Evaluating Concussion Protocol Best Practices and Implementation Challenges

Transcription

1 Evaluating Concussion Protocol Best Practices and Implementation Challenges A Scientific Background for the Development of the Sport Program Background About the author Harry Kerasadis, MD, Cofounded Sport, LLC after 25 years of studying the changes of the electrophysiology of the brain, cognitive function and emotional function resulting from various brain trauma, including concussions. Kerasadis is also a regular contributor to Psychology Today and Athletic Business magazines. Over the last decade, medical science has illuminated the serious nature and extent of concussion injury in sport, from the short-term suffering and loss of productivity and academic performance of acute concussion, to the potential longterm consequences such as early onset of Dementia and Chronic Traumatic Encephalopathy (CTE). Concussion injury, and the effects of repetitive brain trauma, have become major concerns of sport program administrators, medical professionals, athletes, and families. Epidemiological studies have only recently begun to bring to light the true reach of the incidence of concussion injury. The U.S. Centers for Disease Control estimates the incidence of concussion injury from recreational and sport related activity at million events per year in the U.S. alone. 9 With this increasing awareness, several well-respected national and international organizations have reviewed the world's scientific literature in attempts to distill this information into concise guidelines and recommendations to help the sport and medical communities safely and effectively prevent, detect, and care for concussion injury. These organizations include: The National Athletic Trainers Association 2 The American College of Sports Medicine 3 The American Academy of Neurology 4 The American Academy of Pediatrics 6,7 The American Medical Society for Sports Medicine 8 The Centers for Disease Control and Prevention 9 The International Conference on Concussion in Sport 12 The American Chiropractic Board of Sports Physicians 14 Copyright

2 The Challenge Further, in response to this scientific information, legislation has swept the U.S., so that now all 50 states have laws mandating concussion management programs for youth in sports. 15 The deluge of these publications has left sports organizations, leagues, school systems, and even medical professionals the task of sifting through this scientific literature in order to craft the protocols, and bring together the people and tools necessary to establish a comprehensive program for effective concussion management. Until now, there has not been a single-source, fully integrated program that provides all of the features outlined in the published guidelines. In the absence of a single comprehensive set of protocols, program administrators must piece together all the components, resulting in protocols that often have gaps. Additionally, without the elements being integrated or interactive with each other, there is a greater risk of system failure, lack of documentation, and potential harm to the athlete. The Sport Concussion Management Program was developed to bring together all of the essential elements identified by the organizations listed above into a single, Internet-based program that leverages the power of instant communications and data processing through modern Information Technology. All of the elements of the Sport program are designed to meet the needs of organizations that are required by law to have these elements in place. The elements of the Sport program can be divided into three functional sections: 1. Preseason Planning, Education and Evaluation 2. Sideline (or Pitchside) Evaluation and Reporting 3. Post Injury Management All of these elements are integrated into Sport based on the scientific recommendations, standard practices, and legal mandates currently applicable to the management of concussion in sport. Copyright

