Mark Bramble, ATC, MS

Marlboro High School

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVELWHY THE HUGE CONCERN??

It’s the biggest story in sports at all levelsEvolving research of the long term effects

History of playing w/symptoms Mis-diagnosis Lack of reporting 2nd impact syndrome Depression Suicide Alzheimer's Neurological effects

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVELWHY THE HUGE CONCERN??

Young population is at the greatest risk High school age children are at a critical stage of brain

development. Reason for not comparing concussion management of

NFL players to how we treat high school athletes.

130,000 concussions reported in high school sports per year reported by the CDC Current research shows that this is probably 10x more Kids hide symptoms from parents, coaches, athletic

trainers and other school staff (nurses, teachers, etc.)

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVELWHY THE HUGE CONCERN??

Energy measuring devices placed in football helmets to measure G forces. Forces measured helmet to helmet impacts of 180

G’s Car traveling at 35mph slamming into a brick wall =

40 G’s Forces have an accumulating effect.

50-80 impacts to the head per practice, measuring 20G’s to 80G’s.

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL

• Hire an athletic trainer ATC’s are the only health care

professionals whose license requires continuing education in the recognition and treatment

of concussionsATC’s are the first line of protection.

for the athlete from further injuryfor the school from liabilityfrom coachesfrom parents

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVELRECOGNIZING A CONCUSSION:

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL

RECOGNIZING A CONCUSSION:

Mechanism of injuryAthlete has a collision w/

another player, the ground, goal post or other structure on the perimeter of the playing area. The athletes’ head may or may not be the actual point of contact. The brain is injured due to the violent shearing forces created during sudden stopping of the skull while the brain continues to move. The brain is basically bruised from it’s collision with the interior of the skull.

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVELSigns and Symptoms:

HeadacheNausea/vomitingBalance/coordination problemsDizzyVision changesSensitivity to light or noiseFeeling like in a fog, dazed, disorientedMemory lossConfusionConcentration difficultiesIrritable or anxiousDifficulty verbalizingLoss of consciousness

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL

Have a school board approved physician with training in concussion management and neurocognitive (ImPact) testing.

The medical field currently does not have a specialty in concussions or concussion management. There is no certification in concussion management.

Neurology as a profession, has little training in return to play decision making.

Board certification for sports medicine physicians is currently using test questions concerning concussions that are over 20 years old.

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL

Develop a Concussion Policy Specific to your school

Follow newest guidelines from NJ DOE (mandate available 3/31/11)

Should be developed by athletic trainer, school physician, school nurse, athletic director, others

Must be board approved documentWill be required for the fall of 2011-2012 school

year

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVELPurchase neurocognitive testing package

such as ImPactEstablishes baseline test prior to any head

injuryNeurocognitive testing is only ONE TOOL for

determining safe return to activityUsed after athlete reports symptoms are goneNOT A DIAGNOSTIC TOOL

Biggest misconception is that neurocognitive testing determines if an athlete has a concussion

A concussion is a SYMPTOM BASED DIAGNOSIS There is currently no computer test or imaging

technique that will determine if a concussion exists

HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL

Establish a standardized recording tool or document, for assessing concussions.

Date, time, mechanism of injuryOrientation Symptom evaluationGlasgow coma scale Balance and coordinationMemory, recall, concentration

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY

BASELINE NEUROCOGNITIVE TESTING (ImPact) DONE WITH ALL ATHLETES

INCLUDING CHEERLEADERS PRIOR TO THE BEGINNING OF TRYOUTS

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY

ALL ATHLETES REPRESENTING SIGNS & SYMPTOMS OF A CONCUSSION REMOVED FROM PLAY

EVALUATION BY THE SCHOOLS ATHLETIC TRAINER (licensed health care provider)

NO RETURN TO ACTIVITY

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICYTHE ATHLETIC

TRAINER RECORDS INFORMATION USING THE SPORTS CONCUSSION ASSESSMENT TOOL (SCAT2)

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICYPARENTS ARE NOTIFIEDSCAT2 FORM AND LETTER EXPLAINING POLICY

SENT WITH ATHLETE, FOR THE PHYSICIANATHLETE IS EVALUATED BY PHYSICIANSCHOOL PERSONNEL NOTIFIED IF COGNITIVE

MODIFICATIONS (temp 504) PLAN FOUND TO BE NECESSARY

IMPACT TESTING INITIATED WHEN ATHLETE IS SYMPTOM FREE FOR AT LEAST 48 HOURS

IMPACT TESTS CONTINUED UNTIL BACK TO BASELINE

IMPACT RESULTS EVALUATED BY SCHOOL PHYSICIAN

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICYATHLETE MUST BE SYMPTOM FREE FOR AT

