9/23/2016 Disclosures No financial conflicts of interest. - - PDF document

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9/23/2016 Disclosures No financial conflicts of interest. - - PDF document

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9/23/2016 Disclosures No financial conflicts of interest. Sport-Related Concussion Research Funding from: Under Armour Guidelines What is the Current Standard of Care? NCAA/DOD Grand Alliance Care Consortium State of DE

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9/23/2016 1 Sport-Related Concussion Guidelines – What is the Current Standard of Care?

Thomas W. Kaminski, PhD, ATC, FNATA, FACSM, RFSA Professor/Director of Athletic Training Education University of Delaware

Bayhealth Trauma Lecture Series Fall 2016 Kent General Hospital Dover, DE

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Disclosures

  • No financial conflicts of interest.
  • Research Funding from:

– Under Armour – NCAA/DOD Grand Alliance Care Consortium – State of DE Economic Development Office – AVEX/Footbeat Medical Advisory Board – Tekscan, Inc.

  • Have performed R&D work for Triax, Inc. but have

received no financial compensation as a result.

  • Isokinetic International website support.

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Concussions Can Happen Anywhere!

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Concussion

  • Definition - a clinical

syndrome characterized by immediate and transient post- traumatic impairment

  • f neural functions,

such as alteration of consciousness, disturbance of vision, equilibrium, etc... due to brain stem(connects cerebral hemispheres with the spinal cord) involvement

Analogous to ice cubes in a glass of water!

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CDC’s Concussion Video

4 Athletic Training Research Laboratory Athletic Training Research Laboratory

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Medical Personnel and Coaches 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

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School coaches often ill-equipped to spot, manage concussions

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http://medicalxpress.com/news/2015-06-school-ill-equipped- concussions.html Youth and middle school coaches were significantly less able to spot concussions, and the researchers said educational programs are needed for coaches at this younger level.

Sports-Related Concussion in the United States

CDC now estimates that 1.6 to 3.8 million sports-related mTBIs occur each year

(Langlois, et al., J Head Trauma Rehab. 2006, (5)375-378)

– In Delaware, teens and young adults (ages 15-24) accounted for 17% of all hospitalizations as a result of traumatic brain injuries (including SRC) during the reporting period of 2003-2007. – Only 8% to 19% of sports-related injuries result in LOC.*

* Guskiewicz KM, et al. Am J Sports Med. 2000; 28(5)643-650 Schultz MR, et al. Am J Epidemiol. 2004;160:937-944. Collins MW, et al. Clin J Sport Med. 2003;13;222-229.

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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 Basketball - 545,000
  • Girls Basketball - 444,000

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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

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Not Just a Football (or a “guy”) 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

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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, CTE

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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

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DE News Journal Media Coverage

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Federal Regulations on the Horizon?

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Recent Editorials in ATSHC

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Even the Kids are Involved Too!

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http://www.kidsconcussion.com/index.html

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9/23/2016 4 So What’s The Big Deal for Health-Care Professionals?

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Lower Liability Standard for Coaches During Competition http://www.parksandrecreation.org/2015/M ay/Lower-Liability-Standard-for-Coaches- During-Competition/ http://www.claimsjournal.com/magazines/special-report/2014/02/17/244535.htm

The Rising Score of Youth Sports Head Injury Claims

Part I – The Legal Stuff

– Terminology:

  • Liability – legal responsibility!

– Check your job description and duties as either a physical educator or coach (or both)

  • Standard of Care - the legal duty to provide health care services

consistent with what other health care practitioners of the same training, education, and credentialing would provide under the circumstances

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Strategies for Avoiding Legal Liability

  • Build relationships
  • Insist on a written contract
  • Obtain informed consent
  • Provide physical exams
  • Know the profession and its

standards

  • Document hazards

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Strategies for Avoiding Legal Liability

  • Establish policies
  • Document activities
  • Maintain confidentiality
  • Provide proper instruction
  • Supervise your staff
  • Participate in CE
  • Recognize your qualifications
  • Maintain insurance coverage

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No Need to Worry I’m Well-Versed in Treating Sport-Related Concussion!