3 Pre-Season Planning, Education, and Evaluation Prior to full-contact practices, scrimmaging, and season gameplay, every sports team must prepare for potential concussions, implement proper evaluation protocols, and comply with newly-established state concussion laws. By 2014, all 50 of the United States passed legislation mandating concussion management protocols for youth and school athletic programs 15. Although these laws vary considerably from state to state, there are three common features consistent across the country. First, all states require an action plan for athletes suspected of having suffered concussion injury. Multiple medical science organizations have recommended that such an action plan be in place in organized sports. 2,3,10,12 Second, almost all state legislation requires that concussion awareness education must be delivered to athletes, parents, and coaching staff outlining the serious nature of concussion, signs and symptoms, and the need to have a protocol in place to handle injured athletes. This education requirement is supported in guidelines and recommendations by several organizations. 2,3,4,6,8,12 Unfortunately, the method of delivery of this educational awareness is typically not specified. More research needs to be done to evaluate the best method of delivering this education. With the loose accountability of education delivery, the majority of school systems and sports organizations simply supply a one-sheet overview of concussion awareness facts that must be reviewed and signed by athletes and parents before gameplay is allowed. This method abbreviates necessary information and does not reflect an adequate level of understanding by the parents or athletes. Alternatively, the Sport program uses an online educational video activity with a post-activity online quiz. This convenient delivery method allows the athlete, parent, or coach to demonstrate that they did, in fact, get effective concussion awareness education. Plus, league officials or administrators can monitor who has and has not completed the activity. The third pre-season activity, generally becoming recognized as a standard practice, and recommended by most scientific organizations, 2,3,4,6,8,10,12,14 is to conduct concussion baseline assessments on the athletes. Baseline testing includes cognitive and emotional measures, as well as an assessment of the presence of baseline concussion-related symptoms. Although it is generally acknowledged that the majority of concussion events do not require post-injury cognitive testing, it is helpful in many cases, and those cases are not predictable ahead of time; 2,3,4,6,10,12 therefore, baseline testing evaluations are recommended for all Copyright

4 athletes in the pre-season. The Sport program includes an expanded baseline symptom checklist that effectively covers the emotional side of concussion-related symptoms. The program also incorporates the - Cog test. This is a computerized cognitive performance test, which is constructed based on existing tests commonly in use today (ImPACT, CNS Vital Signs, Cog Sport, WebNeuro, and others) and internally validated with normative database population statistics and test/re-test reliability studies. The Sport program incorporates each of these pre-season elements. To make this plan easily deliverable, the Sport program is available online, and offers an Sport Policies and Procedures Manual that may be downloaded and printed for distribution. This document is fully customizable to the needs of the organizations or school systems that require such a written manual in place. Sideline (or Pitchside) Evaluation and Reporting During practice and gameplay, sports teams must have a protocol in place to help identify the incidence of concussions that may occur on the field of play. Referred to as sideline or pitchside evaluations, they are designed to guide the user through a series of tests that help discover the presence of a possible concussion. If the sideline assessments show enough suspicion of injury, then the player must sit out, and enter a recovery protocol prior to returning to practice, gameplay, and in some cases, back to academic activities. All the organizations listed above provide a set of best practices, and recommend a systematic approach to the completion of a sideline or pitchside assessment on Copyright

5 the potentially-injured athlete. 2,3,4,6,8,10,12,14 Many suggest examples of tools that are useful in helping the organization, systemization, and standardization of this assessment. These include the SCAT3, 5 the SAC, 11 and others. Included in the sideline evaluation is an assessment of balance. 2,5,8,11,12 It is generally acknowledged that these tools are not sufficient to diagnose concussion injury, but rather help guide the evaluation and document the signs and symptoms of a potentially-injured athlete to assist a healthcare provider in making this diagnosis 2. The Sport program contains a smartphone-based app that guides a responsible user in a step-by-step process that assesses signs and symptoms of concussion, including observed signs, athlete-reported symptoms, orientation, auditory verbal memory, and an objective assessment of balance using smartphone accelerometer-based detection. The evaluation is also tailored to the competency of the user in their ability to do a sideline assessment. Many states concussion laws include a requirement that parents must be notified of a potential concussion injury has occurred. To fulfill this requirement, the Sport program includes an alert notification system, instantly alerting parents, Athletic Trainers, team physicians, and even personal healthcare providers whenever a potential injury report is filed in the system. Many state legislations also mandate reporting of the incidence of concussion at the school, district, and the state level to state government agencies. The Sport program tracks all reported concussions, along with all other pertinent information such as time to return to gameplay, and provides such reports at all hierarchical levels. Post-Injury Management Symptom tracking using a graded symptom checklist is a ubiquitous recommended guideline. 2,3,4,8,10,12 Most concussion-graded symptom checklists consist of about 20 concussion-related symptoms, largely revolving around the physical manifestations of concussion symptoms, and are loosely organized, if at all 1. The Sport program incorporates a 35-item symptom checklist, expanded to include more of the emotional side of concussion-related symptoms such as mood, worry, and anger. Copyright

