Title: Sports Concussions A presentation in conjunction with NFHS Power Point for Concussion Education
1Sports ConcussionsA presentation in conjunction
with NFHS Power Point for Concussion Education
- Julie Moyer Knowles DPT EDD ATC, Vice Chair
- DIAA SPORTS MEDICINE COMMITTEE
2Outline of 30-60 minute program
- Video Introductions (5 min) http//www.youtube.c
om/watch?vyIqZDbk3M40 - NFHS On line Concussion Program (30 min-
including first quiz, 20 minutes if starting
after first quiz) http//www.nfhslearn.com/index.
aspx - This NFHS online may be done independently
go to above website and sign in (set up user name
and password) Select concussion course and add it
to your box/check out (it if free) Under my
homepage click begin next to my available
courses. Bring certificate to your Athletic
Director upon completion. - Sports Concussions Power Point Presentation (20
min) - Questions/ Discussion (5 min)
3What is a Concussion?
- A concussion is a mild traumatic brain injury
(tbi) that interferes with normal function of the
brain - It effects Function, not Structure, like other
types of head injuries. That is why you dont
see concussions on tests like CAT scans - Four areas of function involved are how an
athlete Feels, Thinks, Sleeps, and their Emotions
4What is a Concussion?
- Repeated mild TBIs can cause a condition known
as chronic traumatic encephalopathy (CTE). This
condition is marked, among other things, as
causing severe memory problems. - Repeated TBIs can also cause a life threatening
disorder known as second impact syndrome. - Evolving knowledge
- dings and bell ringers are serious brain
injuries - Do not have to have loss of consciousness ( lt10
have loc) - Young athletes are at increased risk for serious
problems
5Coaches and even Medical Personnel have
historically mis-assessed concussions
- There is much variation in the knowledge of
health care providers managing concussed
athletes. Need to make sure the person clearing
for return to sport is current with knowledge! - Physicians (MD/DO)
- Physician assistants
- Nurse practitioners
- Chiropractors
- Athletic trainers
- School nurses
- New and emerging research and technologies will
lead to a continuing evolution of care
6Problems for Athletes-Post-Concussion Syndrome
- 85-90 of concussed young athletes will recover
within 1 to 2 weeks - The remainder may have symptoms lasting from
weeks to months interfering with school and daily
life - Subtle deficits may persist a lifetime
7Second Impact in New Jersey-News Journal 1/2010
Had headaches during a game after a hit. Left
game. Headaches continued. About a month later
hit again and developed 2nd impact. He has major
head injury, lives in WC, and low cognition. Cant
perform ADLs LaSalle University lost the lawsuit
8Problems for Administrators Just a few mouse
clicks away
-
- At Burg, Simpson, Eldredge, Hersh, Jardine,
P.C., our brain injury lawyers represent brain
injury victims caused during high school sports
in Colorado, Wyoming and nationwide. We have the
resources and experience with complex brain
injury lawsuits to fully assess your injuries and
take your case to a jury. If you or your loved
one has suffered a brain injury while playing
high school sports, please email or call us
today.
9Extent of the Problem
- Professional athletes get a great deal of
attention- but just tip of iceberg! - 1600 NFL players
- Much more common in US high school than any other
level- due to large number of participants - HS Sports Participants
- Football- 1.14 million
- Boys Soccer- 384,000
- Girls Soccer- 345,000
- Boys Hoops- 545,000
- Girls Hoops- 444,000
- WHAT ABOUT THE REST? YOUTH? CLUBS? RECREATION
LIKE SKIING?
10Extent of the Problem
- 19.3 of all FB injuries in 2009!!!
- Over 100,000 concussions nationally in HS
athletes yearly based on CDC estimates, - Over 1,000 concussions in HS athletes in
Delaware each year (T Reed MD)
11Delaware higher than national average
- Overall significant injury rate for all sports,
games and practices in Delaware (3.37) is higher
than national norm (2.31 injuries per 1000
exposures), except during football competition
where DIAA regulations require qualified medical
personnel present.
