Concussions in sports

1. Concussionsin sports Mary Tovornik, MA, ATC Assoc. Athletic Trainer, Head Football Athletic Trainer Stony Brook University May 11, 2012

2. Introduction • Overall: Give a REAL picture of the current situation of head injury management in sports • 1. Recent changes/updates in protocols • 2. Various case examples • 3. Challenges facing sports med professionals • 4. Research and future testing

3. Concussions in sports- the reality

4. Recent policy updates • NCAA • No same day clearance IF Dx = concussion • MD/or designee consult for clearance • Written and signed yearly educ for athletes/coaches • VA Tech “STAR” Helmet Grading System Research; HITS

5. Recent policy updates • NFL • No same day clearance IF Dx = concussion • As of April 2012: 1300 lawsuits filed by former NFL players • Kick-off spot moved up 5 yds (2012 NCAA) • Independent neurologist clearance after game • Knee Jerk Reactions (McCoy- Browns 12/8/11) • Neutral ATC in press box of games (12/20/11) • Med staff allowed to review injury film immediately on sidelines • Likely independent neurologist on sidelines • Authorities not yet convinced of HITS system

6. Summary of sbu head injury management • Educational Component • Baseline Testing • PHx forms, BESS, ImPACT • Diagnosis • Same Day Management • Follow Up and Management • Medical Clearance • Return to Play • 4 phases (Light aerobic, Heavy aerobic and/or resistance, non-contact/limited px, contact) • Yearly review of policy

7. Specific Possible case examples • Med staff sees the hit, athlete stumbles getting up, you walk off field with athlete, they “stumbled due to unrelated injury,” pass all sideline tests

8. Specific Possible case examples • Athlete is in pile on far sidelines, eval on field and sidelines,but didn’t see the hit, Passes all sideline tests • Next day players reveal more details

9. Specific Possible case examples • Ath took hit to head during game, evaluated for concussion; only s/s is a headache, which he had complained about PRIOR to the game • Ath typically throws up in 1st half of game, due to nerves. Takes a hit on kick-off, vomits a few minutes later, no other s/s. • Player that waves off medical staff as they approach • Do you pull these athletes from activity???

10. Specific Possible case examples • Concurrent health problems: • Flu- nausea, fatigue • Migraine- vision changes • General cold- fatigue, headache • Heat- headache, dizzy, fatigue, nausea • Headache only • FB PLAYERS MAY HAVE MINOR HEADACHE “NORMALLY” • Post acute? • How do these possibilities affect our RTP decisions?

11. Challenges facing sports medicine professionals • Concussions are still not fully understood • It just doesn’t fit neatly in a management plan based on medicine, research and logic • There will never be a way to account for every possible variable • Being too restrictive that athletes hide any and all symptoms from you • Judgment and reaction by those outside of sports medicine who do not understand full scope • As the team doctor or ATC, you HAVE to make athlete’s well-being a priority

12. Challenges: the football culture- toughness, play hard

13. Challenges: Culture- NFL Player’s perspective (1) "The bottom line is: you have to be able to put food on the table,” Maurice Jones-Drew has been quoted to say and surely this is a common view. “No one's going to sign or want a guy who can't stay healthy. I know there will be a day when I'm going to have trouble walking. I realize that. But this is what I signed up for. Injuries are part of the game. If you don't want to get hit, then you shouldn't be playing."  (RB Jacksonville Jaguars) 12/26/11, USA Today

14. Culture: NFL Player’s perspective (2) • Anon NFL Player: rule changes are good, “but the truth remains, players are still hiding concussions, because they want to protect their careers. In some cases, teams know a player is concussed and let it go. Yes, that still happens.” (www.cbssports.com) • Polamalu (Steelers LB): “…I have the fear…but I’m willing to fight it.” (www.cbssports.com)

15. Culture: NFL Player’s perspective (3) • Gilmore (Saints TE): “I think a lot of it has to do with where a player is in his career and life. When you start having kids and families, your perspective on things kind of changes…” (www.cbssports.com) • 23 of 44 NFL players admitted they would hide a possible “C” rather than miss one game (Dec 2011, AP Survey, ESPN)

16. We are left with more questions than answers • How do sports medicine professionals manage the “grey area” head injuries? • Does a headache alone indicate a concussion acutely and post-acutely? • How do we educate coaches and players to not hit helmet-to-helmet, to at least reduce potential number of concussions? • How will research and society affect the sport of football in the short term and the long term? • What IF the player is willing to take the risk?

17. Recent , possible future findings and assessments • Chronic Traumatic Encephalopathy • Research at BU • Links to suicides, depression? • 5/2/12 death of Junior Seau? • Is it definitive though…???

18. Recent, possible future findings and assessments • SCAT2 (updated 2009) • Not full proof, but well accepted • Blood Tests- Cleveland Clinic • S100B marker • King-Devick Test • Dyslexia • Visual test for rapid precise eye movement • Ahead System • UMD • Why can some sustain hard hit w/o “C” and others get a “C” with a low impact collision? (www.cleveland.com)

19. So now what…..? • Yes, helmets can be improved and tackling technique can change, but reality is: • In a contact sport your brain is still at risk for concussion- anatomy of brain/skull • Whiplash, hitting the ground, hit under the jaw • Our responsibility to know changes in laws and protocols, but also to educate players, parents, coaches, health care professionals • ***Did the health of the athlete take priority in my decision?

20. Thank you for your time