6 The symptom checklist reporting is highly organized to reflect seven domains of concussion-related symptoms: Migraine Cognition Vestibular impairment Sleep Mood Worry Anger This more comprehensive organization of these domains allows the healthcare provider to give a rapid assessment of the athlete's concussion-related symptoms. The Symptom Checklist is filled out daily by the concussed athlete either online or through the smartphone app. reminders are sent in the evenings to injured athletes who have not filled out their symptom checklist for the day. alerts are also sent to the healthcare providers once the athletes are symptom free. Many of the published guidelines acknowledge that the majority of sport concussion cases can be managed without post-injury computerized neurocognitive performance testing, while at the same time recognizing that this testing can be helpful in many cases. 2,3,4,6,8,10,12 The Sport program offers post-injury computerized neurocognitive testing, using Reliable Change Index statistics and advanced reporting technology to assist the healthcare provider in making decisions regarding concussion management. Post-injury concussion guidelines call for a progressive exertion protocol to begin once the athlete becomes symptom free at rest. 2,4,6,8,9,10,12,14 While the number of steps in this progressive exertion program vary among the listed organizations, all guidelines recommend a 24-hour period of remaining symptom free before advancing to the next step. The recovery protocol concludes when the athlete reaches a level of maximal exertion without provocation of symptoms. If, while progressing through the stages, an athlete suffers a return of concussion-related symptoms, the athlete must returns to the previous level of exertion for at least 24 hours of being symptom free before re-attempting the level. The Sport program fosters an integration between healthcare providers, coaches, physical therapist, and other involved parties using a daily symptom checklist to monitor and supervise the athlete going through the progressive exertion portion Copyright

7 of the program. At each step, the level of exertion is clearly defined for the athlete and all others participating in his or her care. More important than giving the return-to-play clearance, due consideration must be given to the appropriate time to return to normal academic activities in student athletes. Student athletes are students first and athletes second. Recent literature calls for return to normal activity as quickly as possible to avoid further psychological distress of missing academic work and becoming socially isolated. 13 On the other hand, this athlete may not have recovered sufficiently to be able to engage in the full rigors of the academic environment. In this situation, adjustments and accommodations to assist the athlete in returning to the learning environment are appropriate. 2, 6,7,8,9,13 The American Academy of Pediatrics guidelines recommend that return to academic activity adjustments should be tailored to the student s needs based on the symptoms this athlete may be experiencing. 6,7 The Sport program includes an Academic Care Planfeature in which the appropriate healthcare provider can create a fully customized return-to-learn care plan. The Academic Care Plan includes an automated feature in which the symptoms endorsed by the athlete on the most recent symptom checklist are mapped directly to the appropriate academic adjustments. The healthcare provider can then modify these recommendations, if desired, based on the needs of the athlete. Documentation Many of the concussion guidelines and position statements outlined by the organizations listed above highlight the need for proper documentation as an essential element for any concussion management program. 2, 3,10,12 Appropriate policies and procedures should be available so that all participants have a clear understanding of what is expected before, during, and after concussion injury. Proper documentation serves multiple functions, which include: Providing essential information regarding the athlete's condition for the healthcare provider to make informed decisions regarding the athlete's care, and providing a record that can be later referred to, which helps justify the decision-making process. Providing data demonstrating compliance with state laws regarding the mandated concussion awareness education, concussion detection reporting, and epidemiological statistics regarding the incidence and characteristics of concussion injury. Copyright

