1. Mark Bramble, ATC, MS Marlboro High School

2. MS University of Arizona
BS Temple University
Adjunct Instructor Rutgers Univ
MS University of Arizona
Member ATSNJ Executive Council
Assistant Athletic Trainer
NJSIAA Service Award 2006
Phila./Balt. Stars USFL
Princeton University
ATSNJ Distinguished Service Award 2010
Head Athletic Trainer
Chair ATSNJ Golf Committee
Salpointe Catholic High School
Marlboro High School
Chair EATA Sponsorship Comm
Member ATSNJ Concussion Prevention Task Force

3. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
If only it was this easy!

4. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
WHY THE HUGE CONCERN??
It’s the biggest story in sports at all levels
Evolving research of the long term effects
History of playing w/symptoms
Mis-diagnosis
Lack of reporting
2nd impact syndrome
Depression
Suicide
Alzheimer's
Neurological effects
2nd impact syndrome is the catastrophic condition we are trying to prevent by not allowing athletes w/ symptoms to return to activity. Depression,suicide,alzheimers,neurological deficits are the long term problems that we are recently finding in many older athletes who did not report concussions as far back as high school

5. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
WHY THE HUGE CONCERN??
Young population is at the greatest risk
High school age children are at a critical stage of brain development.
Reason for not comparing concussion management of NFL players to how we treat high school athletes.
130,000 concussions reported in high school sports per year reported by the CDC
Current research shows that this is probably 10x more
Kids hide symptoms from parents, coaches, athletic trainers and other school staff (nurses, teachers, etc.)
Why are we here today? ///// Education for everyone is the key factor in preventing short term and long term problems

6. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
WHY THE HUGE CONCERN??
Energy measuring devices placed in football helmets to measure G forces.
Forces measured helmet to helmet impacts of 180 G’s
Car traveling at 35mph slamming into a brick wall = 40 G’s
Forces have an accumulating effect.
50-80 impacts to the head per practice, measuring G’s to 80G’s.
//////Accelerometers//////Football is not the only sport w/ concussions, but this is a real good eye opener. //// that’s a lot of violent impacts to consider when the athlete comes out of the game or practice w/ symptoms and there was no “single blow” that can account for the injury. We are finding long term memory and cognitive problems in x-athletes w/o a documented concussion. Another study found impacts as high as 300 G’s

7. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
Hire an athletic trainer
ATC’s are the only health care professionals whose license requires continuing education in the recognition and treatment of concussions
ATC’s are the first line of protection.
for the athlete from further injury
for the school from liability
from coaches
from parents
The new laws and regulations coming from the state legislature and DOE are very labor intensive. If you don’t have an athletic trainer on staff, who on your staff is qualified to handle every aspect from recognition, calling parents to making sure the athlete sees the proper physician, implementing ImPact testing on hundreds of students, contacting school doctor to following all the steps required for return to play?

8. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
RECOGNIZING A CONCUSSION:
Even the officials get this one right

9. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
RECOGNIZING A CONCUSSION:
Mechanism of injury
Athlete has a collision w/ another player, the ground, goal post or other structure on the perimeter of the playing area. The athletes’ head may or may not be the actual point of contact. The brain is injured due to the violent shearing forces created during sudden stopping of the skull while the brain continues to move. The brain is basically bruised from it’s collision with the interior of the skull.
Justin Morneau has been out since July. Sydney Crosby of the Pitts Penguins has been out since January

10. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
Signs and Symptoms:
Headache
Nausea/vomiting
Balance/coordination problems
Dizzy
Vision changes
Sensitivity to light or noise
Feeling like in a fog, dazed, disoriented
Memory loss
Confusion
Concentration difficulties
Irritable or anxious
Difficulty verbalizing
Loss of consciousness

11. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
Have a school board approved physician with training in concussion management and neurocognitive (ImPact) testing.
The medical field currently does not have a specialty in concussions or concussion management. There is no certification in concussion management.
Neurology as a profession, has little training in return to play decision making.
Board certification for sports medicine physicians is currently using test questions concerning concussions that are over 20 years old.
ImPact offers courses for physicians many times throughout the year at various locations in NJ and around the country///just because it says doctor doesn’t mean it’s right. If you suspect the athlete still has symptoms, you need your school physician to step in to protect the athlete from further injury////I bring these points up because not all physicians are equal and not all of them are up to date w/ the latest research. /////// A doctors note does not override your policy

12. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
Develop a Concussion Policy Specific to your school
Follow newest guidelines from NJ DOE (mandate available 3/31/11)
Should be developed by athletic trainer, school physician, school nurse, athletic director, others
Must be board approved document
Will be required for the fall of school year

13. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
Purchase neurocognitive testing package such as ImPact
Establishes baseline test prior to any head injury
Neurocognitive testing is only ONE TOOL for determining safe return to activity
Used after athlete reports symptoms are gone
NOT A DIAGNOSTIC TOOL
Biggest misconception is that neurocognitive testing determines if an athlete has a concussion
A concussion is a SYMPTOM BASED DIAGNOSIS
There is currently no computer test or imaging technique that will determine if a concussion exists
Cat scans and MRI’s will find catastrophic injuries not the mild traumatic brain injuries we normally see. There is research in this area but we are a long way from imaging concussions. We may see a blood test for concussions before any imaging is used for high school age students

14. HOW TO MANAGE CONCUSSIONS AT THE HIGH SCHOOL LEVEL
Establish a standardized recording tool or document, for assessing concussions.
Date, time, mechanism of injury
Orientation
Symptom evaluation
Glasgow coma scale
Balance and coordination
Memory, recall, concentration
This document should be on the sidelines for all events. Record all necessary information

15. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
New legislation mandates that every school district establish a concussion management policy based on the policies established by:
NJSIAA
NCAA
ATSNJ
BRAIN INJURY ASSOC. OF NJ
Other medical organizations w/ concussion management expertise
Commissioner of education, K-12 model issued by 3/31/11
What are we doing in Freehold Regional, more specifically Marlboro High School //// early indications from the DOE will stick pretty much to what we have been doing for concussion management, but the model will establish stricter education guidelines for ATC’s, coaches, athletes, parents, school doctors and school administrators. Most importantly, your policy must be based on the most current research available, must be reviewed and approved on a yearly basis.

16. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
BASELINE NEUROCOGNITIVE TESTING (ImPact) DONE WITH ALL ATHLETES
INCLUDING CHEERLEADERS
PRIOR TO THE BEGINNING OF TRYOUTS
Getting this done requires cooperation from many. Athletic director must help arrange facility use of computer room or media center. Outside coaches must arrange their other jobs to be available. Students must be made to feel that they can’t tryout unless this is completed just like their physical forms.

17. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
ALL ATHLETES REPRESENTING SIGNS & SYMPTOMS OF A CONCUSSION REMOVED FROM PLAY
EVALUATION BY THE SCHOOLS ATHLETIC TRAINER (licensed health care provider)
NO RETURN TO ACTIVITY

18. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
THE ATHLETIC TRAINER RECORDS INFORMATION USING THE SPORTS CONCUSSION ASSESSMENT TOOL (SCAT2)

19. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
PARENTS ARE NOTIFIED
SCAT2 FORM AND LETTER EXPLAINING POLICY SENT WITH ATHLETE, FOR THE PHYSICIAN
ATHLETE IS EVALUATED BY PHYSICIAN
SCHOOL PERSONNEL NOTIFIED IF COGNITIVE MODIFICATIONS (temp 504) PLAN FOUND TO BE NECESSARY
IMPACT TESTING INITIATED WHEN ATHLETE IS SYMPTOM FREE FOR AT LEAST 48 HOURS
IMPACT TESTS CONTINUED UNTIL BACK TO BASELINE
IMPACT RESULTS EVALUATED BY SCHOOL PHYSICIAN

20. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
ATHLETE MUST BE SYMPTOM FREE FOR AT LEAST 7 CONSECUTIVE DAYS AND CLEARED BY A PHYSICIAN BEFORE ANY ACTIVITY RESUMES
ATHLETIC TRAINER MAINTAINS TIMELINE
GRADUAL RETURN TO ACTIVITY FOLLOWS THE ZURICH CONSENSUS STATEMENT GUIDELINES
5 days of increased activity each day
as long as no symptoms re-occur due to prior days activity
Day 5 is return to activity (usually practice not game)

21. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
ZURICH CONSENSUS STATEMENT GUIDELINES
Day 1, low impact activity, walking/stationary bike 10 minutes
Day 2, increase heart rate w/ increased activity on bike, push ups, sit ups, jumping rope, strength training, 20 minutes
Day 3, running, sport specific activities, sprinting,30 minutes
Day 4, non-contact sport specific drills, sprinting, full equipment
Day5, return to “controlled”, full practice w/contact

22. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
ZURICH CONSENSUS STATEMENT GUIDELINES
Progression to the next day’s activity is dependant on remaining symptom free following each day of increased activity
Recommended that the first day of full return to activity is not a game. Practice is controlled and removal from activity can be self monitored w/o use of time outs or relying on an official to stop play. Coaches and athletic trainer can be on the field and next to the huddle, etc.

23. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
HOW IS THIS POLICY WORKING AFTER TWO FULL SEASONS OF APPLICATION
POSITIVES:
There is no doubt that this benefits the student athlete.
Combination of passing the ImPact test, gradual symptom free return, physicians clearance, and minimum of 12 days rest, almost guarantees safe return to his/her sport.
Creates an atmosphere of concussion management awareness for athletes, parents, coaches, teachers, physicians and administrators.
It takes the emotional “need to play” out of the equation.

