolling yourself or your children in community sports and camps.
The information presented below is based on interviews with representatives from the Town of Pelham, Pelham Panthers Basketball Association, Niagara Centre Skating Club, Pelham Minor Hockey Association, E. L. Crossley Secondary School, a local physiotherapy practice, plus original research. Details of where to access Rowan’s Law information are included at the end of the article.
First off, what is a concussion, and why are they so dangerous to youth?
Concussion is defined as a form of mild traumatic brain injury (TBI), usually happening because of a hit to the head, neck, face or another part of the body, causing the brain to move inside the skull and become injured. The short and long-term consequences of concussion and other TBI can be severe, especially for children and youth. Although concussion signs and symptoms usually resolve within 10 days to four weeks, children and youth often take longer to recover than adults.
That definition is from the 2018 Public Health Agency of Canada study, “Baseline Survey on Understanding and Awareness of Sport-Related Concussions.”
Amongst concussion experts, many would argue that the term “mild” should be removed from the definition above, especially when discussing multiple concussions.
The same study provided the following data, based on public opinion research with parents, coaches, athletes, school staff and health professionals: Fifty percent of Canadians have little or no knowledge about concussion; 25 percent don’t know how concussion is treated; only 15 percent can correctly identify the best ways to treat concussion; and just 40 percent are aware of available concussion tools or resources.
To gain an anecdotal sense of how these findings related to Pelham, I spoke with Patrick Maddalena, certified in Concussion Management, and Mark Georgiev, Concussion Management Practitioner, both practicing in Fonthill.
Maddalena and Georgiev responded that their experience suggests only 12 – 15 percent of Pelham parents know how concussion is treated, which is about half the number suggested by the Public Health Agency survey.
While the study claims 40 percent of those polled are aware of available concussion tools or resources, Maddalena opinion differs.
“No way, I’d say 20 percent.”
Georgiev adds, “It’s starting to get there, but it’s not that high. I bet less than one in ten [concussions] are reported.”
When asked “reported to who?” he included coach, trainer, parent, first responders, health care practitioners, anyone involved.
Their comments are supported by a follow-up Public Health Agency of Canada study, “Understanding and Awareness of Sport-Related Concussions, With a Focus on Youth (May 23, 2019).” The age group studied was 5 – 19 year olds, our kids at their most vulnerable age.
The research concluded that Canadian youth know very little about where to obtain concussion information or who is responsible for identifying a concussion and how to treat it; 80 percent have little or no knowledge of concussion; 70 percent incorrectly believe wearing a helmet will prevent a concussion; 70 percent identify that a concussion is a hit to the head that causes headache or blurry sight.
These are not encouraging numbers, but they are improving. Georgiev says parental responses to concussion have changed over the last decade, and that parents are paying more attention to concussion. He also noted that parents are pulling their kids from certain sports because they’re afraid of concussion.
How is Rowan’s Law improving this situation, and what are the benefits to youth?
Rowan’s Law ensures that resources on concussion awareness are easily accessible to parents, youth, coaches, anyone, and mandates compliance with specific policies and procedures to make children safer. The implementation of Rowan’s Law has been incremental within the following timeline.
As of July 1, 2019, organizations were required to have a Code of Conduct and Concussion Awareness Resources policy.
Under the Concussion Awareness Resources section of the law, a sport organization (which includes municipalities and schools) “must not register athletes under 26 years of age into a sport activity unless they, as well as their parent (for athletes under 18), provide confirmation that they have reviewed one of the Concussion Awareness Resources within the previous 12 months. Sport organizations must also not allow coaches, team trainers and officials to serve ... unless they provide confirmation that they have reviewed one of the Concussion Awareness Resources every year.”
The Code of Conduct template carries the same annual requirement, and the material is available to anyone via e-booklet, video, and e-module.
