Sports Head Injury Journey to Law Protecting Children from Future Injury - PowerPoint Presentation

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Sports Head InjuryJourney to Law Protecting Children from Future Injury

Brian P Rieger, PhDChief Psychologist & Clinical Assistant ProfessorDepartment of Physical Medicine & RehabilitationSUNY Upstate Medical UniversityDirector, Upstate Concussion CenterNYSPHSAA Concussion Team & Safety CommitteeNYS TBI Coordinating Council  Public Education Committee

20

th

Annual Nurse Practitioner Conference 2013

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Sports Concussion—A hot topic

Growing awareness of problems due to unrecognized or mismanaged concussionGrowing evidence of possible long-term problems due to concussionIncreased media attention to concussionGrowing attention to academic effectsCongressional hearings on concussion, forcing the NFL to change its policiesOver 30 states have passed sports concussion laws, including NY

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Concussion—What are the risks?

Athletes who return to play while still symptomatic from a concussion may be at increased risk of . . .Another concussionDeath or severe disabilityAggravation of symptomsProlonged recovery, with associated medical, psychological, and academic difficulties

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Concussion—What are the risks?

Athletes who suffer multiple concussions may be at increased risk of . . .Another concussion (increasing concussability)More severe symptoms or prolonged recoveryPermanent problemsHeadacheDementiaDepression

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Chronic Traumatic Encephalopathy

Progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain traumaNormal 45 year-old former NFL player 73 year-old boxertau protein

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Concussion Legislation

Concussion Management Awareness ActPassed in NYS last fall and goes into effect in July 2012Covers public schoolsImmediate removal of athlete from game or practice if suspected concussionAthlete must be symptom-free for 24 hoursMust be cleared by licensed physicianMandates concussion education for coaches, P.E. teachers, nurses, and athletic trainers

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Concussion Legislation

State Education Department GuidelinesStrongly advise schools to develop a written concussion management policyApply to all students who have suffered a concussion, regardless of where the injury occurredNote that students should not be required to see a district-chosen provider for a fee to obtain return-to-play clearance

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Concussion Legislation

State Education Department GuidelinesEmphasize that students diagnosed with a concussion need both physical and cognitive restRecommend that districts form a Concussion Management Team Outline the role of students, parents, school staff, and medical personnel on the teamProvide suggested academic accommodations

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What is a concussion?

Mild traumatic brain injuryA disruption in normal brain function due to a blow or jolt to the headCT or MRI is almost always normalInvisible injury

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Epidemiology

of ConcussionFalls, motor-vehicle accidents, and assaults are the most common causes20% are sports-related (with a higher percentage among adolescents) Only 10% of sports concussions involve loss of consciousnessRisk of TBI is 4-6 times greater after one, and 8 times greater after two

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Epidemiology

1.6 to 3.8 million sports concussions each year in the United StatesFootball, hockey, and soccer are the riskiest male team sports Soccer and lacrosse are the riskiest female team sportsConcussion can occur in any sport

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Mechanisms of Injury

Complex physiological processsudden chemical changestraumatic axonal injury

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Neurometabolic Cascade

(Giza and Hovda 2001)Abrupt neuronal depolarizationRelease of excitatory neurotransmittersChanges in glucose metabolismAltered cerebral blood flowThe brain goes into an ENERGY CRISIS that usually last up to 7 – 10 dayssymptoms often get worse before they get better

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Traumatic Axonal Injury

Brain is shaken and rotated inside the skullStretching and tearing of axons

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Common Physical Symptoms

HeadacheNausea and vomitingFatigue and lack of energyClumsiness and poor balanceDizziness and lightheadednessSleep problems

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Vision Problems

Blurred or double visionBothered by bright or flourescent lightEyes tire more easilyTrouble reading (e.g., words move on the page, skipping words or lines)

Standard eye exam usually shows normal ocular health and acuity

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Common Emotional Symptoms

IrritabilityAnxiety or depressionExtreme moodsEasily overwhelmedPersonality change

Lack of motivation

Emotional outbursts

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Common Cognitive Symptoms

Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’Easily confusedSlowed processingEasily distracted Memory problems

Trouble reading

Poor mental stamina

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Exertion effects

Symptoms are worsened by . . . mental effort environmental stimulation emotional stress physical activity

