EATA Presentation January 2013 - Kaminski

8/16/2019 EATA Presentation January 2013 - Kaminski

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12/28/20

Understanding the Standardof Care for Managing Sport-

Related Concussions

Thomas W. Kaminski, PhD, ATC, FNATA, FACSM, RC Fellow

Professor/Director of Athletic Training Education

University of Delaware

Lecture #2 Saturday 1/5/13

65th Annual EATA Meeting & Clinical Symposium

Buffalo, NY

Athletic Training Research Laboratory

Learning

“All of life should be alearning experience, not

just for the trivialreasons but because bycontinuing the learningprocess, we arechallenging our brainand therefore building

brain circuitry”

Arnold Scheibel (Professor of

Neurobiology and Psychiatry and former Director of theBrain Research Institute, UCLA Medical Center)


Concussion

• Definition - a clinicalsyndrome characterized by immediate andtransient post-traumatic impairmentof neural functions,such as alteration ofconsciousness,disturbance of vision,equilibrium, etc... dueto brain stem(connects

cerebral hemispheres with the spinal cord)involvement

Analogous toice cubes in aglass of

water!


Anquan Bolden Concussion Fall 2008


Typical Sport-RelatedConcussion in Soccer


Watch Here!

Athletic Training Research Laboratory 5



12/28/20

Medical Personnel and Coaches havehistorically mis-assessed concussions

• There is much variation in theknowledge of health careproviders managing concussed

athletes. Need to make surethe person clearing for returnto sport is current withknowledge! – Physicians (MD/DO) – Physician assistants

– Nurse practitioners

– Chiropractors – Athletic trainers – School nurses

• New and emerging researchand technologies will lead to acontinuing evolution of care


Sports-Related Concussionin the United States

CDC now estimates that 1.6 to 3.8 million sports-related

mTBIs occur each year(Langlois, et al., J Head Trauma Rehab. 2006, (5)375-378)

– In Delaware, teens and young adults (ages 15-24) accounted for17% of all hospitalizations as a result of traumatic brain injuries(including SRC) during the reporting period of 2003-2007.

– Only 8% to 19% of sports-related injuries result in LOC.*

* Guskiewicz KM, et al. Am J Sports Med. 2000; 28(5)643-650Schultz MR, et al. Am J Epidemiol. 2004;160:937-944.Collins MW, et al. Clin J Sport Med. 2003;13;222-229.


Extent of the Problem

• Professional athletes get agreat deal of attention- but just tip of iceberg! – 1600 NFL players

• Much more common in UShigh school than any otherlevel- due to large number ofparticipants – HS Sports Participants

• Football- 1.14 million

• Boys Soccer- 384,000

• Girls Soccer- 345,000• Boys Basketball - 545,000

• Girls Basketball - 444,000


Extent of the Problem

• 19.3% of all FB injuries in2009!!!

• Over 100,000concussions nationallyin HS athletes yearly based on CDC estimates,

• Over 1,000 concussionsin HS athletes inDelaware each year


Not Just a Football(or a “guy”) Problem

Injury rate per 100,000 player

games in high school athletes

• Football 47• Girls soccer 36• Boys soccer 22

• Girls basketball 21

• Wrestling 18• Boys basketball 7

• Softball 7

• Data from HS RIO

» JAT, 2007


What has happened tomake this such a big deal?

• Increasing awareness andincidence

– Number of high profileathletes over the past 10 years

– Bigger and faster kids,increased opportunities

– Increased litigation frommisdiagnosis, treatment,and removal from sport




12/28/20

What has happened to make thissuch a big deal?

• High profile cases

– Second Impact

Syndrome• Death or devastating

brain damage whenhaving a secondinjury when not

healed from the first

– Long-term effects

• Possible long-termeffects - dementia,depression, CTE


Problems for Athletes-Post-Concussion Syndrome

• 85-90% of concussed young athletes will

recover within 1 to 2 weeks

• The remainder mayhave symptoms lastingfrom weeks to monthsinterfering with schooland daily life

• Subtle deficits maypersist a lifetime


News Journal Media Coverage


‘Train Wreck of a Play’ Collides With

ConsciencesBy JUDY BATTISTA

Published: December 15, 2012

Op-Ed Columnist

Should Kids Play Football?By JOE NOCERA


Concussion Liability Costs May Rise,

and Not Just for N.F.L.By KEN BELSON


Why the NFL Sucks at Testing for

Concussions•By Sean Conboy •12.28.12•6:30 AM

Student athletes return too soon after

concussionsBy Lisa Kocian

| Globe Staff December 28, 2012

December 25

Concussion diagnosis, managementput to the test

A neurocognitive exam may enable

Maine schools to better determine when

an in jured athlete may resume

competition.By Noel Gallagher

[email protected]@mainetoday

.com

Staff Writer

Federal Regulations on theHorizon?


