NHCS CONCUSSION & TRAUMATIC BRAIN INJURY EDUCATION REVIEW

Transcription

1 NHCS CONCUSSION & TRAUMATIC BRAIN INJURY EDUCATION REVIEW A brief discussion about concussions based on the most current data The New NC Law & what it means The practices & procedures New Hanover County Schools follow Future Considerations

2 A CONCUSSION IS: A Traumatic Brain Injury caused by direct or indirect impact to the head & more specifically to the brain. The direct or indirect impact to the head will lead to a disruption of normal brain function. This disruption ranges from subtle symptoms that may go unnoticed during your standard evaluation to the more common severe symptoms easily recognized. The impact may sometimes lead to loss of consciousness, but in most cases will not. The Concussion grading scale has ceased. One is either Symptomatic or Asymptomatic. Gfeller-Waller Concussion Awareness Act, (August 2011). CDC, (August 2011).

3 WHY ARE WE SO CONCERNED? The incidence of TBI's has increased drastically over the past 15 years Approximately 7.3 million high school students participate in interscholastic sports in the U.S. Each year million sports-related TBI's are reported every year High school athletes make up approximately 21% of these reported TBI's More than 5% of all high school athletes who participate in the traditional contact sports (football, lacrosse, hockey) will sustain a concussion every year Beaumont et al., (2011). Frommer et al., (2011).

4 A Concussion Can Occur from the following scenarios: Any form or type of blow to the head. -This can range from a very mild trauma such as a slap to the head all the way to a severe trauma such as helmet-to-helmet launching. A fall that results in impact to head and/or causes the head/brain to move quickly back and forth. -A fall from a bike or a fall while skiing -Falling down a flight of steps without making head-to-object contact. The bouncing and uncontrolled movement of the brain inside the head can cause TBI A blow to the body that causes the head and the brain to move quickly back and forth. -Such as a body-to-body tackle. The impact is at the body, but the force and motion continue through the head and causes the brain to impact against the skull Gfeller-Waller Concussion Awareness Act, (August 2011).

5 EXAMPLES OF WHEN A TBI MAY OCCUR

6 What is occurring inside Picture your brain as a floating mass inside a fishbowl. The fishbowl being your skull. You brain is not reinforced by bone structure or cushioned. It does not contract like a muscle to resist acceleration/deceleration force. So when an impact or violent motion brings the head to a sudden stop, it causes the the brain to bounce into the skull. Sometimes these impacts are so severe they can cause serious dysfunction. This dysfunction is what produces the concussion symptoms you see. CEMM, (Sept. 2011).

7 Second Impact Syndrome Second impact syndrome is a rare, yet often fatal, condition in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling and often catastrophic results. Second impact syndrome can result from even a very mild concussion that occurs days or weeks after the initial concussion. Most cases of second impact syndrome have occurred in young athletes. The Mortality rate is extremely high (up to 50% of SIS patients die) & nearly all those who suffer SIS will have permanent disability You prevent SIS by following proper treatment procedures and Return to Play Guidelines. No athlete should EVER return to physical activity or other dangerous activity when they still have symptoms CDC, (August 2011).

8 The Steps to Safe TBI management Know your signs and symptoms Watch your LAT-ATC use field exercises & cognitive tests to determine brain function Make sure the injured athlete is referred to proper medical care Properly care for the injured athlete in the following days/weeks

9 Know Your Signs and Symptoms Thinking/Remembering Physical Emotional/Mood Sleep Difficulty Thinking Clearly Headache Irritability Sleeping More Than Usual Feeling Slowed Down Fuzzy or Blurry Vision Sadness Sleeping Less Than Usual Difficulty Concentrating Nausea/Vomiting More Emotional Than Normal Trouble Falling Asleep Difficulty Remembering New Information Dizziness Balance Problems Feeling Nervous or Anxious Sensitivity to Noise or Light CDC, (Sept. 2011).