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Full recovery in 7-10 days. . .

in most casesSymptoms can last weeks or monthsSymptoms can significantly disrupt academic functioningRisk of depression and anxiety

Recovery from

Concussion

a

‘miserable minority’

experience persistent symptoms

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Risk factors for complicated recovery

Re-injury before complete recoveryOver-exertion, especially early after injurySignificant stress

Unable to participate in sports or exercise

Medical uncertainty

Academic difficulties

Prior condition

TBI or migraine

Anxiety

ADHD

Post-concussion syndrome

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Principles of Concussion Management

Avoid re-injury until recoveredAvoid over-exertion during recoveryEarly education and reassurance improves outcomeReturn to school gradually with accommodations as neededReturn to play must follow a medically supervised process

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Managing Complicated Cases

In cases of prolonged recovery (more than 2-3 weeks) or when there is a history of multiple concussions, consider referral to a specialized Concussion Management Program

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Little research to guide treatment

Education and reassurance are often the most helpfulSub-symptom threshold exercise may promote recoveryMedication can help sleep, headache, mood, nausea, and other symptoms

Vision problems often respond well to treatment

Rehabilitation of

Complicated Cases

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Zurich

2012 GuidelinesTreat every concussion seriouslyTreat elite and non-elite athletes the sameRecovery may take longer in children and adolescents

4th

International Conference on Concussion in Sport

FIFA IOC IIHF

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Zurich Return to Play Guidelines

Any athlete who show ANY symptoms or signs of a concussion:athlete should not return-to-play in the current game or practiceAthlete should be monitored for deterioration for 24 hoursreturn-to-play must follow a medically supervised stepwise process

athlete must be symptom-free at rest

and

after exertion

When in doubt – sit ‘em out

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Zurich Return to Play Progression

No activity, complete restLight aerobic exercise but no resistance trainingSport specific exercise and progressive addition of resistance trainingNon-contact training drills

Full contact training and scrimmage

after medical clearance

Game play

Also should be symptom-free after

mental exertion

and have normal neruocognitive test results

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NYSPHSAA

Concussion ChecklistFirst completed by coach or trainer on the sidelineFollows athlete until cleared to RTPReviewed by trainer and school medical director after doctor clearance

Improves communication

Enforces proper protocol

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Neuropsychological Testing

In Sports ConcussionComputerized tests that measure attention, memory, and processing speedSensitive to effects of concussionTests can be repeated multiple times to monitor recoveryHelpful tool in making RTP decisions, and can also guide academic interventions

Pre-injury

baseline

testing can be done

ImPACT, CogSport, HeadMinder

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Striking a balance . . .

Medical need for rest and reduced exertion or stimulationAcademic need to maintain progress and avoid falling too far behindConcussion in the ClassroomParents, school staff and medical professionals need to work together !

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Guidelines for Return to School

after ConcussionOut of school at first if necessary, and then gradual re-entry as toleratedAvoid re-injury in sports, gym classs and crowded hallways or stairwellsProvide academic accommodations

Communicate and Educate

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Academic Accommodations

Rest breaks during school in a quiet location (not always the nurse’s office)Reduced course and work loadDecrease homeworkAvoid over-stimulation, (e.g., cafeteria or noisy hallways)Extra time and a quiet location for tests

Provide reassurance and support

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P.E. Accommodations

Avoid re-injuryBalance, vision, and reaction time may all be affected by concussionAvoid physical and mental over-exertionIncreased HR or BP may increase symptomsLights and noise in gym or at a sporting event will aggravate symptoms

Minimize exertion in first 1-2 weeks

Increase activity gradually, as tolerated

Don’t substitute mental activity for physical activity !

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Return-to-Learn Resources

REAP Program (McAvoy, 2009)www.rockymountainhospitalforchildren.com

Upstate

Concussion in the Classroom

brochure and video

www.upstate.edu/concussion

Centers for Disease

Control and Prevention

www.cdc.gov/concussion

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Summary

Concussion is a brain injuryMost people are better within a week, but recovery can take monthsPhysical and mental rest are important, especially right after injuryAvoid re-injury and over-exertion during recovery

Go back to activities gradually and monitor effect on symptoms (serial assessment)

Return to risky activities only when fully recovered

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Thanks !

upstate.edu/concussionriegerb@upstate.edu