  • With more attention in the media on SRC’s the public has become

more educated about the problem (some high-profile athletes involved)

  • Coaches and physical educators have become a target of lawsuits

alleging failures to meet the “standard of care”.

  • In cases of unfortunate events the actions (or inactions) of the coach

and/or physical educator are likely to be second guessed or blamed.

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Legal Attacks Typically Involve:

  • The evaluation or testing of an athlete (or lack

thereof)

  • Documentation of the injury
  • Communication with the athlete or with a

physician about an athlete

  • Education of the athlete

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Let’s Take a Look at Federal Concussion Legislation

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HR829 - SAFE PLAY Act

State Legislators Want a Piece of the Action Too!

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State Concussion Legislation

  • Most State Legislation follows these main

components:

– Improve education on concussion and increase awareness – Immediate removal of any athlete suspected of sustaining a concussion (coach, athletic trainer or

  • ther medical personnel)

– Can not return to activity until properly cleared (individuals capable of clearing athletes differ from state to state)

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Is Your State Impacted?

  • Check out -

http://www.ncsl.org/research/health/trau matic-brain-injury-legislation.aspx

  • Sample of State of Delaware legislation:

– Vol. 78 Del. Laws, Chap. 192 (2011 SB 111) Requires the Delaware interscholastic athletic association to adopt regulations to address the appropriate recognition and management of student athletes exhibiting signs and symptoms consistent with a concussion during practices, scrimmages and interscholastic contests. This law also requires the signing

  • f an informational sheet by students and their parents or

guardians.

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HB404 recently signed to protect ALL youth athletes in State of DE

Will This Legislation Change Things?

  • Policy Evaluation of State Youth Sports

Concussion/Return to Play Legislation

– Cloudburst has been awarded a contract with the Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC) to conduct a policy evaluation of the implementation of state youth sports concussion/return to play laws, to report on and develop materials to disseminate key findings. Cloudburst will assess the implementation of youth sports concussion/return to play legislation from two states with existing legislation. Following completion of the evaluation, a report shall be created and a presentation shall be made to NCIPC that clearly demonstrates findings, promising practices, and unintended consequences of the state legislation implementation efforts.

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http://www.cloudburstgroup.com/

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What Exactly is the Standard of Care?

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NATA Position Statement

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National Federation of State High School Associations

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http://www.nfhs.org/resources/ sports-medicine/ NFHS Learning Center: Concussion in Sports – What You Need to Know

DIAA Concussion Protocol

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DIAA Concussion Regulations DIAA Regulation 1008/1009 3.1.5 Prior to resuming participation, a player who is

  • therwise properly certified to participate in interscholastic

athletics must present to the administrative head of school

  • r designee, a statement from a qualified physician that the

player is physically able to participate if one of the following conditions has occurred: 3.1.5.1 The player is physically unable to compete due to illness or injury for five(5) consecutive days on which a practice scrimmage or contest is held; 3.1.5.2 The player was apparently unconscious; 3.1.5.3 The player suffered a concussion.

DIAA Concussion Protocol

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  • 1. If an athlete exhibits signs and symptoms consistent with a concussion, they shall be removed

from play immediately. [Be aware of the sport specific rule covering possible concussions] A qualified health care professional must then determine whether or not an apparent concussion has occurred. If one of the aforementioned 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, according to DIAA regulation 3.1.5, “the athlete may only return to practice/game after the administrative head of school or designee receives "written clearance" from a qualified

  • physician. 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 provider or qualified healthcare professional that day.

  • 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 and 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.

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DIAA Concussion Protocol

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  • 3. "Written Clearance from a qualified physician” for return to play after a

potential concussion shall be a MD/DO only. The preferred method would be to use the form that is attached. [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.

  • 4. Failure to comply with medical requirements found in DIAA regulation

section 3.0 shall result in that individual or school being considered "ineligible" and shall be penalized according to DIAA regulation 2.9- The school has used an ineligible player and thus must forfeit the contest

What Should YOU be Doing with Regard to SRC Assessment and Evaluation?