10 Research on Symptoms & Recovery Time Frommer et al., (2011) reported the following during demographic Concussion Research in High School Athletes Headache is the most commonly reported symptom in both male & female athletes Around 70-73% of male & female athletes studied were asymptomatic within 3 days 64% of student-athletes return to play 9 days after TBI 3 days asymptomatic + 6 day progression program = 9 days Just one example of why the seven day asymptomatic rule is a very smart rule to follow The average high school athlete won't be able to successfully follow proper progression protocol in less than 7 days. Frommer et al., (2011).

11 Signs & Symptoms Demographics Studies Show males have a tendency to demonstrate the following symptoms more often Amnesia confusion/disorientation Studies show females have a tendency to demonstrate the following symptoms more often Drowsiness Sensitivity to noise So yes, Male & Female Athletes may show different signs and symptoms. This does not mean their TBI is any less severe than the opposite sex Frommer et al., (2011).

12 Field Exercises To Test Brain Function Sometimes the obvious signs and symptoms are not easily noticed when an athlete suffers a TBI. Just because an athlete does not have a headache or is vomiting profusely, does not mean he/she is out of danger Certified Athletic Trainers use the following field tests to help better assess if a TBI has occurred. Balance & Postural Testing Cognitive Testing

13 Balance & Postural Testing Simple Balance testing can quickly determine if an athlete has suffered a TBI Some quick tests include Heel-to-toe walk along straight line; forwards then backwards Feet together and balance with eyes open then closed; add finger to nose One-leg balance with eyes open and then closed

14 Don't Forget the Mental Math! An Athletic Trainer will also use many cognitive exercises to test the involved athlete's brain Some simple tests you might see are ABC's backwards Starting at 100 & count backwards by specified intervals Be wary, many subjects have a hard time doing this under normal conditions Three Words Ask subject to remember three unrelated words. Ask them to repeat the words to you a short time later

15 Referral If any of the previous signs, symptoms, or testing determine there is a TBI, proper medical care needs to be activated RULE 1: If in doubt, activate EMS RULE 2: Always make sure the athlete is seen by proper medical care before returning to play (Refer to the laws and policies in your area) RULE 3: If an an athlete is worried they suffered a TBI even without obvious symptoms, refer to proper medical personnel before they are allowed to participate again.

16 Treatment Always make sure an athlete who has TBI symptoms is treated properly, fairly and most of all safely. The following suggestions are standard protocol for a recovering TBI athlete REST, do not exercise at all! Sleep Relax physically and mentally Avoid heat, sunlight, humidity, and anything that may cause dehydration (this includes hot tubs & saunas) Refrain from school-related reading/work Avoid computer use & video games Avoid text messaging excessive socializing with peers. These activities can affect the concussed area of the brain & also prolong the concussion symptoms Highly recommended that an athlete should not return to school until symptoms have cleared. Lee, M. & Perriello, V.

17 Is this a TBI? During a football game the whistle blows a play dead. An offensive lineman is seen standing up. He begins to shake his head and sways back and forth momentarily. He then proceeds to head to sideline. He states to the Athletic Trainer that he got hit hard, saw stars for a few seconds and was wobbly for a few minutes. Five minutes later he is normal. All major tests are negative and athlete has returned to baseline

18 Is This a TBI? YES! Although symptoms were very mild and resolved within a few minutes that athlete did sustain a form of TBI. His brain was effected by a direct or indirect force. He is not allowed to return to play. This is where Education & Research need to trump the traditional mentality of what a TBI/Concussion is. PLEASE UTILIZE ALL THE NEW INFORMATION AVAILABLE!!

19 THE LAW Gfeller-Waller Concussion Act Official Gfeller-Waller Concussion Awareness Act Implemented June 16, 2011 The parts of the Law Broken Down Part 1: Consent Form Part 2: RTP Rule Part 3: EAP Part 4: Record Keeping