As of January 31, 2020, “All school boards are required to establish: Concussion Codes of Conduct for individuals participating in board-sponsored inter-school sports; a process for removing students with suspected concussion from physical activity and, for those diagnosed with a concussion, a Return-to-School Plan, which includes their return to learning and to physical activity; and a process to document and track a student’s progress.”
As of July 1, 2020, “Removal from Sport/Return to Sport Protocols” came into effect for all sport organizations, including municipalities and schools.
A significant improvement under Rowan’s Law is in concussion reporting, so that a better understanding of the magnitude of the problem is understood. Consider the following numbers, pre-Rowan’s Law.
The Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) which includes just 11 pediatric and eight general hospitals in various-sized Canadian communities, reported that in 2016-2017, before Rowan’s Law, 46,000 children aged 5 to 19 visited one of the 19 hospitals with a concussion: 26,000 boys and 20,000 girls.
Canada has approximately 1,400 hospitals, and the 46,000 number represents the reporting of just 19. Hypothetically, apply Georgiev’s assertion that only 10 percent of concussions are reported. The number of youth concussions becomes enormous.
Which sports and activities are most likely to cause concussion? Nationally, based on CHIRPP data, the sports with the highest incidence of concussion proportional to participation are, in order: For females 10 – 19 years old, ringette, ice hockey, and rugby. For males 10 – 14, hockey, rugby and lacrosse. For males 15-19, rugby, hockey and boxing/martial arts.
Georgiev says his local experience indicates more girls than boys are concussed. Basketball, volleyball, cheerleading, and figure skating are the top four. Maddalena adds this is in part because participants don’t wear helmets.
For adolescent males in Pelham, hockey is the major source of concussion, but Georgiev postulates this may be because concussion in hockey is watched and reported more. Second is football, soccer is third.
Rowan’s Law demands that young athletes view, and hopefully understand, 45 minutes of information about concussion-related dangers, symptoms, and protocols. To assist this effort, on September 30, 2020, the Ontario government announced a $200,000 grant through Concussion Legacy Foundation Canada towards producing a documentary film showcasing Rowan Stringer's life and highlighting the importance of recognizing the signs of a concussion in young athletes.
For cultural change to occur, young athletes themselves must take some responsibility for their brain health, something that doesn’t always happen.
“It comes down to the actual athlete,” Georgiev says. “Is [he or she] going back to the bench and tell the coach they’re fine when they’re not? Are they going to be true to themselves and say ‘I have dizziness, I don’t feel good?’ Sometimes they’ll mask that, especially at the higher levels, so they don’t lose their spot [on the team].”
The pressures young athletes face can be enormous, as can be the support. In general, parents don’t want to harm their kids, and will act in the child’s best interests. However, the traditional stereotypes live on.
“There’s a battle going on between the medical professional and the parent and the kid all the time,” says Georgiev. “I have this kid who has a severe concussion, and he came to me. Now the trainer has been calling me, pressuring this kid to get back [to playing]. The trainer says if he’s off more than a week, he’ll have to go on the injured reserve list, and then we’ll cut him. This player’s now reporting to me that he’s no longer got symptoms. I’m reading between the lines, so I put him in the blackout goggles, and there’s still vestibular symptoms, I see them there, so I know he’s not good. [The trainer] is still calling me.”
Does concussion in youth cause depression? Lead to suicide?
Maddalena and Georgiev don’t see a direct physiological link, a conclusion shared by most studies. However, they become passionate when discussing the role that family life and coaches play in mental recovery from concussion by youth.
“It’s the outside factors,” says Georgiev. “They’re not able to do what they’re used to. Initially they were stuck in a dark room for 24 hours, no phone, no TV, no nothing, no stimulation... this is changing now... it’s like prison, it’s depressing. Their life isn’t the same. An athlete wants to get back and if they’re told they can’t go back for two to three weeks, the mind starts to change, they get depressed. They’re told they can’t do this, they can’t do that, it becomes a depressive/anxious cycle —when am I going to be ready.”