12Not Just a Football Problem
- Injury rate per 100,000
- player games in high
- school athletes
- Football 47
- Girls soccer 36
- Boys soccer 22
- Girls basketball 21
- Wrestling 18
- Boys basketball 7
- Softball 7
- Data from HS RIO
- JAT, 2007
-
-
13What has happened to make this such a big deal?
- Increasing awareness and incidence
- Number of high profile athletes over the past 10
years - Bigger and faster kids, increased opportunities
- Increased litigation from misdiagnosis,
treatment, and removal from sport
14What has happened to make this such a big deal?
- High profile cases
- Second Impact Syndrome
- Death or devastating brain damage when having a
second injury when not healed from the first - Long-term effects
- Possible long-term effects- dementia, depression
15Chronic Traumatic Encephalopathy (CTE)The BIG
wake up call!
- Concussions are medically known as Traumatic
Brain Injuries (TBIs). - CTE- progressive degenerative disease of the
brain found in athletes (and others) with a
history of repetitive TBIs - Tau protein
- This degeneration can result in early signs and
symptoms of cognitive, emotional and physical
impairment. These symptoms include severe
depression, emotional outbursts, excessive risk
taking, balance disorders, and also dementia as
is seen in Alzheimer patients.
16 - The CSTE was created in 2008 as a collaborative
venture between Boston University School of
Medicine and Sports Legacy Institute (SLI). The
mission of the CSTE is to conduct
state-of-the-art research on Chronic Traumatic
Encephalopathy (CTE) through the study of its
neuropathology, pathogenesis, clinical
presentation, disease course, genetic and
environmental risk factors, and ways to prevent
this progressive dementia.
- CSTE has a brain bank that welcomes donated
brains, including those of professional athletes.
This research has significantly increased
awareness of the problem of concussions
www.bu.edu/cste/
17Chronic Traumatic Encephalopathy
- Pro Football
- Lou Creekmur former All-Pro football player with
Detroit Lions/lineman - Note stained brown areas showing tau protein, a
bad protein in the brain that is usually seen in
patients with Alzheimer
18Chronic Traumatic Encephalopathy
- On left is slice of a normal brain of a 65 year
old. Middle is a slice of John Grimsleys
(former Oilers and Dolphins linebacker that died
of gunshot wound at 45yo ). Right is former
professional boxer.
19Chronic Traumatic Encephalopathy
- College Football
- Right Mike Borich college football wide receiver
who died of a drug overdose in 2009. Note the
brown tau protein damage - Left 1 61 yo normal brain
20Chronic Traumatic Encephalopathy
- High School Football
- 18 year old high school football player who
suffered multiple concussions in high school.
(Died of internal injuries in MVA) - Note the tau proteins and small blood vessels
deg. (holes)
21Time to Make Changes
- PRO TEAMS making new concussion policies
- NFL
- Hiring of independent neurologists to make RTP
decision - No RTP same game in most cases
- New contract player protection and long term
treatment for head injuries
22GOVERNMENT MAKING CHANGES pushing for improved
national safety standards in equipment (NOCSAE)
- NOCSAE tests helmets now (using a 60 inch drop
test) , but the test is not effective for
prevention of concussions. Manufacturers test
their own helmets to see if they meet NOCSAE
standards. Is this the fox guarding the hen
house?
23Many Manufacture Claims Flawed
- Concussion prevention has become the holy
grail for sports equipment marketers - Soccer head gear
- Girls Lacrosse head gear/helmets
- Pole vaulting helmet
- New football helmets, soccer head pads, mouth
guards- NO PROVEN PROTECTION FROM CONCUSSION!! - Multiple flaws in a study looking at Riddell
Revolution helmet - Neurosurgery, 2006
24Future helmet improvements
- One example of potential improvements in helmets
is Liquid Armor, a new invention by University of
Delaware in which liquid hardens and strengthens
under force (and then returns to liquid when the
force is removed) UD Research 2(2)2011
25NCAA Follows NFL lead
- December 2009
- NCAA now making changes in response to what NFL
has done - No return to play same day of concussion
- Pushing for helmet improvements with NOCSAE also
26WHAT HAS THE NFHS DONE?
