Staying Ahead on Head Safety
July 6, 2015
By Rob Kaminski
MHSAA benchmarks editor
Three stacks of concussion-related material offered precious little space on MHSAA Executive Director Jack Roberts’ desk, and perhaps consumed even more room in his head as he tried to wrap his mind around the seemingly daily “latest and greatest” documents outlining signs, detection and return-to-play elements involving head trauma.
Without a doubt, the scene is quite similar on any given day in the offices of his cohorts across the country as school sports leaders are faced with the daunting, dizzying task of devising plans to address concerns aimed at the health of their games.
Lawmakers, rules makers, medical experts and the court of public opinion all want the same thing for student-athletes: a reduction in the chances of head-related injuries. And they all are perfectly willing to offer instant fixes to those in charge.
They often expect those in Roberts’ position to analyze, digest and create action plans as soon as possible without considering the research and resources it will take to get there.
“All parties involved want the same thing. We all want to provide the safest environment for educational athletics through protocols and practices that will offer the most minimal risk of injury,” Roberts said. “But, this can’t be accomplished through unfunded mandates which would stifle the already struggling athletic budgets in many schools.
“Changes have to occur through training and education, orchestrated through state offices and executed locally. And, it takes time to research the best and most effective means. There is so much information, and so many devices in the field today that those in athletic leadership roles almost have to have a medical background as well.”
For instance, there are documents which list as few as five symptoms for concussions, and those listing as many as 15. There are sideline detection methods which purport to take 20 minutes and those which claim to determine concussions in 20 seconds. There are as many return-to-play protocols as there are state associations.
Increasingly, state high school associations are seeking opinions and expertise from local medical personnel. In March, in one of many such meetings, Roberts and other MHSAA staff welcomed several from the Michigan Department of Health and Human Services to their office to discuss sideline detection methods and return-to-play issues.
“There are two areas that concerned us most,” Roberts said. “One, sideline detection of head injuries is inconsistent across the state in terms of both results and resources. Two, we need methods which generate immediate reports and permanent records.”
As the group which convened in March discussed the topic, potential hurdles and new perspectives on sideline management came to the forefront.
On the money and manpower front, who would be responsible for administering sideline tools? Most ideally they would need to be overseen by medical personnel rather than coaches or team managers.
From a perspective standpoint, an interesting view was volleyed out to the group: could sideline detection actually speed up a student’s return to play rather than slow it down? Current protocol prescribes that if competition continues while an athlete is withheld for an apparent concussion, that athlete may not be returned to competition that day but is subject to the return-to-play protocol. And, clearance may not be on the same date on which the athlete was removed from play. Only an M.D., D.O., Physician’s Assistant or Nurse Practitioner may clear the individual to return to activity. With immediate sideline detection, are parties more vulnerable should a student pass immediate tests, only to have undetected effects of the incident increase over time?
“The group shed a different light on the various scenarios, which was a primary purpose for the meeting,” Roberts said. “As one can see, there are so many variables to consider when attempting to determine the next plausible and practical steps toward minimizing and detecting head injuries.
“Further, we have to take into consideration practice sessions as well as competitions, and all sports, not just select sports.”
Adding to the challenge is simply the nature of athletics. Competitors at any level are just that: competitive. Often, students – or their parents – will attempt to hide symptoms or be reluctant to come forward with injuries, particularly head injuries which can’t be seen.
In more cases, perhaps the symptoms simply are not recognized, which is why education is paramount.
First, association leaders have to tackle the due diligence of researching issues and potential solutions to situations currently threatening the well-being of scholastic sports. Considering that some 1,620,000 results are offered when “sideline concussion detection tools” is typed into a search engine, this is a laborious and continual chore.
Such information then needs to be packaged and presented to leaders at the local levels – athletic directors – to pass on to coaches, the individuals who have as much or more influence on students that perhaps any other adults, including parents in some cases.
This is why MHSAA rules meetings, Coaches Advancement Program sessions and other statewide forums continue to bang the drum on health and safety issues; to make sure the messages and procedures reach the student-athletes.
And, it’s why the MHSAA is asking coaches and ADs to be accountable in verifying that the plans in place are being carried out.
Less Could Mean Less
There are times when it’s good to say, “less means more,” but in the case of contact sports, practices and competitions, the idea is for less to mean less. As in less time for collisions to occur yielding fewer injures.
It’s early yet, and one year does not constitute a large sample size, but the MHSAA Football Practice Policy instituted last August could be one step toward reducing head injuries.
Beginning this past football season, the number of practices with helmets, shoulder pads and full pads were limited to start the season, and preseason “collision” sessions were limited to one per day. During the season, such practices were limited to two per week, while the length of practices was also regulated.
Dr. Steven Broglio of the University of Michigan Neurosport department is conducting a three-year study of the Ann Arbor Gabriel Richard football program with the assistance of Richelle Williams to determine the “Effects of Concussion and Sub-Concussion.” The study began in 2013, one year prior to the new MHSAA guidelines.