24. FREEHOLD REGIONAL HIGH SCHOOL DISTRICT CONCUSSION POLICY
HOW IS THIS POLICY WORKING AFTER TWO FULL SEASONS OF APPLICATION
DRAWBACKS
Lack of trained physicians
Proving the concussion, discrepancy between athletic trainers findings and the family/ER physician.
Timing of days. Snow days, holidays, absences of athlete/athletic trainer, game schedule
Off campus teams (swimming, hockey, etc)
Professional athletes vs. high school athletes
Not a musculoskeletal injury. Confusing “comfort with cure”
No guidelines for multiple concussions

25. FINAL NOTES ON MANAGING CONCUSSIONS
Incidence of concussions can be reduced if the rules of each sport are properly enforced by officials and coaches continue to teach proper techniques. This is where the NFL is a good example.
The NOCSAE test standard for helmets is and has always been established as a measure of energy absorption to prevent SCULL FRACTURES not CONCUSSIONS.
Independent studies have not found any helmet to be better than another at preventing concussions.
There are no standards and there has been no independent testing of the soft headgear. Just because it’s there doesn’t mean that it’s good or even does what it appears like it might do
High School athletes are still children, long term effects of concussions on a developing brain are still unknown.
It’s better to miss one game or even one season than to have a lifetime of missed activities.
Grading of a concussion is done after the athlete recovers.
A CONCUSSION IS A BRAIN INJURY. TAKE IT SERIOUSLY.
Soft headgear may give a sense of false security. Also sends the wrong message to those not involved w/ making the decision to wear it.

26. REFERRENCES ATSNJ-www.ATSNJ.org CDC-www.cdc.gov/concussion
ImPact-
Brain Injury Assoc. NJ-
NJ Legislature-
Find a doctor—

27. Thank you Mark Bramble, ATC, MS
Thank you for inviting me.

28. ROLE OF THE SCHOOL PHYSICIAN
NEW LEGISLATION WILL MAKE IT MANDATORY FOR SCHOOL PHYSICIANS TO HAVE TRAINING IN CONCUSSION MANAGEMENT AND RETURN TO PLAY GUIDELINES
IF YOUR SCHOOL ADOPTS NEUROCOGNITIVE TESTING YOUR PHYSICIAN MUST BE TRAINED IN INTERPRETING THE INFORMATION
The brain injury association of NJ offers ImPact training courses several times every year.
ImPact offers courses throughout the country all year long

29. ROLE OF THE SCHOOL PHYSICIAN
At Marlboro, the school physician is notified about all catastrophic injuries
Non-catastrophic head injuries are reported if there are differences between myself and the athletes physician about whether a concussion exists
School physician interprets all ImPact tests and gives the OK to start progressive return to activity.
School physician assists w/ establishing temporary 504 plans if necessary
School physician has authority to overrule the athletes physician if the athlete’s safety is at risk or if the doctors timeline does not follow the concussion policy
Last point is very important due to lack of training for many pediatric and ER physicians. This will be in the new DOE model plan. As mentioned before even neurologists have limited knowledge in return to play management and should not be considered the ultimate authority in concussion management at this time.

30. ROLE OF THE SCHOOL PHYSICIAN
What does the ImPact test look like? A quick look
Series of words at beginning and end. ///// three x’s or o’s will be a different color, then they are distracted by clicking the numbers backwards starting w/25, then this comes back and they click on which 3 they think were different in the previous window.///// shapes are at beginning and end.////// symbol match changes, later the symbols will not be there and they are asked to match the symbol to the number it previously represented.

31. ROLE OF THE SCHOOL PHYSICIAN
Interpreting the data
This was We no longer do the test this closely in time. But it is a good example for those of you unfamiliar with the ImPact test.//// Currently we don’t do the test until the athlete tells us he/she is symptom free. What they say, is often different, than what they report, on this section of the test. The progression of decreasing symptoms is exactly what we look for. This window is at the beginning of the demographics section and as of January a second window has been added at the end. This checks to see if the test itself re-creats symptoms.

32. ROLE OF THE SCHOOL PHYSICIAN
Interpreting the data
In this time line you can see that these scores took 20 days to get back to acceptable levels. Bold or red items show a statistical difference from the baseline and are our big red flag to continue rest and maybe initiate cognitive modifications in school.

33. ROLE OF THE SCHOOL PHYSICIAN
Interpreting the data
Sometimes it’s easier to see in the bar graph, the progression of improvement, and gradual return to near baseline. According to ImPact this is close enough to baseline to allow gradual return to activity. The school physician makes the decision to begin return to play activities. The athlete does not need an actual appointment unless there are complications like unusual time to recover or multiple concussions. The test is internet based and can be read by both the atc and school physician. It’s password protected. The student athletes can not open, change or review their tests. I always provide a paper copy to the athlete or parent to take to their own physician.