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The Concussion Management and Awareness Act

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Title: The Concussion Management and Awareness Act


1
The Concussion Management and Awareness Act
  • Sharon M. Edwards, MD
  • Associate Professor
  • Department of Pediatrics
  • September 16, 2013

2
Learning Objectives
  • To review the Concussion Management and Awareness
    Act
  • To understand why the law was enacted
  • To understand the role of the physician as
    defined by the law
  • To understand your role as an advocate

3
Case
  • Jessica, a 16 year old while playing soccer
    outside in the school yard tripped and hit her
    head. She did not have a loss of consciousness
    but is complaining of a headache and .
  • There is a major game this evening and she is
    aware that prospective college coaches are in
    the audience
  • She would like to continue to play as she has
    only a headache
  • Discussion Questions--
  • Is it appropriate for her to continue to play?
  • Who decides if/when she can return to play?
  • What is the role of the school team?
  • What is the role of her primary care provider?

4
Who is Zachary Lystedt?
  • He sustained a concussion in 2006 while playing
    middle school football. He hit his head on the
    ground during a tacklehe did not have any loss
    of consciousness. He was sidelined for 3 plays.
    While resuming play he collapsed on the field and
    had to be air lifted to Harborview Hospital
    where he had emergency surgery for brain swelling
    and increased intracranial pressure.

5
The State of Washington passed the first
concussion in sports law, called the Zackery
Lystedt Law
  • The Seattle Seahawks bonded with Zach and his
    family and worked with legislators to develop a
    law to protect student athletes from concussions
  • In May 2009 Washington State passed the Zachery
    Lystedt Law that provides guidelines for
    concussion management for student athletes.
  • The passing of this law led to a flow of
    legislation aimed at protecting young athletes
    nationwide

6
States with Legislature on Concussions--Source
National Conference of State Legislatures,
2013.6 http//www.cdc.gov/concussion/policies.htm
l
7
Core Elements of the Lystedt Law
  1. Annual Education of Parents and Athletes
  2. Mandatory removal from play athletes suspected of
    having a concussion
  3. Health professional clearance for return to play

8
Core Elements of the US Concussion Laws
  1. Annual Education of Parents and Athletes
  2. Mandatory removal from play athletes suspected of
    having a concussion41 states and Wash. DC have
    this as a component of their law
  3. Health professional clearance for return to
    play40 states and Wash. DC

9
National Youth Sports Concussion Laws -common
themes
  • Minimum mandatory removal from play (typically 24
    hours)
  • Health care Professional Assessment
  • Coach training in TBI management
  • Information for parents
  • Liability Waivers
  • Focus on secondary prevention (reducing the risk
    of repeat TBIs)

10
Law Pitfallsthe controversies
  • Who is a health professional?physicians with
    no TBI training? Athletic trainers? Nurses?
    Neuropsychologist? Of the states that require
    clearance by the health professional only about
    50 require the person to have training in TBI!
  • Education component is not standardized
  • No consensus on coach trainingcontent and how
    often and how to evaluate? of 45 jurisdictions
    which have concussion laws only 25 require coach
    education in recognizing symptoms of TBI!
  • Lack of consensus on liability waivers
  • Should sports with high risks of TBI be banned
    for children/adolescents?

11
New York Gov. Andrew Cuomo signed his state's
youth-concussion legislation into law last week,
making New York the 33rd state (not counting the
District of Columbia) to pass such a law.
  • S T A T E O F N E W Y O R K ______________________
    __________________________________________________
    3953--B Cal. No. 280 2011-2012 Regular Sessions
    I N S E N A T E March 10, 2011 ___________
    Introduced by Sens. HANNON, MAZIARZ, BALL, ADAMS,
    ALESI, AVELLA, CARLUC- CI, FUSCHILLO, HUNTLEY,
    LARKIN, LAVALLE, NOZZOLIO, SQUADRON, ZELDIN --
    read twice and ordered printed, and when printed
    to be committed to the Committee on Health --
    committee discharged, bill amended, ordered
    reprinted as amended and recommitted to said
    committee -- reported favorably from said
    committee, ordered to first and second report,
    ordered to a third reading, amended and ordered
    reprinted, retaining its place in the order of
    third reading AN ACT to amend the education law
    and the public health law, in relation to
    directing the commissioners of education and
    health to establish rules and regulations for the
    treatment and monitoring of students of school
    districts, boards of cooperative educational
    services and nonpublic schools who suffer mild
    traumatic brain injuries THE PEOPLE OF THE STATE
    OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
    BLY, DO ENACT AS FOLLOWS 1 Section 1. Short
    title. This act shall be known and may be cited
    as 2 the "concussion management and awareness
    act".