http://www.nflevolution.com/medical-research

Recent Editorials in ATSHC


http://www.healio.com/jour

nals/atshc

Even the Kids are Involved Too!


http://www.kidsconcussion.com/index.html

http://bostonglobe.com/staff/kocian

http://topics.nytimes.com/top/reference/timestopics/people/b/judy_battista/index.html

http://www.wired.com/playbook/author/sean-conboy/











http://www.pressherald.com/contact/Noel_Gallagher.html




http://www.pressherald.com/news/concussion-diagnosis-management-put-to-the-test_2012-12-26.html



http://topics.nytimes.com/top/reference/timestopics/people/b/ken_belson/index.html





mailto:[email protected]@mainetoday.com



http://www.healio.com/journals/atshc
















http://topics.nytimes.com/top/reference/timestopics/people/b/ken_belson/index.html




12/28/20

So What’s The Big Deal for ME?


Part I – The Legal Stuff• Terminology:

– Liability – legal responsibility!

• Clearly defined in the DE State Practice Act


4.0 Athletic Trainers (24 Del.C. 2602) 4.1 Athletic injuries:4.1.1 Athletic trainers may treat athletic injuries. Athletic injuries shall be consideredmusculoskeletal injuries to athletes that occur while currently participating in, or currentlytraining for, scholastic, professional, or sanctioned amateur athletics, where such injurylimits the athlete’s ability to participate or train for their sport. Athletic Trainers may alsotreat musculoskeletal injuries received by athletes that occur while currently participatingin recreational activities, where such recreational activities are recognized by the Amateur

Athletic Union (see website for list of activities within the AAU). All Athletic injuries must be documented by the Athletic Trainer as interfering with participation in or training forsuch athletic activities. Nothing prohibits the Athletic Trainer from treating minor sprains,strains, and contusions to athletes currently participating in professional, scholastic,recreational, or sanctioned amateur athletic activities.

Part I – The Legal Stuff

– Terminology:

• Standard of Care - the legal duty to providehealth care services consistent with whatother health care practitioners of the sametraining, education, and credentialing wouldprovide under the circumstances


What Does the BOC Have to Say About the “Standard of Care”?


Strategies for AvoidingLegal Liability

• Build relationships

• Insist on a written contract

• Obtain informed consent

• Provide physical exams

• Know the profession and itsstandards

• Document hazards


Strategies for AvoidingLegal Liability

• Establish policies

• Document activities

• Maintain confidentiality

• Provide proper instruction

• Supervise your staff

• Participate in CE• Recognize your qualifications

• Maintain insurance coverage




12/28/20

No Need to Worry I’m Well-Versed inTreating Sport-Related Concussion!

• With more attention in the media on SRC’s the public has become

more educated about the problem (some high-profile athletesinvolved)

• ATC’s (and others) have become a popular target of lawsuits alleging

failures to meet the “standard of care”.• In cases of unfortunate events the actions (or inactions) of th e ATC,

coach, physical educator are likely to be second guessed or blamed.


Legal Attacks Typically Involve:

• The evaluation or testing of an athlete (or lackthereof)

• Documentation of the injury

• Communication with the athlete or with aphysician about an athlete

• Education of the athlete


Part II - What Exactly isthe Standard of Care?


AMSSM PositionStatement 2012


http://www.amssm.org/Content/pdf%20files/2012_ConcussionPositionStmt.pdf

NATA Position Statement


A newer updated position statement is forthcoming!

NFL Health and Safety


http://www.nflevolution.com/home







12/28/20

NCAA Sports Medicine Handbook

Athletic Training Research Laboratory Athletic Training Research Laboratory 31

NCAA Sports Medicine Handbook

National Federation ofState High School Associations


http://www.nfhs.org/SportsMed

.aspx

NFHS position statements:http://www.nfhs.org/content.aspx?id=5786

NFHS Learning Center:

Concussion in Sports – What You

Need to Know

DIAA Concussion Protocol


DIAA Concussion Regulations DIAA Regulation 1008/10093.1.5 Prior to resuming participation, a player who isotherwise properly certified to participate in interscholasticathletics must present to the administrative head of schoolor designee, a statement from a qualified physician that theplayer is physically able to participate if one of the followingconditions has occurred:

