What is a Concussion?

1. 2010-11 NFHS Concussion Rule – What State Associations Need to Know Michael Koester, M.D., ATC ChairNFHS Sports Medicine Advisory CommitteeJuly 2010

2. What is a Concussion? A concussion is a mild traumatic brain injury that interferes with normal function of the brain Evolving knowledge “dings” and “bell ringers” are serious brain injuries Do not have to have loss of consciousness Only 4% in Football- 2009 Young athletes are at increased risk for serious problems

3. Extent of the Problem Professional athletes get a great deal of attention 1,600 NFL players Much more common in high school than any other level- due to large number of participants HS Sports Participants Football- 1.14 million Boys Soccer- 384,000 Girls Soccer- 345,000 Boys Hoops- 545,000 Girls Hoops- 444,000 NFHS 2008-09

4. Extent of the Problem 9% of all sports injuries 19.3% of all Football injuries in 2009!!! Likely at least 140,000 concussions in HS athletes yearly based on High School RIO estimates

5. Not Just a Football Problem Injury rate per 100,000 player exposures Football 52 Girls’ Lacrosse 39 Girls’ soccer 35 Boys’ Lacrosse 32 Wrestling 22 Girls basketball 20 Boys’ soccer 17 Softball 15 Boys basketball 7 High School RIO 08-09

6. Concussions Dominant sports and health topic Medical community not driving the agenda Easy to understand problem/solution Huge media focus New Yorker- Malcolm Gladwell New York Times- Alan Schwarz Sports Legacy Institute 60 Minutes Parents of injured/deceased athletes

7. Becoming a Political Issue • NFL, NCAA and NFHS have all testified to Congress • State laws in WA and OR in 2009 • Others have followed in 2010 • What’s happening in your state? • Keep your ear to the ground • Potential national legislation • Return to play guidelines • Education policies

8. History of Sports and Concussions • The flying wedge, football's major offense in 1905, spurred the formation of the NCAA • Large numbers of players injured and killed • President Roosevelt summoned college athletic leaders to the White House • Reform game or have it banned

9. Problems for Administrators: Just a few mouse clicks away…… “At Burg, Simpson, Eldredge, Hersh, & Jardine, P.C., our brain injury lawyers represent brain injury victims caused during high school sports in Colorado, Wyoming and nationwide. We have the resources and experience with complex brain injury lawsuits to fully assess your injuries and take your case to a jury. If you or your loved one has suffered a brain injury while playing high school sports, please email or call us today.”

10. What has happened to make this such a big deal? • Increasing awareness and incidence • Number of high profile athletes over the past 20 years • Steve Young, Troy Aikman, Eric Lindros, etc • Bigger and faster kids, increased opportunities

11. What has happened to make this such a big deal? • High profile cases • Second Impact Syndrome • Death or devastating brain damage when having a second injury when not healed from the first • Long-term effects • Possible long-term effects- dementia, depression

12. NFL Making Changes • NFL Commissioner before Congressional Sub-committee in October 2009 • NFL’s response since that time: • Resignation of concussion committee co-chairs • Hiring of “independent” neurologists to make Return to Play (RTP) decision • No RTP same game in most cases

13. NCAA Follows NFL Lead • June 2010 • NCAA now making changes in response to what NFL & NFHS has done • No return to play same day of concussion?? • Much disagreement

14. Concussion Management: Zurich Guidelines, 2008 Consensus statement of international concussion experts No same day return to play for adolescents Graded Return to Activity NFHS SMAC strongly suggested no same day RTP and initiated rule change before Zurich statement was published Previous rulebooks required removal from contest if “unconscious or apparently unconscious.” RTP only if signed note from MD/DO

15. 2010-11 NFHS Rule Book Changes on Concussion • Any athlete who exhibits signs, symptoms, or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) shall be immediately removed from the contest and shall not return to play until cleared by an appropriate health-care professional. (Please see NFHS Suggested Guidelines for Management of Concussion). • Approved by NFHS Sports Medicine Advisory Committee – October 2009 • Approved by the NFHS Board of Directors – October 2009

16. 2010-11 NFHS Rule Book Changes on Concussion Suggested Management: No athlete should return to play (RTP) or practice on the same day of a concussion. Any athlete suspected of having a concussion should be evaluated by an appropriate health-care professional that day. Any athlete with a concussion should be medically cleared by an appropriate health-care professional prior to resuming participation in any practice or competition. After medical clearance, RTP should follow a step-wise protocol with provisions for delayed RTP based upon return of any signs or symptoms.

17. Appropriate Health-Care Professional Who should it be?? • MD/DO • Athletic Trainer • Nurse Practitioner • Physician Assistant • Neuropsychologist? • ??????? Ideally • Should have knowledge and extra training in sports-related concussion management

18. Officials Responsibility • Recognize the signs or symptoms of a possible concussion and remove the athlete from play • The responsibility of the official is limited to activities that occur on the field, court, or mat • Once the participant has been removed from a contest due to a suspected concussion, the coach or appropriate health-care professional(s) assumes full responsibility for that athlete’s further evaluation and safety • No signed document is needed nor is verification of the appropriate health-care professionals’ credentials

19. Concussion Management - The Basics Develop Coach Education Awareness and Recognition When in doubt, sit ‘em out!! RTP Policies No return to activity on the same day of a concussion No return to activity if having symptoms of a concussion Appropriate Health-Care Professional Clearance

20. Concussion in Sports What You Need to Know FREE COURSE!

21. Prevention • “Concussion prevention” has become the “holy grail” for sports equipment marketers • Soccer head gear • Girl’s Lacrosse head gear/helmets • Pole vaulting helmet • New football helmets, soccer head pads, mouth guards- NO PROVEN PROTECTION FROM CONCUSSION!!

22. Concussion in the Classroom Heads Up to Schools: Know Your Concussion ABCs • Material for teachers, counselors, school nurses, and parents http://www.cdc.gov/concussion/HeadsUp/schools.html

23. REAP Reduce, Educate, Accommodate, Pace Emphasizes team approach to concussion management in school setting Developed in Colorado http://cokidswithbraininjury.com/mild-tbi-concussion-info/

24. Conclusions • Educate • Everyone dealing with young athletes must be aware of the signs, symptoms, and ramifications of concussions • Coach education a must!! • Communicate • Everyone must know role • Mandate or Legislate? • Concussion management policies must be in place at every level • If you don’t do it, someone will do it for you

25. THANK YOU!!!!!! Thad Stanford, MD, JD- Salem The late Vito Perriello, MD Bill Bowers- Executive Director, OADA Tom Welter- Executive Director, OSAA Mickey Collins, PhD- Pittsburgh Ron Savage, EdD- New Jersey Brian Rieger, PhD- New York Ann Glang, PhD- Eugene

26. Contact Feel free to contact me with any questions: michael.koester@slocumcenter.com

27. Open Discussion on2010-11 NFHS Concussion Rule – What State Associations Need to Know