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DESIGNING AND IMPLEMENTING A SUCCESSFUL MIDDLE AND UPPER SCHOOL CONCUSSION EDUCATION AND PREVENTION PROGRAM: FROM IDEA TO IMPLEMENTATION.

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Presentation on theme: "DESIGNING AND IMPLEMENTING A SUCCESSFUL MIDDLE AND UPPER SCHOOL CONCUSSION EDUCATION AND PREVENTION PROGRAM: FROM IDEA TO IMPLEMENTATION."— Presentation transcript:

1 DESIGNING AND IMPLEMENTING A SUCCESSFUL MIDDLE AND UPPER SCHOOL CONCUSSION EDUCATION AND PREVENTION PROGRAM: FROM IDEA TO IMPLEMENTATION

2 Concussion history  Ancient Greeks described “commotion of the brain” characterized by hearing, vision and speech loss  Persian Physician, Dr. Razi, in 10 th Century AD first described concussion as a distinct brain injury  First termed Cerebral Concussion  Transient loss of function with no physical damage  16 th 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%)

3 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

4 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?

5 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

6 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?

7 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

8 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

9 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.traumatic brain injury (TBI)  Mayo Clinic - A concussion is a traumatic brain injury that alters the way your brain functions

10 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:provide management guidelines for sport-related concussions ”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”

11  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.

12 How Complex?

13 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

14 Symptom Breakdown

15 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

16 Symptoms and Recovery

17

18 Days until Symptom Resolution

19 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

20 Concussion Rates

21 Concussion Rate Breakdown

22 % of Injuries per Sport

23 Concussion rates: Rec vs. Sports

24 Frequency/Magnitude/Games vs. Practice  Football  Median linear head acceleration – 20.5g (range g)  Median rotation head acceleration – 973 rad/s 2 ( rad/s 2 )  Threshold from previous research 98 g  76% of impacts above threshold  Total impacts ranged from (avg )  Highest number of impacts - top of head (44%)

25 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

26 Mechanism: Player/Surface/equipment

27 Risk Factors

28 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

29 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

30 Additional Considerations  Insurance  PPO  HMO  Out-of-pocket  Out-of-network  Geographical considerations  Language barriers  Cultural barriers Religion  Continuing education for staff

31 Protocols  Evidence-based  Credibility  Absence of evidence? 2012 Zurich statement  Available resources  Commitment from parents administration, teachers, coaches & community?

32 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

33 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

34 4 Factors for Recovery  Resolution of symptoms at rest  Post-concussion testing performance  Step-wise academic return  Step-wise physical exertion testing

35 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

36 Learn from Others  One Hit Away One Hit Away   Example of a High School/Middle School Program Example of a High School/Middle School Program  px px  Sport Legacy Institute Sport Legacy Institute 

37 If you're not making mistakes, then you're not doing anything. I'm positive that a doer makes mistakes. John Wooden

38 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

39 Myths and Fallacies  Equipment prevents concussions  Mouth guards  Helmet add-ons – football/soccer

40 Throw-out the Grading Scales  Mild  Moderate  Severe  Numbered grading  Trash them all and treat as individual

41 Knowledge is Key!  Stay up-to-date on research  Expert contacts  Strong support system  Administration  Parents  Physicians

42 Questions


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