Concussion in Sports Becky Oakes NFHS Director of Sports NISCA Convention Indianapolis, IN March 29, 2013

National Federation of State High School Associations About the National Federation of State High School Associations (NFHS): The NFHS Office is located on the White River State Park next to the National Collegiate Athletic Association (NCAA) and the Indiana State Museum in downtown Indianapolis, Indiana. The first full-time executive director, H.V. Porter, was appointed in 1940 and established the first office in Chicago, Illinois. Cliff Fagan replaced H.V. Porter as executive director in 1958, and the national office was moved from Chicago to suburban Elgin, Illinois, in 1972. Brice Durbin became the organization’s third executive director in 1977, and the national office was moved to Kansas City, Missouri, in 1979. Bob Kanaby was named the NFHS’ fourth executive director in 1993, and the office was moved to Indianapolis, Indiana, in 2000. In 2010, Bob Gardner was named the organization’s fifth executive director.

National Federation of State High School Associations NFHS: National leadership organization for high school sports and fine arts activities; Writes playing rules for 17 boys and girl sports at the high school level; National authority on interscholastic activity programs. Conducts national meetings; Sanctions interstate events; Produces publications for high school coaches, officials and athletic directors; National source for interscholastic coach training; and national information center. About the National Federation of State High School Associations (NFHS) cont: The NFHS, based in Indianapolis, Indiana, is the national leadership organization for high school sports and fine arts activities. Since 1920, the NFHS has led the development of education-based interscholastic sports and fine arts activities that help students succeed in their lives. The NFHS sets direction for the future by building awareness and support, improving the participation experience, establishing consistent standards and Rules for competition, and helping those who oversee high school sports and activities. The NFHS writes playing Rules for 17 sports for boys and girls at the high school level. Through its 50 member state associations and the District of Columbia, the NFHS reaches nearly 19,000 high schools and 11 million participants in high school activity programs, including more than 7.6 million in high school sports.

National Federation of State High School Associations Membership = 50 member state associations and D.C. NFHS reaches nearly 19,000 high schools and 11 million participants in high school activity programs, including more than 7.6 million in high school sports. About the National Federation of State High School Associations (NFHS) cont: The NFHS, based in Indianapolis, Indiana, is the national leadership organization for high school sports and fine arts activities. Since 1920, the NFHS has led the development of education-based interscholastic sports and fine arts activities that help students succeed in their lives. The NFHS sets direction for the future by building awareness and support, improving the participation experience, establishing consistent standards and Rules for competition, and helping those who oversee high school sports and activities. The NFHS writes playing Rules for 17 sports for boys and girls at the high school level. Through its 50 member state associations and the District of Columbia, the NFHS reaches nearly 19,000 high schools and 11 million participants in high school activity programs, including almost 7.5 million in high school sports.

NFHS SPORTS MEDICINE ADVISORY COMMITTEE Mission Statement The Sports Medicine Advisory Committee (SMAC) shall advise the NFHS concerning sports medicine issues as they relate to rules writing, as well as the other programs and services of the NFHS. It will monitor and disseminate current information to the NFHS and its membership relative to the sports medicine field. Through this committee, the NFHS will work to educate its constituency concerning sports medicine issues. The committee will proactively address health and safety issues of general concern to the NFHS membership.

Member State Associations Sports Medicine Advisory Committees

State Concussion Legislation (As of March 2013)

NFHS Rules Books Baseball Basketball Cross Country Field Hockey Football Girls Gymnastics Ice Hockey Boys Lacrosse Soccer Softball Spirit Swimming and Diving Track and Field Volleyball Water Polo Wrestling

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

Member State High School Associations Need to be aware of current state laws on concussion. Need to define who is an appropriate health-care professional. Need to define return to play criteria. Need to determine the mechanics for removal or re-entry for return to play for the same contest. Need to educate member schools on concussion recognition and management. Need to educate officials, parents, athletes and the media on concussion.

Appropriate Health-Care Professionals Need to be aware of current NFHS rules, state laws and state association rules in regard to concussion management. Need to understand that they share a responsibility for recognition, removal and proper management of concussion in competition. Need to update knowledge!

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

Coaches Need to be educated in concussion recognition and management. Need to understand the role of the official and appropriate health-care professional. Need to understand that they share a responsibility in recognition of concussion in competition and practice. Need to follow school district and state association policies on return to play.

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, pool 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 Need to be aware of current NFHS rules, state laws and state association rules in regard to the signs and symptoms of a concussion. Follow protocol from state association for compliance with concussion rule.

PIPER NFHS Injury Surveillance System The National High School Sports Injury Surveillance Study: High School RIOTM R. Dawn Comstock, PhD Associate Professor Pediatric Injury Prevention, Education, and Research (PIPER) Program Colorado School of Public Health, Epidemiology

Swimming and Diving Injury Data Boy’s and Girls’ swimming and diving had the lowest injury rates of the 20 sports under the NFHS Injury Surveillance System in 2011-12. About 50% of all injuries were overuse type injuries with 44-49% of the injuries involving the shoulder in 2011-12. Boys: Diving accounted for 9.2% of all injuries, swimming for 69.7% and other for 21.1% from 2008/09 – 2011/12. Girls: Diving accounted for 4.3% of all injuries, swimming for 78.6% and other for 17.1% from 2008/09 – 2011/12.

