1. Keeping Athletes Safe

2. Definition Concussion is a brain injury and is defined as a complex patho- physiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: Caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’ force transmitted to the head. Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms & signs may evolve over a number of minutes to hours. May result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury &, as such, no abnormality is seen on standard structural neuroimaging studies (CT or MRI) Results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged

3. Concussions in Adolescents The developing brain may be affected more severely than the mature brain The developing brain takes longer to recover than the adult brain Symptoms may be more severe in adolescents Children diagnosed with ADD or ADHD may take longer to recover than the average athlete Once you have suffered one concussion, you are more susceptible to future concussions Athletes must be immediately removed from activity if a concussion is suspected Athletes are not allowed to return to play until they have been evaluated by a medical professional trained in concussion evaluation & treatment Athletes are not allowed to return to full contact competition until they have been cleared by a physician trained in concussion evaluation & treatment Athletes who sustain more than 1 concussion per season should be restricted from activity for 1 year

4. Symptoms Clinical Symptoms Headache Blurred Vision Nausea Sensitivity to Light or Noise Physical Signs Slow Reaction Times Fatigue Behavioral Changes Irritability, getting Angry Sensitivity, Crying Cognitive Changes Confusion Trouble with concentration Difficulty remembering Sleep Disturbance No two concussions are the same

5. Who is Allowed to Evaluate My Child? Sideline Evaluation Physician, M.D. or D.O. Medical Professional working under the direction of a physician trained in concussion evaluation & treatment ATC PA NP Medical Clearance to Return to Participation Physician, M.D. or D.O. * Per SC Law & SCHSL

6. Evaluation Sideline Evaluation SCAT2 Gives us Symptom Score Cognitive Concentration Recall Balance Medical Evaluation The physician should evaluate the athlete for clinical symptoms, physical symptoms, behavioral changes, cognitive changes, & sleep disturbance The physician should ask to see results of sideline assessments or neurocognitive testing It is best to have you child evaluated by a physician who specializes in concussion evaluation & treatment

7. Complete Concussion Treatment Plan Prior to the season do Neurocognitive testing, Baseline test Sideline evaluation & diagnose, 1 st SCAT 2 Step 1 = Rest until asymptomatic 2 nd SCAT 2 & If athlete makes an ‘A’ they can begin step 2 Step 2 = light aerobic exercise, no resistance Step 3 = Moderate Activity Step 4 = Heavy Non-contact training drills, no equipment or sports implements Step 5 = Non-contact Sport Specific practice, with equipment If athlete completes Step 1 – Step 5 without becoming symptomatic, they complete post injury neurocognitive testing See a physician for return to contact clearance = send all test results Step 6 = Full contact practice Return to play in full contact game, normal game play ** Athlete remains at each stage for 24 hours. If the athlete becomes symptomatic, they must stop activity. The athlete returns to previous asymptomatic step after a 24 hour rest period

8. Why are we concerned? Post-concussion Syndrome Complex disorder in which a variable combination of post-concussion symptoms last for weeks & sometimes months after the initial injury Fatigue Irritability Anxiety Insomnia Loss of concentration and memory Noise and light sensitivity Post-concussion syndrome symptoms usually occur within the first 7 to 10 days & go away within three months. However, PCS can persist for a year or more. There is no specific treatment for post-concussion syndrome. Post- concussion syndrome treatments are aimed at easing specific symptoms Amitriptyline Dihydroergotamine (D.H.E. 45) combined with metoclopramide (Reglan

9. Cody Lehe - 2006 Zack Lysedt - 2009

10. Why are we concerned? Second Impact Syndrome: SIS occurs when a second brain injury is sustained before a previous brain injury has healed. SIS causes uncontrollable brain bleeding. (Subdural Hematoma or Epidural Hematoma) Ryan Dougherty - 2009 Damon Janes - 2013 Nathan Stiles - 2010 JaQuan Waller - 2008 Matthew Gfeller - 2008

11. Chronic Traumatic Encephalopathy Build up of Tau Proteins in the brain; caused by repeated brain injury. 17 year old Nathan Stiles is the youngest diagnosed case of CTE. He died in 2010 from Second Impact Syndrome. His brain was donated to be studied after his death.