8 Allowing participating organizations to quantify the incidence of concussion injury, severity of symptoms, and duration of recovery in order to identify trouble areas within the organization that may require attention and intervention. Keeping the parents and healthcare providers informed so that care can effectively and efficiently be delivered to the athlete. Providing a level of transparency and accountability that fosters the much needed cultural shift to prioritizing brain health over gameplay. One strength of the Sport program is in centralized data management, which facilitates the documentation and communication of information to all necessary individuals to prevent, detect, and care for concussion injury among athletes. The Sport program leverages the power of the Internet and Information Technology to provide the framework for documentation of the preseason education and assessment process, sideline detection, and post-injury care in sport-related concussion. Every event regarding an athlete is recorded so that a comprehensive report of all activities of any given athlete can be generated into a PDF file that can be shared with other healthcare providers or imported into an electronic health record or injury tracking software. De-identified statistics are provided at hierarchical levels up to the state level documenting athlete participation, compliance with state laws, and providing concussion incidence statistics for further research in the field. Conclusion Youth sports, high school and collegiate athletics, and professional sports leagues face the increasingly important challenge of providing proper concussion management. Despite published guidelines with recommended best practices by many respected organizations, most athletic teams struggle with applying all the necessary elements of the concussion protocols. Gaps have emerged in proper concussion handling during the pre-season, from the sidelines, and after the injury has occurred. By accumulating all the best practices and incorporating modern technological advances, Sport provides a complete suite of tests, tools and resources that can be easily administered for all athletes, while providing the necessary documentation. To receive a demonstration of Sport, please info@xlntbrain.com or call (814) More information is available at.com. Copyright

9 Citations 1. Alla, S., S. J. Sullivan, L. Hale, and P. Mccrory. "Self-report Scales/checklists for the Measurement of Concussion Symptoms: A Systematic Review." British Journal of Sports Medicine 43.Suppl_1 (2009): I3-I12. Web. < 2. Broglio, Steven P., Robert C. Cantu, Gerard A. Gioia, Kevin M. Guskiewicz, Jeffrey Kutcher, Michael Palm, and Tamara C. Valovich Mcleod. "National Athletic Trainers' Association Position Statement: Management of Sport Concussion." Journal of Athletic Training 49.2 (2014): Web. < n_statement.pdf> 3. Cantu, R.c. "Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement 2011 Update." Yearbook of Sports Medicine 2012 (2012): Print. 4. Giza, C. C., J. S. Kutcher, S. Ashwal, J. Barth, T. S. D. Getchius, G. A. Gioia, G. S. Gronseth, K. Guskiewicz, S. Mandel, G. Manley, D. B. Mckeag, D. J. Thurman, and R. Zafonte. "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 (2013): Print. 5. Guskiewicz, K. M., J. Register-Mihalik, P. Mccrory, M. Mccrea, K. Johnston, M. Makdissi, J. Dvorak, G. Davis, and W. Meeuwisse. "Evidence-based Approach to Revising the SCAT2: Introducing the SCAT3." British Journal of Sports Medicine 47.5 (2013): Print. 6. Halstead, M. E., and K. D. Walter. "Sport-Related Concussion in Children and Adolescents." Pediatrics (2010): Print. 7. Halstead, M. E., K. Mcavoy, C. D. Devore, R. Carl, M. Lee, and K. Logan. "Returning to Learning Following a Concussion." Pediatrics (2013): Web. 8. Harmon, Kimberly G., Jonathan Drezner, Matthew Gammons, Kevin Guskiewicz, Mark Halstead, Stan Herring, Jeff Kutcher, Andrea Pana, Margot Putukian, and William Roberts. "American Medical Society for Copyright