20 Gfeller-Waller Concussion Awareness Act Official Document Gfeller-Waller Concussion Awareness Act, (August 2011).

21 Gfeller-Waller Act Part 1 All coaches, school nurses, athletic directors, first responders, volunteers, students who participate in interscholastic athletic activities, and the parents of those students shall receive, on an annual basis, a concussion and head injury information sheet. School employees, first responders, volunteers, and students must sign the sheet and return it to the coach before they can participate in interscholastic athletic activities, including tryouts, practices, or competition. Parents must sign the sheet and return it to the coach before their children can participate in any such interscholastic athletic activities. The signed sheets shall be maintained in accordance with sub-subdivision d. of this subdivision. For the purpose of this subdivision, a concussion is a traumatic brain injury caused by a direct or indirect impact to the head that Page 2 Session Law SL results in disruption of normal brain function, which may or may not result in loss of consciousness Concussion Education Form for Student Athletes Concussion Education Form for Parents, Coaches, Volunteers Gfeller-Waller Concussion Awareness Act, (August 2011).

22 Gfeller-Waller Act Part 2 If a student participating in an interscholastic athletic activity exhibits signs or symptoms consistent with concussion, the student shall be removed from the activity at that time and shall not be allowed to return to play or practice that day. The student shall not return to play or practice on a subsequent day until the student is evaluated by and receives written clearance for such participation from (i) a physician licensed under Article 1 of Chapter 90 of the General Statutes with training in concussion management, (ii) a neuropsychologist licensed under Article 18A of Chapter 90 of the General Statutes with training in concussion management and working in consultation with a physician licensed under Article 1 of Chapter 90 of the General Statutes, (iii) an athletic trainer licensed under Article 34 of Chapter 90 of the General Statutes, (iv) a physician assistant, consistent with the limitations of G.S , or (v) a nurse practitioner, consistent with the limitations of G.S Gfeller-Waller Concussion Awareness Act, (August 2011).

23 Gfeller-Waller Act Part 3 Each school shall develop a venue specific emergency action plan to deal with serious injuries and acute medical conditions in which the condition of the patient may deteriorate rapidly. The plan shall include a delineation of roles, methods of communication, available emergency equipment, and access to and plan for emergency transport. This plan must be (i) in writing, (ii) reviewed by an athletic trainer licensed in North Carolina, (iii) approved by the principal of the school, (iv) distributed to all appropriate personnel, (v) posted conspicuously at all venues, and (vi) reviewed and rehearsed annually by all licensed athletic trainers, first responders, coaches, school nurses, athletic directors, and volunteers for interscholastic athletic activities. Gfeller-Waller Concussion Awareness Act, (August 2011).

24 Gfeller-Waller Act Part 4 Each school shall maintain complete and accurate records of its compliance with the requirements of this subdivision pertaining to head injuries. All public schools in the state of North Carolina MUST be in compliance with all four parts of this Act Is New Hanover County Schools in compliance with this new law?...» YES Gfeller-Waller Concussion Awareness Act, (August 2011).

25 NHCS TBI STANDARS OF CARE Policy Links Forms <===== Policies and education are improving at all levels of sports Picture of poster in locker room of Real Salt Lake of MLS during USL open cup 2011

26 NHCS TBI Policy New Hanover County Schools in accordance with the Gfeller-Waller Concussion Act Part 1 All high schools and middle schools should have distributed and collected concussion consent forms Part 2 Athletic Directors & proper administrators should be handling communication NHCS goes above and beyond the required RTP guidelines in the law Mandatory 7 day RTP when athlete becomes asymptomatic Athlete must go through Concussion Progression Program Part 3 Athlete must have NHCS Head Injury Report/Release form filled out by Medical Doctor & returned All NHCS should have an EAP available at Each School Part 4 should continue to update their EAP periodically Schools should have taken proper procedures to file, record & document all information pertaining to their concussion injuries

27 Web page Links to TBI Information NHCS TBI/concussion forms & practices can be found at Provides one-stop for most concussion information Continue to update and add forms Centers for Disease Control and Prevention (CDC) TBI information can be found at Excellent source of all information pertaining to head injuries Gfeller-Waller Concussion Awareness Act Provides updates pertaining to NC Concussion TBI law Provides resources from Matthew Gfeller Foundation

28 New Hanover County Schools Athletic Head Injury Report/Release Form (in compliance with NCHSAA form) This Form must be filled out by school's Athletic Trainer & sent with injured athlete to Medical Doctor MD must fill out and return form If there is no ATC at school (middle schools), attending MD must fill out entire form to best of knowledge