Girls’ Swimming and Diving Injury Rates In 2011/12, girls’ swimming and diving had the second lowest injury rate (after boys’ swimming and diving) in the 20 sports under surveillance. 28 injuries during 73,788 athlete exposures overall -Overall injury rate 0.38 per 1,000 AE 2 competition injury during 13,841 competition exposures -Competition injury rate 0.14 per 1,000 competition AE 26 practice injuries during 59,947 practice exposures -Practice injury rate 0.43 per 1,000 practice AE

Boys’ Swimming and Diving Injury Rates In 2011/12, boys’ swimming and diving had the lowest injury rate in the 20 sports under surveillance. 12 injuries during 63,883 athlete exposures overall -Overall injury rate 0.19 per 1,000 AE 1 competition injury during 12,231 competition exposures -Competition injury rate 0.08 per 1,000 competition AE 11 practice injuries during 51,652 practice exposures -Practice injury rate 0.21 per 1,000 practice AE

Extent of the Problem Concussions About 9% of all sports injuries Likely at least 140,000 concussions in HS athletes yearly based on High School RIO estimates

Burden of Concussion by Sport, 2008/09 -2011/12 Girls’ and boys’ swimming and diving are both here among these tiny slices of the pie. *Girls’ swimming and diving accounted for 0.2% (n=8) of all concussions while boys’ swimming and diving accounted for 0.1% (n=6) of all concussions.

Swimming and Diving Injury Data Concussions 2008-09* 2009-10* 2010-11* 2011-12* Overall # of concussion (rate/10,000 AEs) Boys’ Swimming & Diving total 2 (0.17) 0 (0.00) 1 (0.13) 3 (0.47) 6 (0.18) Competition 1 (0.65) 1 (0.15) Practice 2 (0.21) 3 (0.58) 5 (0.18) Girls’ Swimming & Diving total 3 (0.23) 1 (0.10) 1 (0.12) 3 (0.41) 8 (0.21) 1 (0.40) 1 (0.48) 1 (0.63) 1 (0.72) 4 (0.53) 2 (0.19) 2 (0.33) 4 (0,13)

Swimming and Diving Injury Data Concussions Basic injury mechanism * Sport athlete was participating in Crosstabulation Sport athlete was participating in Total boys swimming and diving girls swimming and diving Basic injury mechanism contact with another person 2 4 33.3% 25.0% 28.6% contact with playing surface 8 66.7% 50.0% 57.1% contact with playing apparatus .0% 14.3% 6 14 100.0%

Swimming and Diving Injury Data Concussions Swimming activity at time of injury * Sport athlete was participating in Crosstabulation Sport athlete was participating in Total boys swimming and diving girls swimming and diving diving off board/platform/ block 2 .0% 25.0% 14.3% swimming 3 5 50.0% 35.7% touch turn off wall 1 12.5% 7.1% flip turn off wall 16.7% other 33.3% 37.5% 6 8 14 100.0%

Swimming and Diving Injury Data Concussions Type of exposure * Sport athlete was participating in Crosstabulation Sport athlete was participating in Total boys swimming and diving girls swimming and diving Competition 1 4 5 16.7% 50.0% 35.7% Practice 9 83.3% 64.3% 6 8 14 100.0%

Concussion Management - The Basics Develop Coach Education Awareness and Recognition When in doubt, sit ‘em out!! Return to Play 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

What Can You Do? Coaches Be educated about concussion recognition and management Have an Emergency Action Plan Help schools educate game officials, parents, athletes and the media on concussion Need to understand the role of the game official and appropriate health-care professionals Follow school district and state association policies on return to play

NFHS Coach Education “Concussion in Sports – What You Need to Know” On-line training for coaches NFHS/CDC Heads Up collaboration Free!! Coaches, game officials, administrators, parents www.nfhslearn.com Additional resources Over 725,000 courses delivered since May 2010. 325,000 in 2012

Concussion in Sports What You Need to Know FREE COURSE!

Concussion in Sports – What You Need to Know www.nfhslearn.com FREE! 175,000+ since July 1.

Concussion Resources PDFs and Videos NFHS Suggested Guidelines for Concussion Management NFHS SMAC - A Parent’s Guide to Concussion in Sport Athlete Fact Sheet Coach Guide Concussion Physiology Emergency Care Plan Gender Differences Main Message Poster Parents Fact Sheet NFHS Rules Book Language Signs and Symptoms Poster Take Concussion Out of Play Tracking the Impact of Traumatic Brain Injuries School Concussion Policy Example CDC Heads up to Schools Checklist Laminated Card Magnet Nurses Fact Sheet Poster Teachers Fact Sheet Clipboard Sticker Position Statement Regarding Soccer Headgear Wallet Card Videos: A Mother’s Perspective Student’s Concussion Experience Student Interviews

First Aid, Health and Safety for Coaches www.nfhslearn.com

First Aid, Health and Safety for Coaches

NFHS Equipment Guidelines

Concussion Prevention Mouth guards No proven benefit in reducing concussion risk – very effective at preventing peri-oral and dental injury

NFHS Suggested Guidelines for Management of Concussion In the Appendix in all of the 2012-13 NFHS Rules Book 35

NFHS Suggested Guidelines for Management of Concussion 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.

NFHS Sports Medicine 2011, 4th edition June 2014, *5th edition will be Concussion chapter June 2014, *5th edition will be released 37

Concussion Chapter

NFHS SMAC Position Statements

NFHS High School Today

Future Direction from the High School Perspective State and Federal Concussion Legislation- Concussion Education is Very Important- Playing Rules and Equipment to Minimize Risks- Injury Surveillance and Concussion Research- Academic Accommodations After a Sports -related Concussion-

Thank You for your support of High School Athletics! www.nfhs.org