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 linear head acceleration –

20.5g (range 10.0-152.3 g) Median rotation head acceleration –

973 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 of evidence?

2012 Zurich statement Available resources Commitment from parentsadministration, 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 resultsDisadvantages- interpretation and use of results Considerations: resources & cost

Protocols

Sideline assessment Who performs Who removes from competition Who communicates with parents, coaches, administration and

media? Immediate care instructions? Short-term care instructions?

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/concussi

on/index.aspx 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