29 North Carolina High School Athletic Association RTP medical form Vs. NHCS Form Does not provide minimum RTP days Dangerous because law can be interpreted in different ways Athlete could still be allowed to return too quickly after symptoms subside if MD is negligent NHCS form provides more specific information to better evaluate TBI

30 NHCS Concussion Progression Program Progression Program for Return to Play (steps can not be performed on same day) The following progression steps must be taken before an athlete can return to full sport specific activity 1. After symptoms resolve, low levels of physical activity (i.e. symptoms do not come back during or after the activity). Includes walking, light jogging, light stationary biking, and light weightlifting (low weight moderate reps, no bench, no squats). 2. Moderate levels of physical activity with body/head movement. This includes moderate jogging, brief running, moderate intensity on the stationary cycle, moderate intensity weightlifting (reduce time and or reduced weight from your typical routine). 3. Heavy non-contact physical activity. This includes sprinting/running, high intensity stationary cycling, completing the regular lifting routine, non-contact sport specific drills (agility with 3 planes of movement). 4. Allowed to return to full contact in a controlled drill or practice. 5. Return to competition

31 NHCS When to Return to Play/Activity (RTP) Concussion Minimum Time After Being Asymptomatic Before Being Allowed to Return to Activity (Must be Asymptomatic with Normal Neurological Assessment at Rest and with Exercise:) First Concussion Second Concussion Third Concussion MINIMUM 1 week (7 days) & follow progression program. RTP can be withheld even longer if MD specifies to do so. MINIUM 2 weeks (14 days) & follow progression program. RTP can be withheld even longer if MD specifies to do so. OUT FOR SEASON

32 Future Considerations Sport Concussion Assessment Tool 2 (Scat2) Positives Could Replace current post-concussion evaluation forms used in county A low cost standardized protocol Accurate. Negatives Smart phone applications available Need durable forms for all medical personnel for on-field use Time Consuming Could county-wide computer program be created? Most applications for phones cost $ Already have post-concussion assessment forms to use

33 Future Considerations Pre-participation baseline TBI testing Concussion Vital Signs: computer/web-based baseline & follow-up testing The most affordable program on the market. Endorsement of Kevin Guskiewicz of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center. High School TBI safety trends indicate that a pre-participation program is going to be required sooner than later Must organize plan before administering Where do athletes take test? Who helps administer tests? When do athletes take the test (summer, fall etc.)? Does pre-participation testing really prevent more TBI's from being misdiagnosed? Does pre-participation testing increase false positive results?

34 Conclusion Traumatic Brain Injuries, no matter how mild they seem, are far more concerning than even the most debilitating knee/shoulder/ankle injuries Information published as recent as has completely changed the concussion/tbi standards of care.

35 Conclusion New Hanover County Schools must continue to stay ahead of the ever-changing face of these head injuries Don't forget: Lets not overlook other serious health ailments in the process Heat-related illnesses are becoming more prevalent Pre-Existing cardiac conditions continue to slip pass basic medical screenings When In Doubt Be Smart and Safe

36 Created by: Matthew Triche LAT, ATC Presented by: Dr. Rick Holliday

37 References Beaumont et al. (2011). Persistent Motor System Abnormalities in Formerly Concussed Athletes. Journal of Athletic Training, 46(3), May-June Frommer et al. (2011). Sex Differences in Concussion Symptoms of High School Athletes. Journal of Athletic Training, 46(1), Jan.-Feb Gfeller-Waller Concussion Awareness Act (2011). Retrieved from Gfeller-Waller Concussion Awareness Act Website: Injury Prevention & Control: Traumatic Brain Injury (2011). Retrieved from Centers for Disease Control and Prevention: Lee, Michael. Perriello, Vito. (2009). Adolescent Concussions Management Guidelines for Schools. Connecticut Medicine, 73(3), Mar Traumatic Brain Injury: The Journey Home (2011). Retrieved from Center of Excellence for Medical Multimedia: