The Next Asbestos: Traumatic Brain Injury and Unionization of Athletes Mike Otworth, CPCU, ARM Senior Unit Claims Manager Genesis Management & Insurance Services Corporation Randy P. Cohen, ATC, DPT Associate Athletics Director for Medical Services University of Arizona Jean Demchak Public Entity and Education Leader Marsh
Collegiate Athletics A Broad Spectrum of Risk
Low Risk
Higher Risk
Even Higher Risk
And This
Sometimes Leading to This
Youth Athletics The Stats More than 3.5 million kids under age 14 receive medical treatment for sports related injuries every year Typically, the rate and severity of injury increases with a child s age According to the CDC, more than ½ of all sports injuries in kids are preventable! *Source: www.stopsportsinjuries.org
By age 13, 70% of kids stop playing youth sports. The top three reasons: Adults Coaches Parents More Numbers
Concussion A complex injury to the brain caused by a traumatic force resulting in many different symptoms or signs Functional Brain Injury Can happen in any sport Different in each athlete The Injury and the Symptoms are still under reported
Concussion Myths You have to be hit in the head to sustain a concussion You must lose consciousness to have a concussion Every concussion needs a CT or MRI A negative CT or MRI rules out a concussion There is a concussion proof helmet If you have three concussions you must stop playing contact sports Concussion is the same for all ages of athletes Every hit to the head is a concussion
Current Return to Play Recommendations CDC Heads Up Program Recommends immediate removal from play of any athlete who is suspected of suffering a concussion. American Academy of Pediatrics ( AAP ) Under no circumstances should a young athlete with a concussion return to play the same day as his/her concussion.
NCAA Requires that all of its member institutions have a concussion management plan for student athletes University of North Carolina ( UNC ) UNC Sport Concussion Policy is a comprehensive protocol for determining an athlete s readiness to play following a concussion When a concussion is suspected, an athlete must be evaluated for symptoms, neurocognitive function, and balance; the findings are then compared to pre season baseline testing Five Step Graduated Exertional Return to Play Protocol
NCAA (cont.) University of Michigan If in Doubt, Sit it Out. Jeffrey S. Kutcher, M.D. Kutcher, et. al recently completed concussion study and published new concussion guideline.
Second Impact Syndrome Can occur when an athlete returns to play too soon after suffering an initial concussion and suffers another one High fatality rate among young athletes Remember this name Zackery Lystedt.
Post Concussion Syndrome Concussion symptoms that last for weeks to months to year. Can be life changing
Chronic Traumatic Encephalopathy (CTE) Suspected to Result from the cumulative effect of repeated concussions Leads to long term abnormalities, such as decreased cognitive function Also known as dementia puglistica because it was first noticed in brains of young career boxers Symptoms: loss of attention and concentration, memory loss, confusion, depression, impulse control, headaches, dizziness Can only be diagnosed through autopsy
CTE Claimed to have been found in autopsied brains of over 20 former NFL players and at least one college player Owen Thomas, a Penn football player hanged himself after suffering a sudden and uncharacteristic emotional collapse; to the surprise of many, his brain showed signs of early stages of CTE
Recent Concussion Study Researchers at University of Pittsburgh School of Medicine recently completed a study on concussion brain damage Study revealed damage to white matter that resembles early stages of Alzheimer s disease Further research needed to examine long term effects
Recent Concussion Study Out of Purdue The most important implication of the new findings is the suggestion that a concussion is not just the result of a single blow, but it's really the totality of blows that took place over the season," said Eric Nauman, an associate professor of mechanical engineering and an expert in central nervous system and musculoskeletal trauma. "The one hit that brought on the concussion is arguably the straw that broke the camel's back "However, we are finding that there is actually a lot of change (on fmri) even when you don't have symptoms." said Larry Leverenz, an expert in athletic training and a clinical professor of health and kinesiology.
Recent Concussion Study Out of Tulsa Measured Hippocampus of the brain in FB players and control group Hippocampus controls many cognitive and emotional processes Collegiate football athletes: had smaller hippocampus vs controlled even without concussions. Also there was a significant inverse relationship of concussion and years of football played with hippocampal volume. Years of football experience also correlated with slower reaction time. Possible brain structural changes without concussion or known symptoms
Approximately a dozen lawsuits have been filed against the NFL claiming that the league and its doctors knew the long term risks of concussions and failed to protect the players SETTLED! AUGUST, 2013 $765 Million NFL Lawsuits REJECTED BY JUDGE!!!» NOT ENOUGH $...
