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

1. Sports ConcussionsA 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.com/watch?v=yIqZDbk3M40 • 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 don’t “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 TBI’s 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 ( <10% 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 ADL’s 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. 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. Delaware higher than national average

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 Grimsley’s (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 • Girl’s 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_family/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 athlete’s 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 don’t 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. OPEN DISCUSSION/ QUESTIONS WHEN IN DOUBT, SIT THEM OUT!