Even if cleared by a physician

Transcription

1 ALATA Annual Meeting May 20, 2012 James B. Robinson, M.D. Head Team Physician, University of Alabama Endowed Chair of Sports Medicine, CCHS Fellowship Director Lystedt Law, Washington state Passed in 2009 Yearly concussion education for athlete s and parents Athlete suspected of sustaining a concussion shall be removed from competition May not return to play until evaluated and cleared by a licensed health care provider trained in evaluation and management of concussion Other States (as of May 2012) 35 states with concussion laws 11 actively considering new laws 4have yet to consider (Arkansas,Georgia,Michigan,Montana) AHSSA Concussion Policy 2012 Established in 2010 Any athlete who exhibits signs, symptoms, or behaviors consistent with a concussion shall be removed from the contest and not return to play until a medical release is issued by a medical doctor. Once concussive signs are identified, only a medical doctor can clear the athlete for return to play Changed this year to reflect the disqualification of a student athlete for the remainder of that day of competition. Even if cleared by a physician Annual concussion training for coaches Lead by Alabama Sports Concussion Task Force Bill (HB 108) passed both sides of state legislature and was signed into law in June 2011 Act # Provisions of Bill Defines concussion Mandates guidelines and forms to educate young athletes and parents on nature and risk of concussion Yearly, signed concussion information sheet prior to participation Annual training for coaches A youth athlete who is suspected of sustaining a concussion or brain injury in a practice or game shall be immediately removed from participation (that day) and not allowed to return to play until evaluated by a licensed physician and until the athlete receives written clearance to return to play from a licensed physician. 1

2 Alabama Legislation 2012 Same bill as HB108 with the addition of: Add same day to the current disqualification Defines youth sports and school systems Defines the role of the Athletic Trainer (a) Each local school system and governing body of each sport or recreation organization shall develop guidelines and other pertinent information and forms to inform and educate youth athletes and their parents or guardians in their program of the nature and risk of concussion and brain injury including continuing to play after suspected concussion or brain injury. On a yearly basis, a concussion and head injury information sheet shall be signed and returned by the youth athlete and the athlete s parent or guardian prior to the youth athlete s initiating practice or competition (b) Each local school system and sports or recreational organization governing body shall ensure that coaches receive annual training to learn how to recognize the symptoms of a concussion and hoe to seek proper medical treatment for a person suspected of having a concussion. (c) Each local school system and sports or recreational organization shall establish by rule the requirements of the training which shall be provided by using designated resources to the extent practicable and timeless to ensure that, to the extent practicable, every coach receives the training before the beginning of practice for the school athletic team. (d) A youth athlete who is suspected of sustaining a concussion or brain injury in practice or a game shall be immediately removed from participation and may not return to play the day of the injury and until he or she is evaluated by a licensed physician and receives written clearance to return to play from a licensed physician. (e) After a youth athlete who has sustained a concussion has been evaluated by a licensed physician, the physician may utilize a licensed athletic trainer (under the Alabama Code of 1975) with specific knowledge of the athlete s condition to manage the athlete s graduated return to play. The licensed athletic trainer will remain within the scope of licensure (under the Alabama Code of 1975) according to the Alabama Board of Athletic Trainers and can be a vital role in the proper day to day care of the youth athlete. 2

3 (e) The physician may choose to use the information from the licensed athletic trainer in the decision for safe return to play. The decision for return to play is solely up to the licensed physician. Education Coaches Parents Athletes Enforcement Penalties Role of ATC s Future: Role of ATCs To aid in the identification of the concussed athlete To help evaluate the concussed athlete: SCAT 2 BESS Neuropsychological Test Administration To manage Concussion Rehab Recognition EAP and concussion protocol Symptom Checklists Pittsburgh Steelers Post Concussion Scale Post Concussion Symptom Assessment Questionnaire (PCSQ) Concussion Resolution Index Post Concussion Questionnaire (CRI) SCAT SCAT 2 Concussion Symptom Inventory (CSI) Removal from activity and monitoring No return to play on same day of injury Symptom Scale Glasgow Coma Scale (GCS) Maddocks questions Orientation Memory Concentration Balance and Error Scoring System (BESS) Not fully validated 3

4 Useful as one component of evaluation Multiple systems available Baseline measurements are ideal BESS Scores in concussed athletes change from baseline on average by 5.7 points (McCrea et al. 2003) Baseline score returns by 3 to 7 days after injury Comparable to Sensory Organization Test (SOT) and other force plate systems Useful with and without symptom screens 4

5 Errors Hands lifted off iliac crests Opening eyes Step, stumble, or fall Moving hip to > 30 flexion or abduction Lifting forefoot or heel Out of test position > 5 seconds Objective measure of brain function First reported use for sports in 1989 Barth et al. Paper/Pencil test battery for concussed collegiate athletes Showed significant decline in neurocognitive functioning after injury compared with baseline Function returned to baseline within 10 days Computer based testing more common over last decade Guskiewicz, KM. Clinics in Sports Medicine, 2011; 30(1): Neurocognitive recovery may overlap with symptom recovery More commonly follows clinical symptom resolution Baseline testing is recommended when possible Testing after concussion reserved until patient symptom free Endorsed by multiple consensus statements 3 rd International Conference on Concussion in Sport, Zurich, 2008 National Athletic Trainers Association Only one component of return to play decision Computer Testing More sensitive than traditional methods More precise measurements of response time No standardization Pro Objective measure of function Standard of care? Used by NFL, MLB, NHL Sense of security Con Cost Time consuming Availability Questions regarding reliability and validity Learning effect Sense of security 1. Asymptomatic at rest 2. Asymptomatic with full physical and cognitive exertion 3. Balance testing returned to baseline 4. Neurocognitive testing returned to baseline if available 5

6 Rehabilitation Stage 1. No activity 2. Light aerobic exercise 3. Sport specific exercise 4. Non contact training drills 5. Full contact practice 6. Return to play Objective Recovery Increase heart rate Add movement Exercise, coordination, and cognitive load Assess functional skills and restore confidence Go, fight, win Validation of SCAT 2 More specific guidelines for pediatrics Standardization of neuropsychological testing Improved concussion surveillance Improved understanding of long term sequelae Improved imaging modalities (fmri, MRS, DTI, PET Scans) Improving legislation 1. AHSAA Concussion Policy, Retrieved May 1, 2011, from 2. Alabama concussion legislation, personal communication with Dr. James Robinson, May Giza CC, Hovda DA. The neurometabolic cascade of concussion. Journal of Athletic Training, 2001; 36(3): Guskiewicz KM. Balance assessment in the management of sport related concussion. Clinics in Sports Medicine, 2011; 30(1): Hemecourt P. Subacute symptoms of sports relaed concussion: outpatient management and return to play. Clinics in Sports Medicine, 2011; 30(1): Johnson EW, Kegle NE, Collins MW. Neuropsychological assessment of sport related concussion. Clinics in Sports Medicine, 2011; 30(1): Lystedt Law, Retrieved May 1, 2011 from SL Legislation.pdf 8. McCrory et al. Consensus statement on concussion in sport: the 3 rd international conference on concussion in sport, held in Zurich, November Journal of Clinical Neuroscience, 2009; 16: Putukian M. The acute symptoms of sport related concussion: diagnosis and on field management. Clinics in Sports Medicine, 2011; 30(1):