He continues, “Pressure from parents, pressure from coaches, if you’re [the concussed youth] not having proper executive functions because you’ve had multiple concussions, that pressure, instead of you being able to regulate it, turns into ‘What do I do with myself, I don’t know what to do’, and eventual suicidal thoughts.”
Youth concussion is a serious medical and social issue. With the final implementation of Rowan’s Law completed just four months ago, amid all the concerns of COVID-19, how prepared are a sample of Pelham sports organizations, E. L. Crossley, and the Town of Pelham?
The drop-down menu on the Pelham Minor Hockey Association’s website includes, “Panther Parents,” and when one clicks on it, “Concussion Awareness” comes up immediately. The first offering found there is a link to Rowan’s Law and the Ontario government Concussion Awareness site.
Paul De Divitiis, Executive Vice President of the PMHA, says having Rowan’s Law information prioritized and easy to find is consistent with the manner in which PMHA is dealing with youth concussion.
“Unfortunately a tragedy makes people more aware...but with Pelham Minor Hockey, we were cutting edge on it. Even before the OMHA mandated it, we were there. We already have the systems and protocols in place. People have the knowledge, they understand what the ramifications are.”
De Divitiis says that the PMHA already had their Return-to-Sport Protocol established, months before being legally required to do so. Also, in the PMHA, a doctor’s certificate is required before a young person can return to training, practicing or playing —a requirement not yet mandated by Rowan’s Law legislation. Plus, the trainers have each child’s medical and past injuries history.
I ask De Divitiis what would actually happen if I tried to enroll my hypothetical 12-year-old daughter in Pelham Minor Hockey. “Before registration [the child, and parent, if the player is under 18] have to read Rowan’s Law, and understand it, and be aware of what concussions are about, and how we monitor them. They have to sign to this, right then and there upon registration. If anyone has not, we make sure the coaches follow through, and everything has to be collected. So we make sure every child registered in Pelham Minor Hockey signs Rowan’s Law [requirements].”
During all interviews for this story, parental pressure on athletes and its relationship to individual concussion treatment was discussed. De Divitiis’ response is thoughtful and cautionary to parents.
“I think that’s with everything today, not just sport. People put a lot of expectations on their children. Society’s that way now, unfortunately. We want to raise the bar, things are a lot more fast-paced...everyone wants that level of excellence for their child.”
De Divitiis explains that he felt having a written, established protocol is significant when dealing with parents.
“The protocol is the protocol, the process is followed every time. The transparency and accountability benefits everyone involved. It’s no longer left to someone’s discretion.”
Brian Bleich, President of the Pelham Panthers Basketball Association, doesn’t mince words when discussing how the PPBA handles Rowan’s Law protocols.
“No kid can go in the gym without a coach. We don’t have pick-up basketball here. If the coach sees a blow to the head, the protocol must be followed. As the president, if I was to find out a coach didn’t follow the protocol, there would be a suspension in place.”
The PPBA has 750 kids playing basketball—40 percent girls and 60 percent boys—in both House League and the Elite Juel Prep (grades 9-10) and Juel (grades 11-12) high school programs before COVID. The 400 players registered now use the Meridian Community Centre exclusively, and focus on skills development and practice during their twice-weekly, one-hour sessions. There are 20 to 24 kids per session, no scrimmages or games, and the school facilities at E. L. Crossley, Wellington Heights, and Glynn A. Green are temporarily unavailable.
As part of the Ontario Basketball Association, their governing body sets the policies. Bleich describes the PPBA sign-up process, which includes the OBA.
“This year has been a massive push for Rowan’s Law for us. So when I register the players with OBA, every parent gets an email from the OBA stating they must read Rowan’s Law and check that they’ve read it. It goes back to the OBA, and before I can register that team, every person must have a checkmark in their column.”
What happens when a player appears to sustain a blow to the head when playing? Bleich responds that anyone in the gym can call a hit to the head. The game will stop, and the player will be out of the game. The incident is noted on the game sheet, and Bleich must forward the information and protocol steps to the OBA. The athlete must go see a doctor, and get a signed note whether there is a concussion or not.