- National organization equivalent to the
- NCAA at the high school level)
- Makes all rule books for sports
- DIAA part of NFHS
- Makes rules regarding concussions governing game
time, but state associations like DIAA , or state
laws must make those regulations for non game
times
27 What has the NFHS done?
FOLLOWING THE ABOVE IT GENERALLY TAKES SIX (6
)DAYS BEFORE AN ATHLETE WITH EVEN A MILD DING
CONCUSSION SHOULD RETURN FULLY TO GAME
28 What has DIAA done?
- RULE CHANGES FOR REMOVAL FROM PRACTICE OR GAME
- RULE CHANGES FOR RETURN TO PLAY REQUIREMENTS
- RULE CHANGES FOR PARENTAL AND PLAYER EDUCATION
29 New DIAA Rules
- 3.1.6.1 If an athlete exhibits signs and
symptoms consistent with a concussion, they shall
be removed from play immediately. A qualified
health care professional as described in 3.1.6.2
must then determine whether or not an apparent
concussion has occurred. If one of the qualified
healthcare professionals is not present, the
injury must be treated as a concussion and the
student not be allowed to return to practice/game
until determined otherwise from a qualified
healthcare professional. If a potential
concussion, loss of consciousness or apparent
loss of consciousness has occurred, the athlete
may only return to practice/game after the
administrative head of school or designee
receives written clearance from a qualified
physician (MD/DO). No athlete shall return to
practice or play (RTP) on the same day of a
concussion. Any athlete with a concussion should
be evaluated by their primary care provided or
qualified healthcare professional that day.
30 New DIAA Rules
- 3.1.6.2 A qualified healthcare professional
shall be defined as a MD or DO or school nurse,
nurse practitioner, physician assistant, or
athletic trainer, with collaboration and/or
supervision by a MD or DO as required by their
professional state laws and regulations. The
qualified healthcare professional must be
licensed by their state, be in good standing with
the State of Delaware and must be approved or
appointed by the administrative head of school or
designee, or the DIAA Executive
Director/Assistant Executive Director.
31 New DIAA Rules
- 3.1.6.3 Written clearance for return to play
after a potential concussion shall be from a
qualified physician (MD/DO) only. The preferred
method would be to use the ACE Care Plan. After
medical clearance, return to play should follow a
step-wise protocol with provisions for delayed
return to play based upon the return of any signs
or symptoms. - 3.1.6.4 Failure to comply with medical
requirements of the DIAA concussion protocol
shall result in that individual or school being
considered ineligible and shall be penalized
according to DIAA regulation 2.10.
32ACE FORM
33 DIAA
- Delaware Interscholastic Athletic Association-
New Parent/ Player Concussion Information Form
(see handouts) This must be read by all players
and parents, and the front of the PPE must be
signed by both indicating they have read the
concussion information - DIAA- return to play ACE for see attached. This
must by signed by a MD or DO (only) for return to
play after a concussion - Copies of both are available on the DIAA website
34Parent Info Sheet
35DIAA web site
- Information regarding DIAA Concussion protocol
and return to play forms can be found at the DIAA
website - http//www.doe.k12.de.us/infosuites/students_fami
ly/diaa/default.shtml
36New Delaware Concussion Law
- WHEREAS, a concussion is a type of brain injury
which changes the way the brain normally
functions and - WHEREAS, recognizing and responding to
concussions when they first occur helps to aid
recovery and to prevent prolonged concussion
symptoms, chronic brain damage or even death and - WHEREAS, a recent study estimated that more than
40 percent of high school athletes return to
participate in school athletics before they have
fully recovered from these serious head injuries
and - WHEREAS, an estimated 400,000 high school
athletes sustained concussions while
participating in five major male and four major
female sports during the 2005-2008 school years
and - WHEREAS, the number of youth athletes taken to
emergency rooms with sports-related concussions
has doubled during the 10 year period from 1997
to 2007 and - WHEREAS, among youth aged 14 to 19, emergency
room visits for concussions sustained during team
sports more than tripled over the same period
and - WHEREAS, eight states have adopted similar
