Transcript Slide 1
DESIGNING AND IMPLEMENTING A SUCCESSFUL MIDDLE AND UPPER SCHOOL CONCUSSION EDUCATION AND PREVENTION PROGRAM: FROM IDEA TO IMPLEMENTATION Concussion history Ancient Greeks described “commotion of the brain” characterized by hearing, vision and speech loss Persian Physician, Dr. Razi, in 10th Century AD first described concussion as a distinct brain injury First termed Cerebral Concussion Transient loss of function with no physical damage 16th Century, term concussion more widely used and symptoms such as memory loss and confusion recognized 1928, Dr. Martland (JAMA) described a condition in boxers called Punch Drunk Extremities affecting gait, mental confusion (drunk appearance) Tremors, vertigo, deafness Single or repeated blows causing hemorrhaging Theory was these repeated head blows caused the condition (50%) Recent History 2006 article in Practical Neurology identified 41 different definitions Grading scales implemented (gr. 1, gr. 2 & gr. 3) 2004 International conference recommended abandoning scales for simple vs. complex Same international meeting in 2008 recommended abandoning simple vs. complex Same international meeting in 2012 recommended recognized the complexity of a concussion or mTBI What’s the Problem? Estimates elusive Reporting inconsistent Short-term – length? Long-term Transient symptoms Evaluation Media Follow-up care Parents Teachers Athletes Healthcare providers What responsibilities do we have? What’s the Solution? Pass Laws! AB 25 (1/1/2012) – Head injury letter & removal from play until evaluated by licensed healthcare provider AB 1451 (1/1/2013) – Coaches education AB 2127 (7/21/2014) – amended AB 25 Contact restrictions for football – (2) 90-min sessions/wk Gradual RTP protocol Evaluation by a licensed healthcare provider, trained in the management of concussions and cleared for return to activity Liability and Ethical Considerations Doctor shopping Pressure from coach/parent/player Waivers to share medical information between coaches, administrators and teachers Ulterior motives regarding postconcussion symptoms and academic considerations – ACT, SAT, AP’s Athlete/parent autonomy vs. protection from harm? Goals Provide a framework for developing an effective concussion program Use evidence-based research Provide consensus statements about best practices in absence of evidence Learn from all my mistakes Questions The Beginning Indentify and define the problem Provide evidence-based material Consensus in absence of EBM Form a team to answer questions about the problem Outline what you want your program to look like Small select sample trials Dynamic process Defining a Concussion Concussion – From Latin “Shake Violently” Merriam-Webster - a stunning, damaging, or shattering effect from a hard blow CDC - A concussion is a type of traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Mayo Clinic - A concussion is a traumatic brain injury that alters the way your brain functions Definition of a concussion In 2012, leading medical experts from around the world gathered in Zurich, Switzerland to provide management guidelines for sport-related concussions. Below was the proposed definition: ”Concussion is a brain injury and is defined as a complex pathophysiological (physical, cognitive and emotional) process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include” Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurological function (headache, dizziness, amnesia, etc) that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of hours. Concussion may result in a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard or structural neuroimaging studies. Concussion results in a gradual set of clinical symptoms that may or may not involve loss of consciousness. How Complex? Signs and Symptoms 4 Categories – 26 listed signs/symptoms Physical – Headache, dizziness, nausea Cognitive – Mental fog, difficulty concentrating/remembering Emotional – Irritability, sadness, change in personality Sleep – Drowsiness, sleep Symptom Breakdown Dizziness and Balance Subjective vs. Objective Vestibular (vertigo) Visual Cardiovascular (syncope) Dizziness tested using Postural/balance testing – BESS, Trendelenburg Self-reporting - scales Balance typically resolves within 3-7 days (BESS) Specific studies have shown between 4 wks & 3 months Symptoms and Recovery Days until Symptom Resolution Identifying the Problem Concussion rates per sport/position Concussion rate exposures Practice vs. games Frequency of hits Dr. Cantu – Hit count initiative Magnitude of hits Concussion by gender Concussion rates by age Concussion Rates Concussion Rate Breakdown % of Injuries per Sport Concussion rates: Rec vs. Sports Frequency/Magnitude/Games vs. Practice Football Median 20.5g Median 973 linear head acceleration – (range 10.0-152.3 g) rotation head acceleration – rad/s2 (2.9 - 7701 rad/s2) Threshold from previous research 98 g 76% of impacts above threshold Total impacts ranged from 129-1258 (avg. 400-600) Highest number of impacts - top of head (44%) Dr. Cantu Hit Count Threshold There is no single acceleration threshold for concussion. A growing body of literature indicates that subconcussive impacts, which do not cause clinical symptoms apparent to the athlete or to a medical professional during a sideline examination, may still change the way that the brain functions and may cause structural damage. There is not yet evidence of a minimum threshold for subconcussive damage to occur. 20 g’s is the ideal threshold because it is the lowest level that will capture abnormal acceleration Mechanism: Player/Surface/equipment Risk Factors Identify and Address Population High school Middle school Club sports Recreation sports – skiing, snowboarding, wakeboarding, etc Do other concussion management programs exist in your area Relationships in community – Tap your population Internet resources CDC: Heads up Concussion program The Dream Team Should consist of: Administrators – dean of students and head of school Parents – current, past and experienced Medical staff – ATC and school nurse Physicians - orthopedics, pediatrics, neurosurgeon, neuropsychologist, neurologist and psychologist Coach (s) Paid or unpaid? Discuss standard of care in community Discuss protocols for return to school and athletics Documentation Additional Considerations Insurance PPO HMO Out-of-pocket Out-of-network Geographical considerations Language barriers Cultural barriers Religion Continuing education for staff Protocols Evidence-based Credibility Absence 2012 of evidence? Zurich statement Available resources Commitment from parents administration, teachers, coaches & community? Protocols Information and education Parents – open communication; meetings, website, newsletters Teachers and administrators – academic return Athletes – expectations and education Coaches – lines of communication and return to play Preseason screening for athletes What instruments to use ImPACT, Axon, Headminder - neurocognitive King-Devick – ocularmotor testing BESS, BioSway, Neurocom – vestibular Advantages – easy to administer & rapid results Disadvantages- interpretation and use of results Considerations: resources & cost Protocols Sideline assessment Immediate care instructions? Short-term care instructions? Who performs Who removes from competition Who communicates with parents, coaches, administration and media? Cognitive Academic Social Physical Long-term care (>10 days) Return to academics Return to Athletics 4 Factors for Recovery Resolution of symptoms at rest Post-concussion testing performance Step-wise academic return Step-wise physical exertion testing Rolling it out Planning and communication Campus or district departments Technology - laptops Facilities – tables, desks, chairs Computer labs – software is updated, mice Supervision of testing – coaches, parents or staff Communication system – web-based Start small Pick one or two sports Follow protocol for entire season Learn from Others One Hit Away http://www.onehitaway.org/ Example of a High School/Middle School Program http://www.punahou.edu/athletics/concussion/index.as px Sport Legacy Institute http://www.concussionchecklist.org/checklist/ If you're not making mistakes, then you're not doing anything. I'm positive that a doer makes mistakes. John Wooden Experiences Assuming every physician is knowledgeable about concussions Assuming every physician is knowledgeable about best practices Assuming parents are responsible Assuming athletes are responsible It’s a dynamic process Myths and Fallacies Equipment prevents concussions Mouth guards Helmet add-ons – football/soccer Throw-out the Grading Scales Mild Moderate Severe Numbered grading Trash them all and treat as individual Knowledge is Key! Stay up-to-date on research Expert contacts Strong support system Administration Parents Physicians Questions