Research in 2013 showed approximately 650 “impacts” per player. In 2014, the number dropped to approximately 500 impacts per player. Impacts are defined as greater than 10 gs of acceleration. Williams stated that a slap on the back is 4 g, coughing is 3.5 g. On average, a helmet hit is 25-45 g. Concussions usually happen (roughly) between 80-150g.
An encoder is embedded into each football athlete’s helmet which monitors head impacts and exactly where the impact is located. Williams sits at each practice and game and through a pager identifies the player’s number and impact from a hit of 90g or more.
They are also looking at those who do not sustain an impact concussion, but rather sustain multiple head impacts and whether those multiple head impacts lead up to brain changes (measured through EEG).
The initial findings, as submitted by the study team, indicated two reasons why there were fewer overall impacts from 2013 to 2014:
Primary reason: The MHSAA adoption that became effective in August 2014 with new limitations that were placed on “collision practices” and conditions that full pads could not be worn until the fifth day of team practice.
Secondary reason: Fewer players evaluated in 2014 than 2013.
Fit for a King?
Editor’s Note: There are many sideline detection tools on the market, as a quick Google on the topic will reveal. The following, the King-Devick test, is among the highly recommended tests, summarized here simply to provide an idea of the types of systems available and how they operate. The following is from King-Devick’s website.
The King-Devick Test is an objective remove-from-play sideline concussion screening test that can be administered by parents and coaches in minutes. The King-Devick Test is an accurate and reliable method for identifying athletes with head trauma and has particular relevance to: Football, Hockey, Soccer, Basketball, Lacrosse, Rugby, Baseball, Softball and Other Collision Activities.
King-Devick Test is an easy-to-administer test which is given on the sidelines of sporting events to aid in the detection of concussions in athletes. King-Devick Test (K-D Test) can help to objectively determine whether players should be removed from games. As a result, King-Devick Test can help prevent the serious consequences of repetitive concussions resulting from an athlete returning to play after a head injury.
How King-Devick Test Works
Concussions are a complex type of brain injury that is not visible on routine scans of the brain, yet are detectable when important aspects of brain function are measured. King-Devick Test (K-D Test) is a two-minute test that requires an athlete to read single digit numbers displayed on cards or on an iPad. After suspected head trauma, the athlete is given the test and if the time needed to complete the test is any longer than the athlete’s baseline test time, the athlete should be removed from play and should be evaluated by a licensed professional.
Remove-From-Play vs. Return-To-Play
Both remove-from-play and return-to-play decisions are crucial in concussion recovery. It is critical to remove a concussed athlete from play in order to prevent further damage. It is also extremely important to keep the athlete from returning to play until they have made a full recovery. There are tools to assist in making both remove-from-play and return-to-play decisions.
King-Devick Test for Remove-From-Play Decisions
- Quick, objective sideline testing
- Measures impairments of speech, language and other correlates of suboptimal brain function
- Instant screening feedback in minutes
- Administered by parents, coaches, athletic trainers and medical professionals in remove-from-play decisions
- Neurocognitive Testing for Return-To-Play Decisions
- Computerized concussion evaluation system (in the computer lab)
- Measures verbal and visual memory, processing speed and reaction
- Tracks recovery of cognitive processes following concussion
- Assists clinicians in making return-to-play decisions
Health & Safety: A Look Back, Gallop Ahead
By
John E. (Jack) Roberts
MHSAA Executive Director, 1986-2018
August 7, 2015
By Jack Roberts
MHSAA executive director
We are just completing year six of eight during which we have been addressing the four important health and safety issues that, for ease of conversation, we call the “Four Hs.”
During the 2009-10 and 2010-11 school years, our focus was on Health Histories. We made enhancements in the pre-participation physical examination form, stressing the student’s health history, which we believe was and is the essential first step to participant health and safety.
During the 2011-12 and 2012-13 school years, our focus was on Heads. We were an early adopter of removal-from-play and return-to-play protocols, and our preseason rules/risk management meetings for coaches included information on concussion prevention, recognition and aftercare.
Without leaving that behind, during the 2013-14 and 2014-15 school years, our focus was on Heat – acclimatization. We adopted a policy to manage heat and humidity – it is recommended for regular season and it’s a requirement for MHSAA tournaments. The rules/risk management meetings for coaches during these years focused on heat and humidity management.
At the mid-point of this two-year period, the MHSAA adopted policies to enhance acclimatization at early season practices and to reduce head contact at football practices all season long.
Without leaving any of the three previous health and safety “H’s” behind, during the 2015-16 and 2016-17 school years, our focus will be on Hearts – sudden cardiac arrest and sudden cardiac death.
Coinciding with this emphasis is the requirement that all high school level, varsity level head coaches be CPR certified starting this fall. Our emphasis will be on AEDs and emergency action plans – having them and rehearsing them.
