Alabama Sports Concussion Taskforce: A statewide resource for you and your practice (part 1)

Joe Ackerson, Ph.D.

Chair Alabama Statewide Sports Concussion Taskforce

This first of two articles is designed to familiarize the reader with the Alabama Statewide Sports Concussion Taskforce (ASCT) in order to utilize it as a resource for their practice and any public health initiatives. The second part will provide specific information on the recognition and management of concussions for your medical practice. It has been estimated that up to 3.8 million sports- and recreation-related traumatic brain injuries occur in the United States yearly with the highest rates of emergency department visits for sports concussion occurring for young people from ages 10 to 19. Youth athletes appear to be especially vulnerable to the effects of concussion, including cognitive difficulties such as memory and attention problems.

The ASCT was created in 2007 as a committee of the Alabama Statewide Head Injury Taskforce (AHIT) to address the growing problem of Sports Related Concussions (SRC) in Alabama. The members of the ASCT represent healthcare providers, athletes, families, school systems, state agencies, researchers, and policy makers. The ASCT has identified three main area of focus: 1) Education and public awareness for athletes, families, healthcare providers, coaches, schools, and the general public, 2) Clinical guidelines for concussion identification and management, including important return to play and “return to think” decisions, 3) Legislative and policy making endeavors to positively impact the systems of care for athletes and their families. Of course none of this is possible without the ability to fund important efforts and initiatives.

The ASCT is chaired by Dr. Ackerson, a pediatric neuropsychologist with nearly 20 years experience diagnosing and treating youth with traumatic brain injuries (including concussions) as well as diverse brain disorders due to a variety of medical conditions. Dr. Ackerson is currently in private practice but has previously served as Director of Pediatric Neuropsychology at UAB as well as Director of Psychology at Children’s Hospital of Alabama.

The ASCT has five committees, each chaired by an expert in the field. The Education Committee (chaired by Dr. Jimmy Robinson, team physician for the University of Alabama football program and member of the AHSAA Medical Committee) is charged with providing educational resources, including training for physician groups, certified athletic trainers, psychologists, athletic organizations, schools etc. The Public Policy Committee (chaired by Drew Ferguson, ATC, clinical director of UAB Sports Medicine and the Children’s Concussion Clinic) is charged with crafting legislation and public policy initiatives, lobbying for concussion related issues, and fostering cooperation between different agencies and groups. Dr. Michael Ellerbusch (team physician for Hoover High School) chairs the Clinical Resources committee which serves to develop clinical guidelines for the recognition and management of concussion based on the latest scientific reviews as well as clinical expertise of our members. Dr. Jim Johnston (pediatric neurosurgeon at Children’s Hospital of Alabama and Chair of the Children’s Hospital Concussion Taskforce) chairs the Research Committee which is charged with promoting statewide research efforts in Alabama, creation of a clinical database, and reviewing and disseminating the latest research findings to other members of the Taskforce. Finally Marie Crowley (Director of the Traumatic Brain Injury program at the Alabama Department of Rehabilitation Services) chairs the Grants and Funding Committee which serves to help procure grant funding for ASCT initiatives as well as ensuring that our activities remain commercial free.

Enabled by the receipt of MCHA grant monies through the Alabama Head Injury Foundation (AHIF) and the Alabama Department of Rehabilitation Services (ADRS) we have accomplished a number of important goals since 2007. The ASCT has become a clearing house for free, expert information for anyone workingin this area. We have conducted workshops for the Alabama Chapter of the American Academy of Pediatrics, the Alabama Psychological Association, the Alabama Association of Certified Athletic Trainers, and the Alabama Association of School Psychologists and provided important presentation ready information which our members have used at the Alabama Statewide Coaches meeting as well as other venues. We consulted with the Medical Advisory Board for the Alabama High School Athletic Association leading them to adopt on the strictest guidelines in the country for the recognition and management of sports related concussions. We also helped The Children’s Hospital of Alabama and UAB develop their new clinical guidelines for the management of SRC which led to the development of the Children’s Concussion Clinic.