3.1.5.1 The player is physically unable to compete due

to illness or injury for five(5) consecutive days on whicha practice scrimmage or contest is held;

3.1.5.2 The player was apparently unconscious;3.1.5.3 The player suffered a concussion.



1. If an athlete exhibits signs and symptoms consistent with a concussion, they shall be removedfrom play immediately. [Be aware of the sport specific rule covering possible concussions] A

qualified health care professional must then determine whether or not an apparent concussionhas occurred. If one of the aforementioned qualified healthcare professionals is not present, theinjury must be treated as a concussion and the student not be allowed to returnto practice/game until determined otherwise from a qualified healthcare professional. If apotential concussion, loss of consciousness or apparent loss of consciousness has occurred,according to DIAA regulation 3.1.5, “the athlete may only return to practice/game after theadministrative head of school or designee receives "written clearance" from a qualifiedphysician. No athlete shall return to practice or play (RTP) on the same day of a concussion. Anyathlete with a concussion should be evaluated by their primary care provider or qualifiedhealthcare professional that day.

2. A qualified healthcare professional shall be defined as a MD or DO, or : school nurse, nursepractitioner, physician assistant, or athletic trainer, with collaboration and/or supervision by aMD or DO as required by their professional state laws and regulations. The qualified healthcareprofessional must be licensed and in good standing with the State of Delaware and must beapproved or appointed by the administrative head of school or designee, or the DIAA executivedirector/assistant executive director.



3. "Written Clearance from a qualified physician” for return to play after a

potential concussion shall be a MD/DO only. The preferred method would be to use the form that is attached. [ACE Care Plan]. After medical

clearance, return to play should follow a step-wise protocol with provisionsfor delayed return to play based upon the return of any signs or symptoms.

4. Failure to comply with medical requirements found in DIAA regulationsection 3.0 shall result in that individual or school being considered"ineligible" and shall be penalized according to DIAA regulation 2.9- Theschool has used an ineligible player and thus must forfeit the contest

http://www.nfhs.org/SportsMed.aspx


http://www.nfhs.org/content.aspx?id=5786



http://www.nfhslearn.com/MyHomePage.aspx















12/28/20

Let’s Take a Look atFederal Concussion Legislation


HR6172 “Protecting Student Athletes from Concussion Act of 2010”

• Purpose: To promote minimum State requirements for the

prevention and treatment of concussions caused by participation inschool sports, and for other purposes.

• “The legislation requires that individual school districts design plansto educate students, parents, and school personnel about concussionsafety and how to support students recovering fromconcussions. Schools also must post information about concussionson school grounds and on school websites, and are encouraged toimplement a ‘when in doubt, sit it out’ policy for students suspectedof sustaining a concussion during a school-sponsored athletic

activity”


NATIONAL ATHLETIC TRAINERS’ ASSOCIATION CHAMPIONS PROPOSED CONCUSSION ACT OF 2010

The Specifics of HR6172

• Education of medical personnel, teachers, coaches,students and parent on concussion and guidelines ofconcussion treatment

• Posting of information on concussions

• Students shall be immediately removed from activity bycoaches, athletic trainers, or other medical personnel andprohibited to return until a written release has beensubmitted by a health care professional

• Written release should state the student is capable ofreturning and may require the student to follow a recoveryplan.


HR6172 “Protecting Student Athletes from Concussion Act of 2010”


111th Congress, 2009–2010

To promote minimum Staterequirements for the prevention andtreatment of concussions caused byparticipation in school sports, and forother purposes.

Introduced: Sep 22, 2010Sponsor:Rep.Timothy Bishop [D-NY1]

Status: Died (Referred toCommittee)

See Instead: This bill was re-introducedas H.R. 469 on Jan 26, 2011. See H.R.469 for current action on this subject.

H.R. 469: Protecting Student Athletes

from Concussions Act of 2011



To promote minimum State requirementsfor the prevention and treatment ofconcussions caused by participation inschool sports, and for other purposes.

Sponsor: Rep. Timothy Bishop [D-NY1]

Status: Referred to Committee

• Directs the Secretary of theDepartment of Health and HumanServices to make grants to statesafter the issuance of guidelinesthrough the Centers for DiseaseControl and Prevention (CDC) forthe following purposes: – Adopt, disseminate, and ensure the

implementation of concussionmanagement guidelines—includingthe proper procedures for clearingstudents to return to playing after aconcussion has been diagnosed;and

– Fund schools’ adoption ofcomputerized pre-season baselineand post-concussion neurologicaltesting.


