1. The Concussion Management and Awareness Act Sharon M. Edwards, MD Associate Professor Department of Pediatrics September 16, 2013

2. Learning Objectives ▶ To review the Concussion Management and Awareness Act ▶ To understand why the law was enacted ▶ To understand the role of the physician as defined by the law ▶ To understand your role as an advocate 2

3. Case Jessica, a 16 year old while playing soccer outside in the school yard tripped and hit her head. She did not have a loss of consciousness but is complaining of a headache and …. There is a major game this evening and she is aware that prospective college coaches are in the audience… She would like to continue to play as she has only a headache… Discussion Questions-- Is it appropriate for her to continue to play? Who decides if/when she can return to play? What is the role of the school team? What is the role of her primary care provider? Mount Sinai / Presentation Slide / December 5, 2012 3

4. Who is Zachary Lystedt ? ▶ ▶ He sustained a concussion in 2006 while playing middle school football. He hit his head on the ground during a tackle—he did not have any loss of consciousness. He was sidelined for 3 plays. While resuming play he collapsed on the field and had to be air lifted to Harborview Hospital where he had emergency surgery for brain swelling and increased intracranial pressure. Mount Sinai / Presentation Slide /September 16, 2013 4

5. The State of Washington passed the first concussion in sports law, called the Zackery Lystedt Law ▶ The Seattle Seahawks bonded with Zach and his family and worked with legislators to develop a law to protect student athletes from concussions ▶ In May 2009 Washington State passed the Zachery Lystedt Law that provides guidelines for concussion management for student athletes. ▶ The passing of this law led to a flow of legislation aimed at protecting young athletes nationwide Mount Sinai / Presentation Slide / September 16, 2013 5

6. States with Legislature on Concussions-- Source: National Conference of State Legislatures, 2013.6 http://www.cdc.gov/concussion/policies.html

7. Core Elements of the Lystedt Law 1.Annual Education of Parents and Athletes 2.Mandatory removal from play athletes suspected of having a concussion 3.Health professional clearance for return to play

8. Core Elements of the US Concussion Laws 1.Annual Education of Parents and Athletes 2.Mandatory removal from play athletes suspected of having a concussion—41 states and Wash. DC have this as a component of their law 3.“Health professional” clearance for return to play—40 states and Wash. DC

9. National Youth Sports Concussion Laws - common themes Minimum mandatory removal from play (typically 24 hours) Health care Professional Assessment Coach training in TBI management Information for parents Liability Waivers Focus on secondary prevention (reducing the risk of repeat TBIs)

10. Law Pitfalls—the controversies… ▶ Who is a “health professional?”—physicians with no TBI training? Athletic trainers? Nurses? Neuropsychologist? Of the states that require clearance by the health professional only about 50% require the person to have training in TBI! ▶ Education component is not standardized ▶ No consensus on coach training—content and how often and how to evaluate? —of 45 jurisdictions which have concussion laws only 25 require coach education in recognizing symptoms of TBI! ▶ Lack of consensus on liability waivers ▶ Should sports with high risks of TBI be banned for children/adolescents? Mount Sinai / Presentation Slide / December 5, 2012 10

11. “ New York Gov. Andrew Cuomo signed his state's youth- concussion legislation into law last week, making New York the 33rd state (not counting the District of Columbia) to pass such a law.”youth- concussion legislation ▶ S T A T E O F N E W Y O R K ________________________________________________________________________ 3953--B Cal. No. 280 2011-2012 Regular Sessions I N S E N A T E March 10, 2011 ___________ Introduced by Sens. HANNON, MAZIARZ, BALL, ADAMS, ALESI, AVELLA, CARLUC- CI, FUSCHILLO, HUNTLEY, LARKIN, LAVALLE, NOZZOLIO, SQUADRON, ZELDIN -- read twice and ordered printed, and when printed to be committed to the Committee on Health -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- reported favorably from said committee, ordered to first and second report, ordered to a third reading, amended and ordered reprinted, retaining its place in the order of third reading AN ACT to amend the education law and the public health law, in relation to directing the commissioners of education and health to establish rules and regulations for the treatment and monitoring of students of school districts, boards of cooperative educational services and nonpublic schools who suffer mild traumatic brain injuries THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: 1 Section 1. Short title. This act shall be known and may be cited as 2 the "concussion management and awareness act". 11