12
Concussion Management and Awareness Act (Chapter
496 of the Laws of 2011)
  • Went into effect 7/1/12 for all public and
    charter schools
  • Requires the Commissioner of Education and the
    Commissioner of Health to disseminate
    rules/regulations for students who sustain a
    concussion at school and at a school district
    sponsored event or activity
  • These guidelines for return to school are
    applicable to all public school students
    irrespective of where the concussion occurred

13
Concussion Awareness Act
  • During school athletic activities schools are
    required to remove from activity (recess/PE
    class/sports) any student suspected of sustaining
    a mild traumatic injury (concussion)
  • When in doubt, sit it out.

14
Concussion Management and Awareness Act
  • Removal from Athletics
  • The student believed to have a concussion must be
    removed immediately from physical activity
  • No student will be allowed to return to the
    athletic activity unless he/she has been symptom
    free for 24 hours and has been evaluated by a
    physician. The physician must give written and
    signed authorization for return to play. For
    interscholastic sports the clearance must come
    from the Schools Medical Director

15
NY Concussion Management and Awareness Act
  • Requirements of School Districts
  • Education
  • Every school coach, physical education teacher,
    nurse, and athletic trainer has to complete an
    approved course on concussion management on a
    biennial basis, starting with the 2012-2013
    school year.
  • School coaches and physical education teachers
    must complete the CDC course.
    (www.cdc.gov/concussion/HeadsUp/onlinetraining.htm
    l)
  • School nurses and certified athletic trainers
    must complete the concussion course.
    (http//preventingconcussions.org)
  • Information
  • 1. Provide concussion management information
  • 2. Sign off on the parental permission forms
  • 3. Make information available on the schools
    website (if there is one)

16
CDC Heads Up Course on Concussion
http//www.cdc.gov/concussion/HeadsUp/online_train
ing.html
  • CDC sponsored free, online course available to
    coaches, parents, and others geared to helping
    keep athletes safe from concussion.
  • Focuses on recognition/management/prevention

17
Mandated Concussion Course Elements
  • Definition of concussion
  • Signs and symptoms
  • Describe how concussions occur
  • Prevention strategies
  • Guidelines for return to play and return to learn

18
Law Pitfalls
  • Youth sports laws should not be one size fits
    allshould be tailored to the sport/age/gender
  • Education efficacy needs to be studied
  • No requirement for data gathering or creating a
    centralized database to track incidence of
    concussion and outcomes
  • The Law does not directly address concussion
    management outside of sports
  • The Law does not emphasize primary prevention

19
Concussion
  • mmmmm

20
Clinical Cases
  • Ryan, a 17 year old lacrosse player collided
    headfirst with another player and felt dizzy
    after
  • Sam, a 13 year old football player was tackled
    to the ground and feels a little foggy
  • Jessica, a 16 year old avid soccer player fell
    while playing and now looks clumsy as she tries
    to head a ball
  • Sharon, a 12 year old fell backwards running
    around a pool and was unconscious for about 15
    minutes

21
Signs and Symptoms of a ConcussionMay present
immediately or in a few hours or evolve over a
few days
  • Headache
  • Nausea and or vomiting
  • Amnesia
  • Confusion
  • Loss of consciousness
  • Balance issues or clumsiness
  • Fatigue/sleep issues/change in sleep patterns
  • Dizziness
  • Visual Changes
  • Sensitivity to sounds and or light
  • Feeling foggy
  • Concentration issues
  • Personality/mood changes
  • Irritability
  • More impulsive

22
Common Myths
  • If you did not have LOC you did not have a
    concussion
  • A concussion is a bruise on the brain
  • If you do not have a headache you do not have a
  • concussion
  • If you are not bleeding or there is no sign of
    injury you can play

23
Common Facts
  • Most concussions (90) occur without a loss of
    consciousness
  • The majority of concussions do not occur in
    sports
  • A concussion is a metabolic derangement so a
    normal imaging study does not rule out a
    concussion

24
Cases
  • Marcus is a 11 year old male who sustained a
    concussion 1 week ago playing softball. He says
    he feels fine. His coach says he was out for
    less than a minute. He did not see his primary
    care provider at the time.
  • Selina is a 1st year college student who fell
    down the subway stairs and sustained a concussion
    3 weeks ago. For her biochemistry exam she
    misplaced her phone with the test room details
    and went to the wrong room. She feels forgetful
    and finds it difficult to concentrate. She was
    not able to take the exam on time. She received a
    failing grade on the examination.