HR 1347 ConTACT Act of 2010"Concussion Treatment and Care

Tools Act of 2010"

Congressman William Pascrell

(D-NJ)

http://www.govtrack.us/congress/bills/111/hr1347





12/28/20

HR 1347 ConTACT Act of 2010"Concussion Treatment and Care

Tools Act of 2010"



To amend title III of the Public HealthService Act to provide for theestablishment and implementation ofconcussion management guidelines withrespect to school-aged children, and forother purposes.

Introduced:Mar 05, 2009Sponsor:Rep. William “Bill” Pascrell Jr. [D-NJ8]

Status: Died (Passed House)

Websites With MoreInformation on Federal Legislation

• http://www.govtrack.us/

• http://www.nata.org/government-affairs-advocacy


State Legislators Want aPiece of the Action Too!


State Concussion Legislation

• Most State Legislation follows these maincomponents:

– Improve education on concussion and increaseawareness

– Immediate removal of any athlete suspected ofsustaining a concussion (coach, athletic trainer orother medical personnel)

– Can not return to activity until properly cleared(individuals capable of clearing athletes differ fromstate to state)


States with Enacted Legislation Targeting Youth Sports-Related Concussions


Source - http://www.ncsl.org/issues-research/health/traumatic-brain-injury-

legislation.aspx

Is Your State Impacted?• Check out -

http://www.sportsconcussions.org/ibaseline/sta

te-laws/statelaws.html

• The first state to enact legislation:

– Washington (effective July 2009)


http://www.govtrack.us/

http://www.nata.org/government-affairs-advocacy

http://www.ncsl.org/issues-research/health/traumatic-brain-injury-legislation.aspx


http://www.sportsconcussions.org/ibaseline/state-laws/statelaws.html




















http://www.govtrack.us/



12/28/20


Is Your State Impacted?• Check out - http://www.ncsl.org/issues-

research/health/traumatic-brain-injury-legislation.aspx


Connecticut

2010 Conn. Acts, P.A. 10-62 (Reg. Sess.) (2010 SB 456)

Requires student athletic coaches to complete annual training andreview regarding concussions and head injuries. To be reissued acoaching permit, coaches are also required to complete refreshercourses once every five years. These training and refresher coursesmust be approved by the State Board of Education. This law alsorequires a student athlete to be removed from play or other kinds ofphysical exertion when showing signs of a concussion, and are not

permitted to resume participation without written clearance from alicensed medical professional.

Is Your State Impacted?

• Check out -

http://www.sportsconcussions.org/laws.html


New York (34 page document!)

2011 N.Y. Laws, Chap. 496 (2011 SB 3953)

Enacts the "concussion management and awareness act" and directs the

commissioners of education and health to adopt and implement rules andregulations for the treatment and monitoring of students with mild traumatic

brain injuries and requires school personnel to receive training in mildtraumatic brain injuries. This law also requires an information pamphlet on

mild traumatic brain injuries to be distributed to parents of pupilsparticipating in interscholastic sports or who have suffered a mild traumatic

brain injury and provides for the establishment of concussion managementteams to implement the provisions established in this law.

Will This Legislation Change Things?

• Policy Evaluation of State Youth SportsConcussion/Return to Play Legislation – Cloudburst has been awarded a contract with the Centers for Disease

Control and Prevention (CDC), National Center for Injury Preventionand Control (NCIPC) to conduct a policy evaluation of theimplementation of state youth sports concussion/return to play laws, toreport on and develop materials to disseminate key findings. Cloudburst

will assess the implementation of youth sports concussion/return toplay legislation from two states with existing legislation. Followingcompletion of the evaluation, a report shall be created and apresentation shall be made to NCIPC that clearly demonstrates findings,promising practices, and unintended consequences of the state

legislation implementation efforts.


http://www.cloudburstgroup.com/

What Should YOU be Doing with

Regard to SRC Assessment andEvaluation?


Hollywood’s Idea of an AppropriateSport-Related Concussion Assessment


http://www.youtube.com/watch?v=TKAUCulZoow





http://assembly.state.ny.us/leg/?default_fld=&bn=S03953&term=&Summary=Y&Text=Y







http://assembly.state.ny.us/leg/?default_fld=&bn=S03953&term=&Summary=Y&Text=Y
















12/28/20

SCAT2 Symptom Evaluation


SCAT2 – Physical Sign Score


Glasgow Coma Scale (GCS)


Maddock’s Questions

Maddocks D, Dicker G. An objective measure ofrecovery from concussion in Australian rulesfootballers. Sports Health 1989; 7: 6-7.


