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Sports Concussions A presentation in conjunction with NFHS Power Point for Concussion Education

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Sports Concussions A presentation in conjunction with NFHS Power Point for Concussion Education Julie Moyer Knowles DPT EDD ATC, Vice Chair DIAA SPORTS MEDICINE COMMITTEE – PowerPoint PPT presentation

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Title: Sports Concussions A presentation in conjunction with NFHS Power Point for Concussion Education


1
Sports Concussions A presentation in conjunction
with NFHS Power Point for Concussion Education
  • Julie Moyer Knowles DPT EDD ATC, Vice Chair
  • DIAA SPORTS MEDICINE COMMITTEE

2
Outline 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)

3
What 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

4
What 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

5
Coaches 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

6
Problems 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

7
Second 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
8
Problems 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.

9
Extent 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?

10
Extent 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)

11
Delaware 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.

12
Not 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

13
What 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

14
What 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

15
Chronic 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/
17
Chronic 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

18
Chronic 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.

19
Chronic 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

20
Chronic 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)

21
Time 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

22
GOVERNMENT 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?

23
Many 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

24
Future 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

25
NCAA 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

26
WHAT 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.

32
ACE 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

34
Parent Info Sheet
35
DIAA 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

36
New 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

37
Delaware 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.

38
Where 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..

39
Neuropsychologic 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

40
King-Devick Test
  • UPenn School of Medicine study at King Devick
    website
  • http//kingdevicktest.com/concussions/

41
So 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/

43
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