US Concussion Legislation: Finally Using Our Heads

Legislative Advocacy Block 4Alex Glick, Laura Kurek, and Evan

Sherman

Epidemiology

• Anywhere from 300,000 to up to 3.8 million sports-related concussions per year in the US

• 8.9% of high school sports injuries

• Usually worse in games vs. practice (other than volleyball and cheerleading)

Halstead and Walter, 2010

Meehan et al, 2011

Meehan et al, 2011

Meehan et al, 2011

Meehan et al, 2011

Meehan et al, 2011

ImPACT

• Immediate Postconcussion Assessment and Cognitive Testing

• Many other similar programs exist including SAC, Headminders’ CRI, CogSport, ANAM

• Beneficial in return to play decisions due to underreporting of symptoms

Schatz et al, 2005

More on neuropsych testing

• One study compared baseline scores of athletes to scores after concussion

• Of the athletes who had a concussion, 12% had neurocognitive deficits in the absence of symptoms

• Used in 41.2% of evaluations evaluated by Meehan et al (2011) during 2009-2010 academic year, up 15.5% from prior year

• Now mandatory in the NHL and used by most NFL teams

Athletic Trainers use of ImPACT

Covassin et al, 2009

Covassin et al, 2009

• 95.5% of respondents would not return athlete to play if symptomatic with normal testing

• If symptom free with scores below baseline, only 86.5% would hold athlete from playing

College vs. high school athletes

Field et al, 2003

• High school athletes have prolonged recover compared to college athletes with working memory, processing speed, reaction time, other tasks

College High School

Field et al, 2003

• High school students continue to report symptoms after resolving in college students

Prolonged symptoms in high school athletes

• One study showed difficulty in cognitive tasks in 23% of high school athletes 3 weeks after concussion

• A similar study showed only 1.6% of NFL players took >14 days to recover

Bahkos et al, 2010

Younger athletes

Collins et al, 2002

Effects of multiple concussions: High school athletes

Multiple concussions

• Athletes at increased risk for concussion after first concussion

• LOC: 6x more likely to have another concussion

Second Impact Syndrome

• Second (often mild) injury after first concussion

• Loss of intracranial autoregulation, cerebral bleeding and edema, brainstem failure

• Worst in athletes aged 16-23• High school football study showed 69% of

players with LOC and 81% without LOC but with concussion returned to play the same day

Meehan and Bachur, 2009

• Go back one step if symptoms return• Can take 7-10 days• Cognitive rest recommended for students

NFL stats

• 100-200 concussions per year or 1 every 2-3 games

• Congressional hearings in 2010 exposing dangers of multiple concussions

NFL deaths• Andre Waters, age 44, committed suicide in 2006

– Forensic pathology: brain of an 85 y/o man, with evidence of early Alzheimer’s.

– NFL’s TBI committee to examine link between concussions and depression

• Dave Deurson, age 50, shot himself in the chest in 2011– Chronic traumatic encephalopathy (CTE)

• Ray Easterling, age 62, suicide in April 2012– Moderately severe CTE

• Junior Seau, age 43, suicide in May 2012– Prelim autopsy shows normal brain. Investigation underway at Boston

University

Fuel to the fire

• NFL facing huge concussion lawsuits from over 3,000 players

• First lawsuit filed in California by 75 players in July 2011.

• Claim that NFL has known about long-term effects of brain trauma for decades but that this information was withheld from players.

• Lawsuit also claims defective helmet design and manufacturing.

Bahkos et al, 2010

Bahkos et al, 2010

Zachary Lystedt

• In 2006, 13 y/o Zachary played in a Junior High football game in state of Washington.

• Hit his head on the ground during a tackle, rested on the sidelines

• Returned to play 15 minutes later• Second hit later in the game caused brain

hemorrhage

• Hospitalized for 2 years• Coma x3 months, unable to move x1 year• Unable to speak x9 months• Tube fed for 20 months• Intense rehab to walk, talk, speak, eat

Wheels of change• Richard Adler, president of the Brain Injury

Association of Washington, visited Zachary and began to craft a bill

• Seattle Seahawks helped distribute CDC posters and helped spread the word

• Mike Holmgren wrote letters to all Washington HS coaches to stress removal from field of players who have appeared to have a concussion.