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Zurich 2012

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1) Current mgmt. consists of monitoring physical and cognitive rest as the concussed patient recovers; it would be ideal if there were some way that clinicians could expedite healing! 2) Remains work to be done with implementation of Consensus in Sport (CIS) guidelines (Zurich, 2008) 3) Need to develop strategies to transform consensus into custom – must address the gap in care worldwide! 4) Realization that the most important people involved in initial concussion intervention are those closest to the player --- coaches, referees, parents! 5) SCAT2 is the clinical “gold standard” but has limitations!

SCAT3

Maddocks D, Dicker G. An objective measure

  • f recovery from concussion in Australian

rules footballers. Sports Health 1989; 7: 6-7.

Any incorrect answer --- referral for follow-up care!

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SCAT3 SCAT3

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SCAT3

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SCAT3

SCAT3 Overall Scoring

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What About Educational Programming

Concussion in Sports - What You Need To Know

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http://www.nfhslearn.com/electiveDetail .aspx?courseID=38000

CDC: Heads Up: Concussion in High School Sports

http://www.cdc.gov/concus sion/HeadsUp/youth.html

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ThinkFirst-SportSmart Concussion Education and Awareness Program

http://parachutecanada.org/

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Nationwide Children’s Hospital: A Coaches Guide to Concussions

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http://www.nationwidechildrens.org/coachs- guide-to-concussions

A YouTube Video Worth Checking Out (Simplifies Sport-Related Concussion)

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http://www.youtube.com/watch? v=zCCD52Pty4A Concussions 101, a Primer for Kids and Parents - Dr. Mike Evans

Suggested Roles and Responsibilities

  • f the School Concussion Management

Team and School Personnel

  • Student athlete
  • Parents and guardians
  • School administrator
  • School medical advisor
  • Licensed health care professional
  • School nurse
  • Director of physical education and/or athletic director (AD)
  • Certified athletic trainer (ATC)
  • Coach
  • Teacher/school counselor/school psychologist

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http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/Concu ssionManageGuidelines.pdf

Return to Learn Considerations

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Importance of ‘Return-to-Learn’ in Pediatric and Adolescent Concussion Christina L. Master, MD; Gerard A. Gioia, PhD; John J. Leddy, MD; Matthew F. Grady, MD

  • Pediatric Annals
  • September 2012 -

Volume 41 · Issue 9: e180-e185

The concept of “return-to-play” after concussion is familiar to pediatricians who routinely care for injured student-athletes. Premature return-to-play of a student-athlete who is still injured from a concussion may result in more severe and potentially long-lasting deficits. In contrast, “return-to-learn” plans for student-athletes have not received as much attention, perhaps because so much regarding concussion awareness comes from lay reports of professional athletes who play a sport for their livelihood, as compared with pediatric and adolescent- aged athletes for whom school is their primary “work.” Pediatric and adolescent concussions have many unique features requiring special attention from the pediatrician in terms of diagnosis and management. This article addresses the importance of properly timing school re-entry.

  • 1. Prescribe physical and cognitive rest for pediatric and adolescent

concussion.

  • 2. Implement a gradual “return-to-learn” plan for student-athletes after

concussion.

  • 3. Communicate specific school-based accommodations to facilitate a

gradual reintegration to full school activities

One Final Thought – Can We Change Attitudes about Concussions at an Early Age by Utilizing Instruction by Health Educators?

  • Children’s perceptions can be molded during their early years; so

perhaps a good time to introduce concussion awareness instruction in PE and Health classes between 3rd – 5th grade?

  • The concept I propose is a “mini-model” on concussion awareness:

– When to suspect a concussion? – Who do I report it to? – What are the consequences of undiagnosed and untreated concussions?

  • Could this work?

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Today’s lecture can be viewed at the following URL address: http://sites.udel.edu/chs-atep/lectures/

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You Must Have Some Questions????

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Thank You

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