On Feb. 10, bills were introduced into both the U.S. Senate and House of Representatives, together called the “Safe Play Act (see below),” which addressed three of the four health and safety “H’s” just described: Heat, Hearts and Heads.
For each of these topics, the federal legislation would mandate that the director of the Centers for Disease Control develop educational material and that each state disseminate that material.
For the heat and humidity management topic, the legislation states that schools will be required to adopt policies very much like the “MHSAA Model Policy to Manage Heat and Humidity” which the MHSAA adopted in March of 2013.
For both the heart and heat topics, schools will be required to have and to practice emergency action plans like we have been promoting in the past and distributed to schools this summer.
For the head section, the legislation would amend Title IX of the 1972 Education Amendments and eliminate federal funding to states and schools which fail to educate their constituents or fail to support students who are recovering from concussions. This support would require multi-disciplinary concussion management teams that would include medical personnel, parents and others to provide academic accommodations for students recovering from concussions that are similar to the accommodations that are already required of schools for students with disabilities or handicaps.
This legislation would require return-to-play protocols similar to what we have in Michigan, and the legislation would also require reporting and recordkeeping that is beyond what occurs in most places.
This proposed federal legislation demonstrates two things. First, that we have been on target in Michigan with our four Hs – it’s like they read our playbook of priorities before drafting this federal legislation.
This proposed federal legislation also demonstrates that we still have some work to do.
And what will the following two years – 2017-18 and 2018-19 – bring? Here are some aspirations – some predictions, but not quite promises – of where we will be.
First, we will have circled back to the first “H” – Health Histories – and be well on our way to universal use of paperless pre-participation physical examination forms and records.
Second, we will have made the immediate reporting and permanent recordkeeping of all head injury events routine business in Michigan school sports, for both practices and contests, in all sports and at all levels.
Third, we will have added objectivity and backbone to removal from play decisions for suspected concussions at both practices and events where medical personnel are not present; and we could be a part of pioneering “telemedicine” technology to make trained medical personnel available at every venue for every sport where it is missing today.
Fourth, we will have provided a safety net for families who are unable to afford no-deductible, no exclusion concussion care insurance that insists upon and pays for complete recovery from head injury symptoms before return to activity is permitted.
We should be able to do this, and more, without judicial threat or legislative mandate. We won’t wait for others to set the standards or appropriate the funds, but be there to welcome the requirements and resources when they finally arrive.
Safe Play Act — H.R.829
114th Congress (2015-2016) Introduced in House (02/10/2015)
Supporting Athletes, Families and Educators to Protect the Lives of Athletic Youth Act or the SAFE PLAY Act
Amends the Public Health Service Act to require the Centers for Disease Control and Prevention (CDC) to develop public education and awareness materials and resources concerning cardiac health, including:
- information to increase education and awareness of high risk cardiac conditions and genetic heart rhythm abnormalities that may cause sudden cardiac arrest in children, adolescents, and young adults;
- sudden cardiac arrest and cardiomyopathy risk assessment worksheets to increase awareness of warning signs of, and increase the likelihood of early detection and treatment of, life-threatening cardiac conditions;
- training materials for emergency interventions and use of life-saving emergency equipment; and
- recommendations for how schools, childcare centers, and local youth athletic organizations can develop and implement cardiac emergency response plans.
Requires the CDC to: (1) provide for dissemination of such information to school personnel, coaches, and families; and (2) develop data collection methods to determine the degree to which such persons have an understanding of cardiac issues.
Directs the Department of Health and Human Services to award grants to enable eligible local educational agencies (LEAs) and schools served by such LEAs to purchase AEDs and implement nationally recognized CPR and AED training courses.
Amends the Elementary and Secondary Education Act of 1965 to require a state, as a condition of receiving funds under such Act, to certify that it requires: (1) LEAs to implement a standard plan for concussion safety and management for public schools; (2) public schools to post information on the symptoms of, the risks posed by, and the actions a student should take in response to, a concussion; (3) public school personnel who suspect a student has sustained a concussion in a school-sponsored activity to notify the parents and prohibit the student from participating in such activity until they receive a written release from a health care professional; and (4) a public school's concussion management team to ensure that a student who has sustained a concussion is receiving appropriate academic supports.
Directs the National Oceanic and Atmospheric Administration to develop public education and awareness materials and resources to be disseminated to schools regarding risks from exposure to excessive heat and humidity and recommendations for how to avoid heat-related illness. Requires public schools to develop excessive heat action plans for school-sponsored athletic activities.
Requires the CDC to develop guidelines for the development of emergency action plans for youth athletics.
Authorizes the Food and Drug Administration to develop information about the ingredients used in energy drinks and their potential side effects, and recommend guidelines for the safe use of such drinks by youth, for dissemination to public schools.
Requires the CDC to: (1) expand, intensify, and coordinate its activities regarding cardiac conditions, concussions, and heat-related illnesses among youth athletes; and (2) report on fatalities and catastrophic injuries among youths participating in athletic activities.