• Dr. Stanley Herring, Seahawks physician and member of NFL Head, Neck, and Spine Committee, was soon on board

Government involvement

• At Adler’s request, state rep. Jay Rodne met Zachary in 2008.

• Concussion legislation became “his #1 priority.”

• Bill passed unanimously in the house, and signed into law on May 14, 2009.

• NFL commissioner Roger Goodell pledged support

• Other states reached out to Washington to start similar legislation.

• Zachary and family began speaking to legislators, doctors, athletic trainers, and school officials

• Adler and Dr. Herring continued to push for national Lystedt Laws.

• By the end of 2009, six states passed youth concussion laws

• There are currently 42 states with similar legislation.

• Gov. Cuomo signed NY’s Youth Concussion Law on Sept 17, 2011.

The Concussion Management and Awareness Act

Three Main Parts

• Education• Guidelines• Plan for Implementation

Education

• Mandates a course for school coaches, PE teachers, nurses, athletic trainers

• Teaches how to recognize sx of mild TBI and when to seek medical attention

• This info is also posted on the websites for the Dept. of Health and the Dept. of Education

Guidelines

Requires immediate removal from athletic activity for any student believed to have sustained a mild TBI

Return to Play Criteria

• Must be symptom free for at least 24 hours• Need evaluation and medical clearance from a

physician

Wait… Physician Evaluation?

• That’s us!• Students with possible mild TBIs may be sent

to clinic or the ED to be evaluated

Implementation

• Suggests the establishment of a “Concussion Management Team” composed of the school athletic director, the school nurse, and at least one coach– This team will be responsible for teaching staff

and students about mild TBIs– Also will make sure everyone’s following the rules

• Went into effect July 1, 2012

References• Bakhos LL, Lockhart GR, Myers R, and Linakis JG. Emergency department visits for concussion in young child athletes.

Pediatrics. 2010; 126:e550-e556.• Casson IR, Viano DC, Powell JW, and Pellman EJ. Twelve years of National Football League concussion data. Sports Health: A

Multidisciplinary Approach. 2010;2:471-483.• Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school athletes.

Neurosurgery. 2002;51:1175-1181.• Covassin T, Elbin RJ, Stiller-Ostrowski JL, Kontos AP. Immediate post-concussion assessment and cognitive testing (ImPACT)

practices of sports medicine professionals. Journal of Athletic Training. 2009;44:639-644.• Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison

of high school and collegiate athletes. The Journal of Pediatrics. 2003;142:546-553.• Grindell SH, Lovell MR, Collins MW. The assessment of sport-related concussion: The evidence behind neuropsychological

testing and management. Clinical Journal of Sport Medicine. 2001;11:134-143.• Halstead ME, Walter KD, and the Council on Sports Medicine and Fitness. Sport-related concussion in children and

adolescents. Pediatrics. 2010;126:597-615.• Kirkwood MW, Yeates KO, and Wilson PE. Pediatric sport-related concussion: A review of the clinical management of an oft-

neglected population. Pediatrics. 2006;117:1359-1371.• Meehan WP and Bachur RG. Sport-related concussion. Pediatrics. 2009;123:114-123.• Meehan WP, d’Hemecourt P, Collins CL, and Comstock RD. Assessment and management of sport-related concussions in

United States high schools. The American Journal of Sports Medicine. 2011;39:2304-2310.• Meehan WP, Taylor AM, and Proctor M. The pediatric athlete: Younger athletes with sports-related concussion. Clin Sports

Med. 2011;30:133-144..• Schatz P and Moser RS. Current issues in pediatric sports concussion. The Clinical Neuropsychologist. 2011;25:1042-1057.• Schatz P, Pardini JE, Lovell MR, Collins MW, and Podell K. Sensitivity and specificity of the ImPACT test battery for

concussion in athletes. Archives of Clinical Neuropsychology. 2006;21:91-99