With the assistance of Alabama State Representative Paul DeMarco and the sponsorship of State Representative Ron Johnson and State Senator Greg Reed, and the advocacy efforts and of Steve Savarese, director of the Alabama High School Athletic Association (AHSAA). 2011-541 HB 108 (passed and signed into law in 2011 with a technical amendment added in 2012) helps to prevent the long-term adverse consequences of youth concussions by requiring all schools and athletic organizations to: provide information on sports concussions to all athletic participants and their families; ensure that all coaches have training in the recognition of concussions; the immediate removal of any athletic participant suspected of having a concussion from participation and not allow him/her to return the same day they are injured and until cleared by a physician.

Concussion symptoms can be broken down into 4 major areas. 1) Mental- any change in their usual mental state (feeling woozy, confused, in a fog, disoriented, problems with memory or concentration),  2) Emotional- change in personality, irritability, nervousness, unexplained or sudden sadness, or extreme moodiness, 3) Arousal- chronic fatigue or lethargy, reduced endurance or tolerance for physical exertion, sleep disturbance, and 4) Physical- blurred or double vision, dizziness, problems with balance or coordination, headache, nausea, overly sensitive to light or sound, numbness or tingling. While many times observers may notice that a player has had a concussion when they fail to get up after a hit or fall, it is important to note that you do not have to lose consciousness to have had a significant concussion.

As the awareness of the need to properly recognition and manage concussions has increased dramatically, primary care, sports medicine, and specialty physicians (PM&R, neurosurgeons, neurologists, etc.) need to develop clinical pathways for their practices. The ASTC is a free, expert resource for any physician wanting to learn more about how to integrate this aspect of care into their practice. In the next article I will provide more specific suggestions for how to do this.

(if there is room please include the following ASCT consensus statement)

ASCT Consensus Statement: Sideline or onsite assessment of sports related concussion (SRC) should occur whenever possible. The assessment should include a certified athletic trainer (ATC) and/or an appropriately trained physician. ATC’s receive specific training in the assessment and management of concussion. When working closely with a qualified physician, they provide an important medical function.

Once it has been determined that a concussion has occurred, the on-site professional should also attempt to determine the severity of the injury. No athlete should return to play the same day they have a concussion, and should not return to play or other high risk activity, including activities that involve significant physical exertion, until such time that a physician trained in the assessment and management of concussion can perform an independent evaluation.

In the absence of available medical personnel, coaches must serve the role of recognizing and referring athletes to a physician for further evaluation and treatment. Referees bear the responsibility of protecting players, such as ordering an injured player off the field, notifying the coach of the injury, and preventing their return. Since coaches and referees are not medical personnel it is possible they may not recognize a concussion when it occurs. Coaches and referees should undergo training and certification in the recognition and management of sports related concussions. Neither coaches nor referees should make return to play (RTP) decisions.

Return to play (RTP) decisions should made by a physician trained in the assessment and management of concussion. The physician’s decision regarding RTP may be enhanced by including ATCs, neuropsychologists, and/or other qualified medical experts whose knowledge, techniques, and experience can provide valuable additional information. The final decision regarding the athlete’s ability to return to play should be a medical decision. We recognize that there are many unknown variables and no one, including the treating or consulting physician, can guarantee that the athlete’s return to play would not continue to present a health risk for the athlete. We believe that by following established guidelines, as well as the information and resources developed by this taskforce, the risk of immediate or long-term adverse consequences from the concussion will be significantly reduced.

Given the established need for cognitive rest following SRC, and the fact that young athletes’ most important task is academic achievement, it is increasingly appreciated that in addition to RTP decisions, we need to formulate Return to Think (RTT) protocols. Once an athlete has incurred a concussion, his or her school should be notified as soon as possible in order for proper planning and monitoring to occur, including appropriate accommodations in the academic program. Every school that has an athletic program must provide a designated contact person to receive and disseminate medical and neuropsychological information required to guide RTT decisions in the academic setting. This contact person at each school should have access to a specified neuropsychologist that will be critical for guiding RTT decisions. In more complex cases a neuropsychological evaluation may be necessary.

Any school that provides sports programs, or any community based sports programs, must disseminate information to athletes and their families pertaining to the recognition and management of SRC.