10 Sports Medicine Position Statement:concussion in sport. Clinical Journal of Sport Medicine 23.1 (2013): Print. 9. "Managing Return to Activities." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 02 Dec Web. 14 Jan < 10. Mccrea, Michael, and Kevin Guskiewicz. "Evidence-Based Management of Sport-Related Concussion." Progress in Neurological Surgery Concussion (2014): Print. 11. Mccrea, Michael, James P. Kelly, Christopher Randolph, Jon Kluge, Edward Bartolic, George Finn, and Brian Baxter. "Standardized Assessment of Concussion (SAC): On-Site Mental Status Evaluation of the Athlete." Journal of Head Trauma Rehabilitation 13.2 (1998): Web. < 12. Mccrory, Paul, Willem Meeuwisse, Mark Aubry, Bob Cantu, Jiri Dvorak, Ruben J. Echemendia, Lars Engebretsen, Karen Johnston, Jeffrey S. Kutcher, Martin Raftery, and Allen Sills. "Consensus Statement on Concussion in Sport the 4th International Conference on Concussion in Sport Held in Zurich, November 2012." Clinical Journal of Sport Medicine 23.2 (2013): Web. < 13. Mcgrath, Neal. "Supporting the Student-Athlete's Return to the Classroom After a Sport-Related Concussion." Journal of Athletic Training 45.5 (2010): Web. < 14. Moreau, William J., and Dustin C. Nabhan. "Development of the 2012 American Chiropractic Board of Sports Physicians Position Statement on Concussion in Athletics." Journal of Chiropractic Medicine 12.4 (2013): Print. 15. "Traumatic Brain Injury Legislation." National Conference of State Legislatures. National Conference of State Legislatures, n.d. Web. < Copyright

11 About the Author Cognitive neurologist Harry Kerasidis, MD, specializes in the full spectrum of concussion care, including education, advanced baseline testing, concussion detection, and recovery protocols. He co-founded, LLC, after treating hundreds of concussions and spending 25 years studying the behavioral, cognitive and emotional function resulting from various brain trauma, including concussions. Through his experience, Dr. Kerasidis noticed existing concussion-related modalities lacked critical cognitive and emotional measures, do he created and began using his own concussion baseline test, acute management, and recovery care plan, which have been incorporated into the online and mobile platform. Dr. Kerasidis also founded Chesapeake Neurology Associates, based in Prince Frederick, Maryland. Through this practice, he also treats other cognitive and behavioral disorders including memory loss, sleep deprivation, ADD, dementia, Alzheimer's, and traumatic brain injury. At Calvert Memorial Hospital, also in Prince Frederick, Dr. Kerasidis serves as the Medical Director for the Center for Neuroscience, Medical Director for the hospital s Sleep Disorders Center, and Medical Director for the hospital s Stroke Center. A graduate of Georgetown University School of Medicine, Dr. Kerasidis completed his residency in Neurology and Fellowship in Clinical Neurophysiology at the Georgetown University Hospital. Dr. Kerasidis is certified by the American Board of Psychiatry and Neurology, American Board of Sleep Medicine, Biofeedback International Certification Alliance, a diplomat for the National Board of Medical Examiners, and member of the International Society of Neuronal Regulation. Dr. Kerasidis contributes regularly to PsychologyToday.com, Athletic Business magazine, NeurologyAdvisor.com, NeurologyTimes.com, and Dr. Oz's sharecare.com. His new book is Concussionology: Redefining Sports Concussion Management For All Levels, published 2015 by Author House. For Dr. Kerasidis full biography and curriculum vitae, visit Copyright

12 The information contained in this paper is based upon the research and the personal and professional experience of the author. This document is not intended as a substitute for professional healthcare advice. The author is not responsible for any adverse effects or consequences resulting from the use of any of the suggestions, preparation, or procedures discussed in this book. All matters pertaining to your physical health should be supervised by a healthcare professional. 137 National Plaza, Suite 300, National Harbor MD (855) , info@xlntbrain.com Copyright 2016 by Sport All rights reserved. No part of this publication may be reproduced, scanned, uploaded, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the copyright owner. Disclosure: LLC s sport concussion management system is a data collection tool and does not intend to diagnose, treat or otherwise suggest any other course of action that would substitute a certified medical professional. All participants should seek the advice of medical professionals for the diagnosis and treatment when necessary, including for final clearance or play. Copyright