concussion-awareness and prevention laws and - WHEREAS, the National Football League and the
National Athletic Trainers Association have
announced a joint effort to promote legislation
to raise awareness and protect youth athletes
from the risk of concussions and - WHEREAS, the Center for Disease Control and
Prevention (CDC) estimates 1.6 to 3.8 million
sports and recreation related concussions occur
in the United States each year and - WHEREAS, an athlete should return to sports
activities under the supervision of an
appropriate health care professional and - WHEREAS, the State Council for Persons with
Disabilities (SCPD) Brain Injury Committee's
mission is to promote a consumer-oriented,
effective injury and prevention service delivery
system and - WHEREAS, the Department of Education and the SCPD
regularly work in consultation regarding
regulations and policies that impact students
and - WHEREAS, the Department of Education has worked
in consultation with the SCPD Brain Injury
Committee in reviewing the Delaware
Interscholastic Athletic Association's (DIAA)
current concussion policy and - WHEREAS, the Department is encouraged to continue
to work in consultation with recognized experts
including the SCPD Brain Injury Committee and the
Brain Injury Association of Delaware in
developing, reviewing, and updating their
concussion policies
37Delaware Concussion Law con.
- NOW THEREFORE
- BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE
STATE OF DELAWARE - Section 1. AMEND 303, Chapter 3, Title 14 of
the Delaware Code by inserting a new subsection
(d) as follows - (d) The Association shall adopt rules and
regulations applicable to member schools
regarding the appropriate recognition and
management of student athletes exhibiting signs
or symptoms consistent with a concussion. The
rules and regulations shall include, but not be
limited to, the following requirements which
shall be effective no later than the 2012-2013
school year - (1) Each student athlete and the athletes parent
or guardian shall annually sign and return a
concussion information sheet designed by the
Association prior to the athlete initiating
practice or competition. - (2) Each coach shall complete concussion training
consistent with a timetable and curriculum
established by the Association. - (3) A student athlete shall be promptly removed
from play if the athlete is suspected of
sustaining a concussion or exhibits signs or
symptoms of concussion until completion of
assessment or medical clearance conforming to
Association regulation.
38Where are We Headed?
- Better State Laws, Better DIAA Regulations,
Better Equipment, Better Knowledge, Better
Medical Coverage, Better Rules for Sport (ex-
move kick off line back) - Concussion symptoms are not just physical- they
are emotional and cognitive as well. In many
cases, having a baseline cognitive test can be a
great tool in helping to make an accurate
diagnosis and determining a safe time for return
to play - Delaware is expanding cognitive testing in high
schools..
39Neuropsychologic Testing
- Manual testing ex- King-Devick test
- Computerized programs
- Easily accessed
- Can be done quickly with immediate results
- Can obtain baseline data on all athletes
- Can assess reaction times and processing speed
40King-Devick Test
- UPenn School of Medicine study at King Devick
website - http//kingdevicktest.com/concussions/
41So Where Are We Headed?
- More Injuries/More Lawsuits
- More Education
- Everyone dealing with young athletes must be
aware of the signs, symptoms, and ramifications
of concussions - Mandate or Legislate
- Concussion management policies must be in place
at every level - If you dont do it, someone will do it for you.
Delaware is heading in right direction. Even
though the final DE law may only pertain to DIAA,
all organized sports programs should be
encouraged, at the minimum, to follow DIAA rules
on concussions for both medical and legal
purposes.
42- Information in this presentation obtained in
part from a Jan 2010 presentation by the Chair of
NFHS Sports Medicine Committee, Dr Michael
Koester MD - Additional information including the NFHS power
point on concussions can be obtained for no cost
at www.nfhslearn.org - Additional information was obtained from the
Boston University Center for the Study of Chronic
Encephalopathy website at www.bu.edu/cste/ and
http//www.bu.edu/alzresearch/cste/
43OPEN DISCUSSION/ QUESTIONS
WHEN IN DOUBT, SIT THEM OUT!