Bleich is adamant about Return-to-Play protocol, the last phase of Rowan’s Law, which was implemented July 1.
“There is more to rehab than just staying home,” Bleich says. “You actually have to work at bringing your eyes and brain to function. It doesn’t just come back. I watched my son train to come back.... I’ve learned it’s the second hit, before the first one is healed, that does the damage.”
The 300-member Niagara Central Skating Club, which uses the community centre as one of its facilities, functions as a member of Skate Ontario, which is governed by Skate Canada.
Jessica Sackett, a professional coach and member of the NCSC Board of Directors, has a certificate of achievement showing that she has completed the Skate Canada course, “Rowan’s Law —Coaches and Officials.” Obtaining this certificate is a prerequisite for all coaches.
COVID protocols have necessitated that skaters (and their parents if appropriate) register for NCSC online at present, and they must indicate that they have reviewed the appropriate Concussion Awareness Resources and Code of Conduct as part of their registration.
In addition, when skaters show up at the arena their first time, they must sign a hardcopy of a Rowan’s Law Acknowledgement Form confirming the above.
“We’ll let you register, but if this is not signed, you’re not getting on the ice,” says Sackett.
NCSC is in a unique situation regarding safety equipment for young athletes. Skate Canada rules for helmet use by young skaters give the choice to wear or not wear a helmet to their parents once a skater has successfully demonstrated Stage 5 skills.
There is a link within Skate Canada’s Helmet Use Policy to the Concussion Awareness Policies of Rowan’s Law, and also their Skate Canada Concussion Pathway form. Sackett says there have been no concussion issues in the last few years.
The Town of Pelham’s requirements to comply with Rowan’s Law are significant, as it is designated as both a municipality and a sports organization under the legislation, and the Town focuses on many sports.
Pelham is a sports organization when it runs its own sports programs, such as Youth Summer Cycling Camp and Tennis Camps.
As a municipality, it must also ensure that all community youth sports organizations which rent ice, use the community centre’s gymnasium facilities, and Town sports fields, are in compliance with Rowan’s Law.
Julie Cook, Recreation and Wellness Programmer for Pelham, says that the Town’s Concussion Information Sheet and Agreement is posted on the Town website. The document, which also serves as an indemnifying agreement, must be signed by an authorized representative of any group or organization prior to using Town facilities.
Cook points out that concussion in youth sports is not a new issue.
“Everybody knew that concussions were an issue, but everyone had their own policies, there were no standards. The Niagara Region approached us a few years ago and said, ‘We can help you develop a concussion policy,’ and council agreed we should have one.”
Cook says this policy was developed and in place before Rowan’s Law was passed, and staff are well trained.
“For public skating, we have monitors on the ice. If we feel we have someone who has sustained a concussion, all of our staff are completely aware of our concussion policy...they know what they need to do. [Anyone with a suspected concussion] can’t go back on the ice, number one. And secondly, they would have to provide a doctor’s statement before they could go back on.”
Cook acknowledges that for public skating, this is hard to police without the cooperation of the individual, but points out that for organized sports clubs, legislation now puts the onus back on each association.
Cook also confirms that all full and part-time Town employees providing youth sport camps will have the training as mandated by Rowan’s Law legislation.
E. L. Crossley, and the District School Board of Niagara in general, are bound by the Education Act as well as Rowan’s Law. Effective September 2019, the Ministry of Education updated its concussion policy to be consistent with Rowan’s Law, and required all schools and school boards to replace their 2015 policies with the updated version.
Also within the Education Act, but beyond the requirements of sports organizations and municipalities, school boards must have “a process for removing students with a suspected concussion from physical activity and, for those diagnosed with a concussion, a Return to School Plan, which includes their return to learning and physical activity.” This also includes a process to document and track a student’s progress from removal to return.