12. Chronic Traumatic Encephalopathy

13. Can cause Alzheimer type symptoms Has recently been linked to ALS – Lou Gehrig’s Disease (Steve Gleason & Pat Grange) Can lead to changes in personality Can lead to changes in cognitive behavior Athletes May Develop : Depression Dementia Anxiety Mania, Erratic Behavior Obsessive Compulsive Disorder Substance Abuse Issues

14. It is Not Just Football

15. The Research Sports Legacy Institute at Center for the Study of Traumatic Encephalopathy, Boston University School of Medicine Brain Injury Research Institute at West Virginia University UCLA – developing brain-imaging tool to identify tau proteins in living brains Centers for Disease Control and Prevention - Atlanta, Georgia

16. New Policies in 2013 NFL NCAA The new policy covers real-time assessment & treatment. Unaffiliated neurotrauma expert on Sideline of each game that will be solely responsible for evaluating & identifying signs an symptoms. Added an additional ATC in the Press Box to watch for injuries that may not be seen from the sideline. ImPACT, neurocognitive testing PAC 12 implemented new practice restrictions: Teams are now limited to 2 full-contact practices per week during the regular season & spring practice. “Full contact" is defined as any live tackling, live tackling drills, scrimmages or other activities where players are generally taken to the ground. NCAA implements automatic ejections for additional helmet-to-helmet contact or targeting. “intentionally viscous & dangerous hits” This is in addition to the 15 yard penalty. The ejection part of the call is reviewable by the replay official. "We can make the statement that you can teach a kid how to play with fewer head impacts in practice," said Stefan Duma, a co-author of the study from the Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences.

17. The Law: H3061 June 7 th, 2013 Each year prior to participation in athletics, each school district shall provide to all coaches, volunteers, student athletes, and their parents or legal guardian, an information sheet on concussions which informs of the nature and risk of concussion & brain injury, including the risks associated with continuing to play after a concussion or brain injury The parent or legal guardian's receipt of the information sheet must be documented in writing or by electronic means before the student athlete is permitted to participate in an athletic competition or practice If someone suspects that a student athlete has sustained a concussion or brain injury in a practice or in an athletic competition, the student athlete shall be removed from practice or competition IMMEDIATELY A student athlete who has been removed from play & evaluated & who is suspected of having a concussion or brain injury may not return to play until the student athlete has received written medical clearance by a physician- SCHSL form Written medical clearance only releases the athlete to begin the Return to Play Protocol Athletes are not permitted to return to full-contact until they have successfully completed the Return to Play Protocol

18. What we know A second concussion in close succession to an initial concussion can be devastating even FATAL Athletes may not be ready for return to play, even after a clear CT It is imperative that the athlete does not return to play until ALL symptoms have resolved A multidisciplinary treatment approach is best Our treatment process is not perfect (will not completely prevent concussions & expect it to get more conservative/strict) The treatment process is still developing: The 1 st International Conference on Concussion in Sport was held in 2001. The 4 th International Conference on Concussion in Sport was help in November of 2012. We must be CONSERVATIVE when treating concussions The only guaranteed way to prevent concussions in the athletic setting is to refrain from participating in athletics.

19. Resources http://sports.espn.go.com/espn/news/story?id=5970086 http://www.sportslegacy.org/ http://espn.go.com/espn/otl/story/_/id/8867972/ucla-study-finds- signs-cte-living-former-nfl-players-first-time http://espn.go.com/espn/otl/story/_/id/8867972/ucla-study-finds- signs-cte-living-former-nfl-players-first-time http://espn.go.com/espn/otl/story/_/id/8697286/boston-university- researchers-discover-28-new-cases-chronic-brain-damage-deceased- football-players http://espn.go.com/espn/otl/story/_/id/8697286/boston-university- researchers-discover-28-new-cases-chronic-brain-damage-deceased- football-players http://www.cnn.com/2012/01/27/health/big-hits-broken-dreams- brain-bank http://www.cnn.com/2012/01/27/health/big-hits-broken-dreams- brain-bank http://www.cnn.com/video/data/2.0/video/sports/2011/11/11/gupta-big- hits-broken-dreams-trailer.cnn.html http://www.cnn.com/video/data/2.0/video/sports/2011/11/11/gupta-big- hits-broken-dreams-trailer.cnn.html http://abcnews.go.com/Health/cte-degenerative-brain-disease-found- 34-pro-football/story?id=17869457 http://abcnews.go.com/Health/cte-degenerative-brain-disease-found- 34-pro-football/story?id=17869457 http://bjsm.bmj.com/content/47/5/250.full