NCAA LAWSUITS Two cases currently consolidated in the Northern District of Illinois seeking class action status Arrington v. National Collegiate Athletic Association NCAA has rejected these claims NCAA has a greater exposure than the NFL NCAA s history with concussions is being questioned
Sample Cases Zemke v. Arreola, et al., 2006 WL 1587101 (Cal. Ct. App.): 16 year old sustained severe head injury during varsity football game and returned to play in same game. Parents sued coaches and school district for negligently allowing player to return to play. Case dismissed on basis of assumption of risk. Cerny v. Cedar Bluffs Junior/Senior Public School, 267 Neb. 958 (Neb. 2004): H.S. football player sued school and school district alleging negligence for allowing him to return to play following a concussion, thereby leading to SIS; case dismissed
Zachery Lystedt Six years ago, 13 year old Zackery Lystedt was playing middle school football when, late in the first half, he tackled an opponent and knocked his head on the ground. A video of the game shows Zack lying on the ground with his hands clutching both sides of his helmet. The official called a time out and Zack was sidelined for just three plays before half time. While Zachary felt rattled after the hit, he shook it off and by the start of the third quarter he was back in the game. After the second half, Zackery collapsed on the field and was rushed to the hospital. It was discovered that Zackery had suffered a traumatic brain injury and was hemorrhaging; he was diagnosed with SIS. Though doctors were able to save his life, Zackery spent three months in a coma and underwent intensive therapy before he could speak or eat again on his own. He remains in a wheelchair to this day. After life saving surgery to remove the left and right side of his cranium to relieve pressure on his injured and swelling brain, Zackery suffered numerous strokes, spent days on a ventilator and three months in a coma before he awoke. Then, the hard work began. Zack spent four weeks in a nursing home, two months in a children s hospital for rehabilitation, nine months before he spoke his first word, 13 months before he moved an arm or leg, and 20 months on a feeding tube. It took three years before Zack was able to stand, with assistance, on his own. A lawsuit filed by his family against the school district reportedly settled for $14.5 million, without the school district admitting liability. The Lystedt Law: A Concussion Survivor s Journey, http://www.cdc.gov/media/subtopic/matte/pdf/031210 Zack story.pdf.
Journey Bailey v. Sherwood High School 15 year old JV player suffered a concussion during game but did not see doctor until 7 days later Player allegedly given OK by doctor to play 2 weeks later Sustained second hit which resulted in second impact syndrome Suit filed against both high schools
Athletic Trainers and Medical Staff
If an individual athlete s best medical interests conflict with the performance expectations of authority figures (coach, parent, administrator), does your system allow the healthcare provider the autonomy to make the right decision without risk to their job or position at your institution?
Priorities of Medical Staff 1. Safety and well being of student athlete 2. Protect the institution and its employees 3. Help the individual and/or team be successful on the field 4. Be fiscally conservative
Does Your Program Set You Up For Success? Do you have health care providers who practice patient centered care? Inter Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges. Courson et al 2013
Team Physician and Athletic Trainers Does your U/C have a designated team physician? Does your U/C have a written agreement with physician that includes roles and responsibilities? Does the Athletic Trainer and Physician have ultimate authority for making medical decisions regarding the athletes' safe participation? Does physician evaluate athletic trainer on the health care he/she delivers? Does your U/C have access to other specialists when needed?
Article in The Chronicle of Higher Education (September 2013) Coach Makes the Call Athletic trainers who butt heads with coaches over concussion treatment take career hits Survey 101 Head AT s or FB AT s 11 said they reported directly to the football coach or a member of the coaches staff 32 said a member of football coaching staff had influence over hiring or firing for their position 53 said they had felt pressure from FB coaches to return a student to play faster than they thought was in his best interest medically 42 said they felt pressure from FB coaches to return an athlete to the field even after he suffered a concussion
Do you have the appropriate number of athletic trainers? Care vs. Coverage Travel Coaches expectations Athletic Trainers Appropriate medical care for intercollegiate athletics document
Athletic Trainers, cont. Resources available to do their job? Studies have asked ATs why they have not done baseline concussion testing, have adequate AED s or done screenings such as Sickle Cell Trait, and many times the answer has been that financial resources were not available. BOC Facility Principles: http://www.bocatc.org/resources/facilityprinciples
Athletic Trainers, cont. Oversight and Supervision of AT s There should not be a supervisory relationship where members of the sports medicine team report to a coach due to both perceived and real conflict of interest. A coach should not have the ability to hire or dismiss any member of sports medicine team!
Athletic Trainers, cont. Owing an obligation to athlete welfare, the institution must establish a clear line of unchallengeable authority to the team physician and athletic trainer. The ability to act unencumbered fosters perceptual, if not actual, best interest medical decisions for and by athletes.