12. Concussion Management and Awareness Act (Chapter 496 of the Laws of 2011 ) ▶ Went into effect 7/1/12 for all public and charter schools ▶ Requires the Commissioner of Education and the Commissioner of Health to disseminate rules/regulations for students who sustain a concussion at school and at a school district sponsored event or activity ▶ These guidelines for return to school are applicable to all public school students irrespective of where the concussion occurred Mount Sinai / Presentation Slide / December 5, 2012 12

13. Concussion Awareness Act During school athletic activities schools are required to remove from activity (recess/PE class/sports) any student suspected of sustaining a mild traumatic injury (concussion”) “When in doubt, sit it out.” 13

14. Concussion Management and Awareness Act Removal from Athletics 1.The student believed to have a concussion must be removed immediately from physical activity 2.No student will be allowed to return to the athletic activity unless he/she has been symptom free for 24 hours and has been evaluated by a physician. The physician must give written and signed authorization for return to play. For interscholastic sports the clearance must come from the School’s Medical Director

15. NY Concussion Management and Awareness Act Requirements of School Districts Education: 1.Every school coach, physical education teacher, nurse, and athletic trainer has to complete an approved course on concussion management on a biennial basis, starting with the 2012-2013 school year. 2. School coaches and physical education teachers must complete the CDC course. (www.cdc.gov/concussion/HeadsUp/onlinetraining.html) 3.School nurses and certified athletic trainers must complete the concussion course. (http://preventingconcussions.org) Information 1. Provide concussion management information 2. Sign off on the parental permission forms 3. Make information available on the school’s website (if there is one)

16. CDC Heads Up Course on Concussion http ://www.cdc.gov/concussion/HeadsUp/online_tr aining.html CDC sponsored free, online course available to coaches, parents, and others geared to helping keep athletes safe from concussion. Focuses on recognition/management/prevention

17. Mandated Concussion Course Elements Definition of concussion Signs and symptoms Describe how concussions occur Prevention strategies Guidelines for return to play and return to learn

18. Law Pitfalls ▶ Youth sports laws should not be “one size fits all”—should be tailored to the sport/age/gender ▶ “Education” efficacy needs to be studied ▶ No requirement for data gathering or creating a centralized database to track incidence of concussion and outcomes ▶ The Law does not directly address concussion management outside of sports ▶ The Law does not emphasize primary prevention September 16, 2013 18

19. Concussion ▶ mmmmm Mount Sinai / Presentation Slide / September 16, 2013 19

20. Clinical Cases ▶ Ryan, a 17 year old lacrosse player collided headfirst with another player and felt dizzy after ▶ Sam, a 13 year old football player was tackled to the ground and feels a little foggy ▶ Jessica, a 16 year old avid soccer player fell while playing and now looks clumsy as she tries to head a ball ▶ Sharon, a 12 year old fell backwards running around a pool and was unconscious for about 15 minutes Mount Sinai / Presentation Slide / September 16, 2013 20

21. Signs and Symptoms of a Concussion May present immediately or in a few hours or evolve over a few days ▶ Headache ▶ Nausea and or vomiting ▶ Amnesia ▶ Confusion ▶ Loss of consciousness ▶ Balance issues or clumsiness ▶ Fatigue/sleep issues/change in sleep patterns ▶ Dizziness ▶ Visual Changes ▶ Sensitivity to sounds and or light ▶ Feeling foggy ▶ Concentration issues ▶ Personality/mood changes ▶ Irritability ▶ More impulsive

22. Common Myths Mount Sinai / Presentation Slide / September 16, 2013 22 ▶ If you did not have LOC you did not have a concussion ▶ A concussion is a bruise on the brain ▶ If you do not have a headache you do not have a concussion ▶ If you are not bleeding or there is no sign of injury you can play

23. Common Facts ▶ Most concussions (90%) occur without a loss of consciousness ▶ The majority of concussions do not occur in sports ▶ A concussion is a metabolic derangement so a normal imaging study does not rule out a concussion Mount Sinai / Presentation Slide / September 16, 2013 23