Pierre Blanchard, Crossley’s Physical Education Program Head, believes the high school, and the DSBN, are significantly ahead of the legislative requirements. The measures that Crossley takes to educate the general student population about concussion have continued, despite the changes to high school sports that COVID has necessitated.
“When you walk into our gym, you’ll see the posters and resources we have there for Rowan’s Law,” says Blanchard. “We have student-led activities that surround the Rowan’s Law date in September, plus in-class lessons that day, as well as an assembly that describes the details of Rowans Law. This is led by student council, athletic council, and student leadership classes.”
There were related lunchtime activities, in-school announcements, and social media posts. This was followed by mandatory Grade 9 in-class concussion lessons for all phys-ed students.
Blanchard points out that this is done throughout the DSBN, adding that Crossley marks the day by wearing purple, Rowan’s favourite colour. Although an assembly was not possible this September because of COVID, Blanchard adds, “We still did an awareness day through our student council, everybody wore purple. We put out Rowan’s Law awareness information virtually through our school website as well. Everybody still felt part of the team.”
When asked about parental pressure on students that might conflict with the goals of Rowan’s Law, Blanchard is quick to reply.
“Bottom line, the parents from E. L. Crossley have been very supportive in following through with concussion protocols established by the school. If the student suspects or has a concussion, they must have a meeting with a teacher-guide, prior to any activity and schooling. The activity is secondary, it’s the ‘Return to Learn’ which is the primary piece.”
Blanchard notes that this doesn’t relate just to sports, but any fall or activity that may cause a concussion. Parents can advise the school of such incidents, and students are encouraged to self-declare.
Iwan Jugley is a Concussion Advisor at Crossley, and works with the students and parents to document all cases and provide information packages, then manage the student’s Return to Learn.
A doctor’s clearance is requested prior to Return to Sport, but Blanchard laments that it is within the parent’s prerogative to not follow Rowan’s Law guidelines. However, he says that it is the responsibility of coaches and teachers to pull a student out of participation if any symptoms are observed.
The DSBN has taken additional steps, adapting their activities based on concussion knowledge. For example, Crossley has gone non-contact in boys’ high school hockey. They are one of six Niagara schools to do so, and compete in a non-contact high school league with other municipalities throughout Ontario.
Unfortunately because of COVID, a motion to have boys’ non-contact hockey recognized for provincial championships by OFSSA and SOSSA, Ontario’s governing body for high school sport, has been put on hold.
Blanchard cites another example.
“When we do soccer we don’t emphasize or teach headers in class. If you want to quote me on my own personal views, I’ve made recommendations that reduce contact in soccer. There’s no need to receive a header off a goal kick, and a header should not be received across a centreline.”
Within the spirit of the game, he is not opposed to heading shorter, more controlled balls within the offensive zone.
Blanchard’s point is that the long balls are travelling at high velocity, increasing the risk of concussion. His view is supported by a 2016 study of amateur soccer players led by Magdalena Ietswaart, professor of psychology at Scotland’s University of Stirling, and published in EBioMedicine, an open access journal.
Ietswaart concluded, “Researchers found that heading a soccer ball —just once — causes instant changes to the brain … They discovered alterations in brain corticomotor inhibition and cognitive function. In particular, memory-test performance was reduced by up to 67 percent.”
Crossley is also involved as a pilot school in a program called Privit during the shortened second semester February 1t to March 13, which has since been put on hold. This is concussion/injury tracking software that allows parents to input and make available updates on student progress, which coaches and teachers can access.
Blanchard reflects the thoughts of educators and concerned coaches throughout youth sport in Pelham when he says, “The whole concept of Rowan’s Law is...we are doing our best to educate and increase awareness now, while they’re young. Ten years from now, the majority of the population will be educated on it, it will be the norm. As these students get older and become coaches, the culture will be established through them for the future.”
Until that future arrives, ensuring that our children receive the proper treatment and concussion management is ultimately the responsibility of vigilant and educated parents. More information on Rowan’s Law can be found at https://www.ontario.ca/page/rowans-law-concussion-safety