25
Concussion Management and Awareness Act
  • Students who have had a concussion or are
    suspected to have one may not return to sports
    until they have been symptom free for 24 hours
    and have been evaluated by and receive written
    and signed authorization to return to activities
    from a licensed physician
  • Thus authorization becomes part of the childs
    permanent school medical record
  • The school is required to follow any and all
    instructions from the childs treating physician
  • School districts are encouraged to establish a
    concussion management team to promote compliance
    with the concussion laws.
  • School districts are also encouraged to provide
    education to parents/guardians on concussions

26
The Concussion Management Team
  • Students
  • Parents/guardians
  • School administrators
  • Doctors
  • The Medical Director
  • School Nurse/Nurse Practitioner
  • Psychologists/Neuropsychologists
  • PCP
  • PE Director
  • Coaches
  • Teachers
  • Trainers
  • Social Workers

27
Guidelines for the Concussion Management Team
  • After a concussion the child may need academic
    adjustments
  • They may include--
  • Shorter school days
  • Rest periods
  • Extended time for tests/homework/class work
  • Peer note takers
  • Audiotapes of class

28
Learning Objectives
  • To review the Concussion Management and Awareness
    Act
  • To understand why the law was enacted
  • To understand the role of the physician as
    defined by the law
  • To understand your role as your patient advocate

29
Case
  • Jessica, a 16 year old while playing soccer
    outside in the school yard tripped and hit her
    head. She did not have a loss of consciousness
    but is complaining of a headache and .
  • There is a major game this evening and she is
    aware that prospective college coaches are in
    the audience
  • She would like to continue to play as she has
    only a headache
  • Discussion Questions--
  • Is it appropriate for her to continue to play?
  • Who decides if/when she can return to play?
  • What is the role of the school team?
  • What is the role of her primary care provider?

30
Your Role as your Patients Advocate
  • Build on education
  • Keeping up to date
  • Workshops, parent child discussion groups,
    distributing pamphlets
  • Communicating with coaches/PE teachers and
    classroom teachers
  • Debunking myths on concussion
  • Prevention
  • Working to make sure athletic equipment is safe
  • Teaching patients/trainers/family members how to
    recognize the signs of a concussion
  • Limiting certain techniques/drills to minimize
    injury
  • Managing Return to Play
  • Supporting and working with the concussion
    management team
  • Helping advocate for the childs physical and
    cognitive rest

31
Take Home Message
  • The NY State Concussion Management and Awareness
    Act law requires that a student suspected of
    having a concussion be removed from activity
    immediately!
  • The child can only be cleared to return to
    activity after evaluation by a licensed physician
  • Schools should consider having concussion
    management teams to help implement the
    regulations and help support a treatment plan
    for the child/adolescent and his/her family
  • You play a major role in educating your patients,
    families, school staff and colleagues on
    concussion and advocating for your patients!

32
Helpful Resources
  1. http//www.cdc.gov/concussion/policies.html
    (includes the Heads Up Course)
  2. http//www.p12.nysed.gov/sss/schoolhealth/schoolhe
    althservices/ConcussionManageGuidelines.pdf
    http//www.p12.nysed.gov/sss/schoolhealth/schoolhe
    althservices/ConcussionManageeGuidelines.pdf
    (Document on Guidelines for Management in the
    School Setting by the NYS Education Department
    June 2012)
  3. http//www.nysphsaa.org. (New York State Public
    Health Athletic Association)
  4. http//bianys.org/ (Brain Injury Association of
    New York State)
  5. Summary of evidence-based guideline update
    Evaluation and management of concussion in
    sports Report of the Guideline Development
    Subcommittee of the American Academy of
    Neurology, Neurology March 2013
  6. Its All in Your headEveryones Guide to
    Managing Concussions Ann Engelland, MD
  7. Play SafeThe Mount Sinai Medical Center
    Concussion Prevention/Evaluation/Management
    Program 1 800 283 8481
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