24. Cases ▶ Marcus is a 11 year old male who sustained a concussion 1 week ago playing softball. He says he feels “fine.” His coach says he was “out for less than a minute.” He did not see his primary care provider at the time. ▶ Selina is a 1 st year college student who fell down the subway stairs and sustained a concussion 3 weeks ago. For her biochemistry exam she misplaced her phone with the test room details and went to the wrong room. She feels forgetful and finds it difficult to concentrate. She was not able to take the exam on time. She received a failing grade on the examination. Mount Sinai / Presentation Slide / September 16, 2013 24

25. Concussion Management and Awareness Act ▶ Students who have had a concussion or are suspected to have one may not return to sports until they have been symptom free for 24 hours and have been evaluated by and receive written and signed authorization to return to activities from a licensed physician ▶ Thus authorization becomes part of the child’s permanent school medical record ▶ The school is required to follow any and all instructions from the child’s treating physician ▶ School districts are encouraged to establish a concussion management team to promote compliance with the concussion laws. ▶ School districts are also encouraged to provide education to parents/guardians on concussions Mount Sinai / Presentation Slide / September 16, 2013 25

26. The Concussion Management Team ▶ Students ▶ Parents/guardians ▶ School administrators ▶ Doctors ▶ The Medical Director ▶ School Nurse/Nurse Practitioner ▶ Psychologists/Neuropsychologists ▶ PCP ▶ PE Director ▶ Coaches ▶ Teachers ▶ Trainers ▶ Social Workers Mount Sinai / Presentation Slide /September 16, 2013 26

27. Guidelines for the Concussion Management Team After a concussion the child may need academic adjustments They may include-- ▶ Shorter school days ▶ Rest periods ▶ Extended time for tests/homework/class work ▶ Peer note takers ▶ Audiotapes of class Mount Sinai / Presentation Slide / September 16, 2013 27

28. Learning Objectives ▶ To review the Concussion Management and Awareness Act ▶ To understand why the law was enacted ▶ To understand the role of the physician as defined by the law ▶ To understand your role as your patient advocate Mount Sinai / Presentation Slide / September 16, 2013 28

29. Case Jessica, a 16 year old while playing soccer outside in the school yard tripped and hit her head. She did not have a loss of consciousness but is complaining of a headache and …. There is a major game this evening and she is aware that prospective college coaches are in the audience… She would like to continue to play as she has only a headache… Discussion Questions-- Is it appropriate for her to continue to play? Who decides if/when she can return to play? What is the role of the school team? What is the role of her primary care provider? Mount Sinai / Presentation Slide / September 13, 2013 29

30. Your Role as your Patient’s Advocate Build on education ▶ Keeping up to date ▶ Workshops, parent child discussion groups, distributing pamphlets ▶ Communicating with coaches/PE teachers and classroom teachers ▶ Debunking myths on concussion Prevention ▶ Working to make sure athletic equipment is safe ▶ Teaching patients/trainers/family members how to recognize the signs of a concussion ▶ Limiting certain techniques/drills to minimize injury Managing Return to Play ▶ Supporting and working with the concussion management team ▶ Helping advocate for the child’s physical and cognitive rest Mount Sinai / Presentation Slide / September 16, 2013 30

31. Take Home Message ▶ The NY State Concussion Management and Awareness Act law requires that a student suspected of having a concussion be removed from activity immediately! ▶ The child can only be cleared to return to activity after evaluation by a licensed physician ▶ Schools should consider having concussion management teams to help implement the regulations and help support a treatment plan for the child/adolescent and his/her family ▶ You play a major role in educating your patients, families, school staff and colleagues on concussion and advocating for your patients! September 16, 2013 31

32. Helpful Resources 1.http://www.cdc.gov/concussion/policies.html (includes the Heads Up Course) 2.http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/ConcussionManageGui delines.pdf http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/ConcussionManageeGu idelines.pdf (Document on Guidelines for Management in the School Setting by the NYS Education Department June 2012) 3.http://www.nysphsaa.org. (New York State Public Health Athletic Association) 4.http://bianys.org/ (Brain Injury Association of New York State) 5.Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology, Neurology March 2013 6.“It’s All in Your head—Everyone’s Guide to Managing Concussions” Ann Engelland, MD 7.Play Safe—The Mount Sinai Medical Center Concussion Prevention/Evaluation/Management Program 1 800 283 8481