What You Don’t Know Can Hurt: Proper Management of Concussions and Complying with the Regulations Linda Brown, MBA Oct. 25, 2016 MAHPERD Webinar Linda.brown@state.ma.us

Overview Background MA Law Overview of MDPH Regulations Data Changing the Culture Resources

What is a Concussion?

What is a Concussion? A concussion is a type of traumatic brain injury caused by a bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells. This is a functional injury not a structural injury. (CDC)

Massachusetts Sports-Related Head Injury Law In July 2010, Governor Patrick signed into law Chapter 166, An Act Relative to Safety Regulations for School Athletic Programs. This is the 5th year of implementation and MDPH has continued to reach out to hundreds of schools and clinicians to raise awareness, collect data, review school policies and provide TA.

Massachusetts Sports-Related Head Injury Law Aimed to improve the prevention and management of these injuries, promoting brain healing and reducing the risk of serious health consequences. MDPH developed a head injury safety program which resulted in regulations passed in 2011.

Key Provisions of the Regulations The regulations provide standardized procedures for persons involved in the prevention, training, management and return to activity decisions regarding students who incur head injuries while involved in extracurricular athletic activities.

Scope of the Regulations Apply to all public middle and high schools (grades 6-12) and all other schools that are members of the Massachusetts Interscholastic Athletic Association Apply to all extracurricular interscholastic sports Does not apply to town or club sports (Little League, Pop Warner, etc.)

Annual Training Annual completion of DPH-approved training for: Coaches; Certified athletic trainers; Trainers; Volunteers; School and Team physicians; School nurses Athletic Directors; Marching Band Directors; Parents of student athletes; Student athletes. Two free, on-line trainings have been identified including the CDC Heads Up Concussion training and NFHS and can be found at www.mass.gov/sportsconcussion Schools need to keep documentation of completion of the training for all the above persons.

Pre-Participation Requirements Students and parents must complete and submit a Pre-participation Form (with history of head injury/concussion) before each sports season This form is reviewed by medical and athletic staff to ensure that it is safe for student to participate in school sports. Kathy will be talking more about the dangers of returning a concussed student athlete to play too soon. The preparticipation form when reviewed by nursing and athletic staff ensures that a student has totally recovered from a prior concussion and it is safe for the student to return to athletics.

Exclusion from Play Students who sustain a head injury or suspected concussion during an extracurricular athletic activity must be removed from the practice or competition immediately and may not return to the practice or competition that day. Parents must be promptly notified of any head injury or suspected concussion. Medical clearance must be provided before a student can return to play.

Graduated Return to Play Each student who is removed from practice or competition and subsequently diagnosed with a concussion shall have a written graduated reentry plan for return to full academic and athletic activities. Returning a student to play after a known or suspected concussion places the student at risk for long-term health consequences, including serious injury or in rare cases even death. This team should work with the family to develop an appropriate program and timeline to meet the student’s needs and explain as necessary the reasons for the resulting plan. Continually reassess the student for symptoms and progress in healing.

Graduated Return to Play The written plan shall include instructions for students, parents and school personnel, addressing but not be limited to: (a) Physical and cognitive rest; (b) Graduated return to extracurricular athletic activities and classroom studies, including accommodations or modifications as needed; (c) Estimated time intervals for resumption of activities; (d) Frequency of assessments by the school nurse, school physician, team physician, certified athletic trainer or neuropsychologist until full return to classroom activities and extracurricular athletics are authorized; and (e) A plan for communication and coordination among school personnel and between the school, parent, and student's primary care provider or physician who is managing the student's recovery. (It is important to identify someone on the team who will function as a case manager and primary point of contact.)

Medical Clearance and Authorization to Return to Play Medical clearance can be provided by physicians (MD), certified athletic trainers (AT), nurse practitioners (NP), physician assistants (PA) and neuropsychologists. Clinicians must use the MDPH Medical Clearance form (not a doctor’s note). If a concussion has been diagnosed, a student must complete a graduated reentry plan before medical clearance. Clinicians providing medical clearance are required to certify that they have received appropriate training in concussion assessment and management.

Elements of Medical Clearance Date, nature of injury Symptoms – nature and duration Prior concussions Final diagnosis – concussion or other Date graduated return to play plan completed

What’s Expected: Coaches Complete training Review Pre-participation Forms Completing Report of Head Injury Form Identifying athletes with suspected head injuries and removing them from play; inform parent Receiving/reviewing Report of Head Injury Form from parents outside of school sports Transmitting Pre-participation and Report of Head Injury Forms to School Nurse for review Teaching techniques aimed at minimizing head injury Discouraging & prohibiting athletes from engaging in any unreasonable dangerous athletic technique

School Reporting Requirements Every school year, schools shall be responsible for maintaining and reporting to MDPH annual statistics which include: The total # of Department Report of Head Injury Forms (or school-based equivalents) received by the school; and The total # of students who incur head injuries & suspected concussions when engaged in any extracurricular athletic activities. These forms are due to MDPH by August 31, every year