LEAST 7 CONSECUTIVE DAYS AND CLEARED BY A PHYSICIAN BEFORE ANY ACTIVITY RESUMES

ATHLETIC TRAINER MAINTAINS TIMELINEGRADUAL RETURN TO ACTIVITY FOLLOWS THE

ZURICH CONSENSUS STATEMENT GUIDELINES

5 days of increased activity each day as long as no symptoms re-occur due to prior days

activity Day 5 is return to activity (usually practice not game)

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY ZURICH CONSENSUS STATEMENT

GUIDELINESDay 1, low impact activity, walking/stationary bike

10 minutesDay 2, increase heart rate w/ increased activity on

bike, push ups, sit ups, jumping rope, strength training, 20 minutes

Day 3, running, sport specific activities, sprinting,30 minutes

Day 4, non-contact sport specific drills, sprinting, full equipment

Day5, return to “controlled”, full practice w/contact

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICYZURICH CONSENSUS STATEMENT

GUIDELINESProgression to the next day’s activity is

dependant on remaining symptom free following each day of increased activity

Recommended that the first day of full return to activity is not a game. Practice is controlled and removal from activity can be self monitored w/o use of time outs or relying on an official to stop play. Coaches and athletic trainer can be on the field and next to the huddle, etc.

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY

HOW IS THIS POLICY WORKING AFTER TWO FULL SEASONS OF APPLICATION

POSITIVES:

There is no doubt that this benefits the student athlete.Combination of passing the ImPact test, gradual symptom free return, physicians clearance, and minimum of 12 days rest, almost guarantees safe return to his/her sport.Creates an atmosphere of concussion management awareness for athletes, parents, coaches, teachers, physicians and administrators. It takes the emotional “need to play” out of the equation.

FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY

HOW IS THIS POLICY WORKING AFTER TWO FULL SEASONS OF APPLICATION

DRAWBACKSLack of trained physiciansProving the concussion, discrepancy between athletic

trainers findings and the family/ER physician.Timing of days. Snow days, holidays, absences of

athlete/athletic trainer, game scheduleOff campus teams (swimming, hockey, etc)Professional athletes vs. high school athletesNot a musculoskeletal injury. Confusing “comfort

with cure”No guidelines for multiple concussions

FINAL NOTES ON MANAGING CONCUSSIONS

Incidence of concussions can be reduced if the rules of each sport are properly enforced by officials and coaches continue to teach proper techniques. This is where the NFL is a good example.

The NOCSAE test standard for helmets is and has always been established as a measure of energy absorption to prevent SCULL FRACTURES not CONCUSSIONS.

Independent studies have not found any helmet to be better than another at preventing concussions.

There are no standards and there has been no independent testing of the soft headgear. Just because it’s there doesn’t mean that it’s good or even does what it appears like it might do

High School athletes are still children, long term effects of concussions on a developing brain are still unknown.

It’s better to miss one game or even one season than to have a lifetime of missed activities.

Grading of a concussion is done after the athlete recovers. A CONCUSSION IS A BRAIN INJURY. TAKE IT SERIOUSLY.

REFERRENCES

ATSNJ-www.ATSNJ.org

CDC-www.cdc.gov/concussion

ImPact-www.impacttest.com

Brain Injury Assoc. NJ-www.sportsconcussion.com

NJ Legislature-www.njleg.state.nj.us/2010/bills/S2500/2106_U1.PDF

www.journalofathletictraining.org

Find a doctor—www.AMSSM.org

Thank youMark Bramble, ATC, MS

ROLE OF THE SCHOOL PHYSICIANNEW LEGISLATION WILL MAKE IT

MANDATORY FOR SCHOOL PHYSICIANS TO HAVE TRAINING IN CONCUSSION MANAGEMENT AND RETURN TO PLAY GUIDELINES

IF YOUR SCHOOL ADOPTS NEUROCOGNITIVE TESTING YOUR PHYSICIAN MUST BE TRAINED IN INTERPRETING THE INFORMATIONThe brain injury association of NJ offers ImPact

training courses several times every year.ImPact offers courses throughout the country all

year long

ROLE OF THE SCHOOL PHYSICIANAt Marlboro, the school physician is notified about

all catastrophic injuriesNon-catastrophic head injuries are reported if there

are differences between myself and the athletes physician about whether a concussion exists

School physician interprets all ImPact tests and gives the OK to start progressive return to activity.

School physician assists w/ establishing temporary 504 plans if necessary

School physician has authority to overrule the athletes physician if the athlete’s safety is at risk or if the doctors timeline does not follow the concussion policy

ROLE OF THE SCHOOL PHYSICIANWhat does the ImPact test look like? A quick look

ROLE OF THE SCHOOL PHYSICIANInterpreting the data

ROLE OF THE SCHOOL PHYSICIANInterpreting the data

ROLE OF THE SCHOOL PHYSICIANInterpreting the data