Standardized Assessment ofConcussion (SAC)


Balance Error Scoring System(BESS) – Modified for SCAT2

Foot Placement Surface

1 Side by side Stable

2 Single, non-dominant foot Stable

3 Tandem, dominant in front Stable

4 Side by side Foam/Unstable

5 Single, non-dominant foot Foam/Unstable

6 Tandem, dominant in front Foam/Unstable




12/28/20

BESSScoring


Coordination Examination


SCAT2 Cognitive Assessment


SCAT2 Overall Scoring


http://www.youtube.com/wa

tch?v=V_Qj70hHhWE

NFL Sideline Concussion Assessment Tool

• Adopted from the SCAT2

• Consists of both a baseline and post-concussion

template.

• Available for download at:

– http://www.nflevolution.com/wordpress/wp-

content/uploads/2012/08/nfl-sideline-tool-baseline.pdf

– http://www.nflevolution.com/wordpress/wp-

content/uploads/2012/08/nfl-concussion-tool-post-

injury.pdf




http://www.youtube.com/watch?v=V_Qj70hHhWE



http://www.nflevolution.com/wordpress/wp-content/uploads/2012/08/nfl-sideline-tool-baseline.pdf



http://www.nflevolution.com/wordpress/wp-content/uploads/2012/08/nfl-concussion-tool-post-injury.pdf



























12/28/20




Athletic Training Research Laboratory73



What About EducationalProgramming

CONCUSSION A fact sheet for student-athletes


http://www.ncaa.org/concussions

What About Educational

Programming Concussion in Sports - What YouNeed To Know


http://www.nfhslearn.com/electiveDetail

.aspx?courseID=38000

CDC: Heads Up: Concussion inHigh School Sports

http://www.cdc.gov/concus

sion/HeadsUp/youth.html



http://www.nfhslearn.com/electiveDetail.aspx?courseID=38000


http://www.cdc.gov/concussion/HeadsUp/youth.html









12/28/20

ThinkFirst-SportSmartConcussion Education and

Awareness Program

http://parachutecanada.org/


DE CARES

(Concussion Assessment Registryand Educational System): A

Proposal to Examine Sport-RelatedConcussions in DE Youth


Why is this of Interest to US?

• The State of Delaware is a microcosm of the country and lends itselfto the study of the SRC dilemma

• Models developed as a result of this “proof of concept” research will be useful for both the State of Delaware and other states as they

develop strategies to treat injured athletes and educate the publicabout SRC

• Pilot data will be used to apply for federal program funding

• Changes in policy governing when student-athletes can return tocompetition following SRC can be implemented as a result of such

research


INTER-INSTITUTIONALRESEARCH TEAM

• Thomas W. Kaminski, PhD, ATC, FNATA, FACSM (Chair)

– University of Delaware

• Bradley Bley, DO

– Delaware Orthopedic Associates

• Kenneth Rogers, PhD, ATC

– Nemours/AI duPont Hospital for Children

• Joseph Tracy, PhD – Thomas Jefferson University


A YouTube Video Worth Checking Out

(Simplifies Sport-Related Concussion)


http://www.youtube.com/watch?

v=zCCD52Pty4A

Concussions 101, a Primer for Kids andParents - Dr. Mike Evans

Summary Information for thePracticing Athletic Trainer

• Stay current by reading and staying abreast of the ever-changingmedical recommendations with regard to sport-related concussions

– “Don’t be the one”!

• Keep in mind that SRC’s are not just a football thing!

• Keep up to date on policies governing the setting you practice in (youth,interscholastic, intercollegiate, professional, etc…)

• Stay current on SRC legislation that may impact your state’s athletictraining practice act! – Don’t rely on federal gov’t to act --- they are letting the states handle

it!

• The Standard of Care for managing SRC is most likely to be derivedfrom governing board policies, position statements from medicalgroups, and legislative acts

• Don’t forget the EDUCATIONAL component of SRC management!



http://www.youtube.com/watch?v=zCCD52Pty4A







12/28/20

You Must Have Some Questions????


Today’s lecture can be viewed at thefollowing URL address:

http://www.udel.edu/HNES/AT/Site/lectures.html


Thank You




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EATA Presentation January 2013 - Kaminski