Percentage of Massachusetts Students(1) Reporting Symptoms of a TBI(2) While Playing with a Sports Team in the Past 12 months 1) Includes only students who played on a sports team in the past 12 months. 2) Reported they suffered a blow or jolt to head while playing with a sports team (during a game or practice) which caused them to get "knocked out", have memory problems, double or blurry vision, headaches or "pressure" in the head or nausea or vomiting. Source: MA Youth Health Survey, MA Department of Public Health

Percentage of Students Reporting Actions Taken Following Symptoms of a TBI(2) While Playing with a Sports Team in the Past 12 months Includes only students who played on a sports team and who reported symptoms of a traumatic brain injury following blow or strike to head during sports in the past 12 months Source: MA Youth Health Survey, MA Department of Public Health

Changing the Culture Reporting symptoms will facilitate an athlete being properly assessed, monitored and treated. In one study researchers interviewed a group of almost 800 high school athletes during a sports season: 69% of athletes with a possible concussion played with symptoms. 40% of athletes said that their coaches were not aware that they had a possible concussion. (CDC)

Changing the Culture Coaches: Tell athletes that you want them to always report concussion symptoms, no matter how important the game or event is. Coaches: Keep a list of concussion signs & symptoms and a concussion action plan with you at practices and games. Parents: Explain to your child why it is important to report a possible concussion right away. Students: Always report symptoms. It is better to miss one day than one sports season. Students: Help your teammates by looking out for signs and symptoms among friends who have had a possible concussion.

In Conclusion….

MDPH Guidance and Resources www.mass.gov/sportsconcussion Required Forms Copy of the Regulations List of approved annual trainings and clinical trainings Head Strong, Model Guidance for Schools www.cdc.gov/concussion

Additional Resources Videos: Keeping Quiet Can Keep You Out of the Game (CDC) https://www.youtube.com/watch?v=yIqZD6k3M40 Concussions 101, A Primer for Kids and Parents (5 minute video) http://www.evanshealthlab.com/concussion101 or www.youtube.com/watch?v=zCCD52Pty4A Brain 101 (4 minute video) - http://brain101/orcasinc.com/5000/ Brain Injury Association of MA: www.biama.org Mass. Interscholastic Athletic Association (MIAA): http://www.miaa.net/miaa/home?sid=38

Graduated Return to Play: Resources The South Shore Hospital has a recovery protocol called HeadSmart™, A Healthy Transition After Concussion and is a recovery protocol developed by physicians and school nurses to facilitate a student’s healthy return to school and sports following a concussion. HeadSmart outlines the four color-coded stages of recovery. It can be found at: http://www.southshorehospital.org/head-smart

Graduated Return to Play: Resources Colorado’s Rocky Mountain Hospital for Children has a program developed by Karen McAvoy, Psy.D. called REAP (Reduce, Educate, Accommodate, PACE). It is a concussion management program that helps families, schools and medical professionals. The REAP booklet can be found at: http://bianys.org/Default.aspx?SiteSearchID=1183&ID=/search.htm MDPH’s model policies, Head Strong: Guidance for Implementing the Massachusetts Regulations on Head Injuries in School Athletics (found at www.mass.gov/dph/sportsconcussion) has examples of Graduated Re-Entry Plans for schools

Where to Get Help Spaulding Rehab, Boston: http://spauldingrehab.org/locations/boston-ma-op UMass. Memorial Medical Center Sports Medicine Clinic https://www.umassmemorialhealthcare.org/umass-memorial-medical-center/services-treatments/orthopedics/services-we-provide/sports-medicine Dr. Robert C. Cantu Concussion Center at Emerson Hospital https://www.emersonhospital.org/MedServicesAndCenters/Centers/Cantu.aspx For more referrals for help, call Concussion Legacy Foundation: http://concussionfoundation.org/learning-center/concussion-clinics?gclid=CjwKEAjw7ZHABRCTr_DV4_ejvgQSJACr-YcwZC0W5hRRlmAbDlu8OzVEpwP7micM7aiBxZm9Hn-kKBoCBqnw_wcB

Where to Get Help Boston Childrens Hospital Concussion Clinic: http://www.childrenshospital.org/conditions-and-treatments/conditions/concussions Mass. General Hospital Concussion Clinic, Boston: http://www.massgeneral.org/children/services/treatmentprograms.aspx?id=1689 South Coast Hospitals, New Bedford: http://www.southcoast.org/sports/concussions.html South Shore Hospital Concussion Management Clinic, South Weymouth: http://www.southshorehospital.org/concussion Spaulding Rehab Cape Cod, East Sandwich: http://spauldingrehab.org/locations/sandwich-ma/programs-services Beth Israel Hospital Plymouth: http://www.bidplymouth.org/rehabilitation