Please reach out and get to know the athletic trainer at your institution!
Managing the Concussion Risk Establish a protocol Baseline testing Know your state law Training in symptom recognition Coaches, players, parents, and teachers Personal responsibility and knowledge of the risks Be aware of the current science and recommendations regarding protective headgear If you can t do it in a reasonably safe manner, don t do it!
Baseline Testing Perhaps the most effective means by which to be prepared for a management of concussion Done in pre season Pre participation exam with previous history of concussion investigated Neuropsychological exam (ImPACT most popular but not only one) Measures cognitive function prior to athletic participation After concussion treating physicians are able to compare the postinjury cognitive function with the pre injury function Balance Assessment Multiple different types May decide to do on only on SA in high risk sports
Know the Law States with Concussion Statutes (and enacted date) Arizona April 2011 Oklahoma May 2010 Colorado March 2011 Oregon June 2009 Connecticut May 2010 Rhode Island June 2010 Idaho April 2010 South Dakota March 2011 Iowa April 2011 Texas April 2011 Massachusetts July 2010 Utah March 2011 New Jersey December 2010 Virginia April 2010 New Mexico March 2010 Washington July 2009 North Dakota April 2011 Mississippi 2014
Establish a Protocol Every school and athletic program should have a protocol in place if a head injury is suspected For example, an athlete displaying any signs of concussion or brain injury, no matter how seemingly mild, should be required to sit out from play immediately, and should not be permitted to return to play without a doctor s permission Complies with state law There is tremendous risk to both the athlete and the team/school/organization in allowing an athlete to return to the field of play too soon following a blow to the head. As the Zackery Lystedt story demonstrates, if an athlete is allowed to return to play prematurely, it can lead to significant further injury and even death. The decision to allow a player to return to action is perhaps the most significant decision made as it relates to the health of a player. It should never be taken lightly, and protocols must be in place for the organized and reasoned handling of this decision
Training in Symptom Recognition All coaches, athletic trainers, and athletic personnel should be trained in how to recognize signs of concussions and other brain injuries Document training
Training of Academic Personnel In many instances, a player can inconspicuously suffer a head injury; in these situations, the player may keep playing and return to school as if all was normal Young athletes do not always recognize the signs of a head injury, and at times, they may ignore the signs, believing they are young and invincible To combat this type of scenario, teachers should be trained in the identification of possible head injuries, and a protocol should be implemented directing a teacher who suspects a possible head injury is to alert the school s medical staff This system also acts as a check and balance on coaches who may be overly aggressive as it relates to returning players to the field following a possible head injury May not be feasible in larger institutions Larger institutions may need to rely on notification of professors after concussion Best Practices!!!
Training of Parents and Student Athletes NCAA requirement for student athletes Schools should consider holding pre season meetings with parents of student athletes to provide information about head injuries and the detection thereof Parents and student athletes need to know the signs of head trauma and should be part of the team when it comes to monitoring the health of student athletes
Personal Responsibility and Knowledge of the Risks Parents and student athletes should also be made fully aware of the risks of injury that accompany athletic participation The athletes should only participate in sports once they and their parents are made aware of the risks This should be accompanied by the review and execution of a written acknowledgment of the risks by all parties
Stay Current Football programs should be aware of the most current standards and recommendations for helmets, including when to recondition helmets and when replacement is necessary. The National Athletic Equipment Reconditioners Association ( NAERA ) announced in March 2011 that it will no longer recondition/recertify any helmet ten years of age or older. Although there are no formal recommendations in place, and practices vary, most high schools recondition helmets at least every two years. The NAERA also certifies face guards, as well as helmets for lacrosse, softball, and baseball. Sports programs should be aware of the most current recommendations and developments regarding protective headgear for their respective sports. For example, although not mandated, some soccer players who have suffered a concussion, or who want to be cautious, are donning protective head gear to protect themselves against collisions with other players and repeatedly heading the ball.
January, 2014: Major League Baseball approved the first Padded Caps for use by pitchers. isoblox Stay Current, cont.
Be Smart! When in doubt about whether a law or recommendation applies to a particular program or sport, err on the side of caution and comply Have adequate personnel (AT s and physicians) to manage concussions and make sure they have the autonomy to do their job Any decision a program makes not to implement a widely recommended protocol or return to play policy may come back to haunt it
Unionization of Athletes Student unionization efforts Graduate students Scholarships at risk? Impact on Workers Compensation Professional sports response Potential considerations Attrition of Athletic Programs?
Thank You