Concussions

Mind Matters Challenge winners to present proposals

The six education challenge winners were announced in July 2015 and have received funding to develop compelling educational platforms that will be presented at a Feb. 5 event. Each winner has been awarded a $25,000 cash prize as well as a $75,000 production budget to develop their planned product.

28 researchers and companies advance to next phase of Mind Matters Challenge

The NCAA announced today the selectees for the second phase of the Mind Matters Challenge. The challenge, which seeks to advance understanding of how to change culture, attitudes and behavior in young adults about concussion, is part of the broader joint initiative between the NCAA and the U.S. Department of Defense.

Concussion Safety

In January 2015, the five Division I conferences with autonomy around student-athlete well-being matters passed concussion safety protocol legislation that builds upon previous NCAA concussion legislation. The legislation states that each school must submit a concussion safety protocol to the Concussion Safety Protocol Committee – also created by the legislation – for review, and the protocol must be consistent with the InterAssociation Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines.

The Concussion Safety Protocol Committee met March 9, 2015, at the NCAA national office. The purpose of the meeting was to define the scope and parameters of the committee, in keeping with the new legislation, and to develop a checklist  that outlines the core components for each institution’s concussion management plan. This checklist serves as guidance for the concussion protocols of autonomy Division I member schools as well as the concussion protocols for non-autonomy Division I, Division II and Division III member schools.   

Under the legislation, the committee assesses submissions from each of the 65 Division I autonomous schools and makes recommendations for improvement and for consistency with checklist and interassociation guidelines. All 65 protocols have been approved for the 2016-17 academic year and are available below.

Competitive safeguards committee supports SEC concussion proposal, wearable technology use

During its December meeting in Indianapolis, the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports discussed and agreed with the core principles of a recent proposal by the Southeastern Conference that calls for the creation of a new Concussion Safety Protocol Committee and encouraged sport committees to permit use of wearable technologies.

NCAA, DOD launch Mind Matters Challenge

The NCAA and U.S. Department of Defense are now accepting proposals for the Mind Matters Challenge, a $4 million educational grand challenge aimed at changing concussion safety behaviors.

Mind, Body and Sport: Post-concussion syndrome

By David Coppel

Over the last decade, sport-related concussions have become an important focus within the general sports injury and sports medicine field. Clinical and research studies regarding this form/context of mild traumatic brain injury have increased geometrically as its position as a public health concern elevated and the Centers for Disease Control and Prevention (CDC) became involved.  

The CDC has compiled guidelines and resources for health care providers, coaches, parents and athletes regarding concussions. Great progress has been made in understanding and managing sport-related concussions, especially in terms of:

  • Incidence and prevalence of sport-related concussion at all levels of sports participation,
  • Delineating acute symptoms and sideline management,
  • Describing the general course of recovery for most athletes, and
  • Identifying risk factors or modifiers associated with prolonged recovery and/or persistent symptoms.  

Expert reviews of available scientific evidence have resulted in a series of consensus or position statements that have guided concussion definitions, evaluation, management and return-to-play guidelines.

The current definition of concussion is a brain injury involving a “complex pathophysiological process affecting the brain, induced by mechanical forces.” Concussion has a number of described features:

  • Concussion may be caused by either a direct blow to the head, face, neck or elsewhere on the body with impulsive force transmitted to the head.
  • Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously or may evolve over  minutes or hours.
  • Concussion may result in neuropathological changes, but the acute clinical changes largely reflect a functional disturbance rather than structural injury.
  • Concussion results in a graded set of clinical symptoms that may or may not involve a loss of consciousness, and resolution of clinical and cognitive symptoms typically follows a sequential course, with some cases having prolonged symptoms.

Diagnosing concussion may be complicated in some instances, as most do not involve a loss of consciousness or overt neurological signs, and impact on functioning can be quite mild and temporary. No consistent biomarkers or neuroradiological findings have been delineated, although the research continues in these areas.

The neuro-pathophysiology of sport-related concussion has been described in terms of changes in brain metabolism and evidence of temporary metabolic-based vulnerability to secondary injury. Typically, concussion events produce physical, cognitive and emotional/neurobehavioral symptoms that are generally most severe in the acute post-injury time frame (one to two days) and then reduce/resolve over subsequent days and weeks.  

Recent consensus guidelines indicate that 80-90 percent of concussions resolve in seven to 10 days, sometimes longer for children and adolescents. The diagnostic complexity emerges when symptoms are delayed or prolonged, or when symptoms are not specific to concussion, but instead are temporally related to the concussive event or experienced/perceived as having been brain-injury related. Due to the range of symptoms (physical, cognitive, emotional) and the individual factors influencing recovery, a multidisciplinary management approach is often indicated. Physicians, athletic trainers, neuropsychologists, academic advisers, physical therapists and clinical/sport psychologists all play roles in clarifying symptoms and providing support.

The strong desire and motivation of some athletes to return to play provides the opportunity for these motivational factors to be manifest in symptom reporting. Since tracking self-reported post-concussion symptoms over time (typically with checklists) is the main aspect of management, some athletes will minimize or report resolved symptoms in order to be seen as “symptom-free” and begin the return-to-play protocol or be cleared. Knowing the athlete and his or her baseline or pre-injury functioning can be crucial in evaluating post-injury symptom reports and presentations.

Acute sport-related concussion signs may include loss of consciousness, headache, dizziness and alteration of mental status (confusion or fogginess). Headache, nausea, fatigue, irritability, sleep disturbance and sensitivity to light and noise may continue over the next few days. Other symptoms seen on post-concussion symptom checklists include attention and concentration difficulties, slowed processing, distractibility, memory problems, slowed visual tracking or vision problems, balance disturbance, and anxiety or depressed mood. Typically, depressed mood or anxiety levels improve as the physical symptoms resolve, but it is important to assess and intervene if these emotional issues persist.

While most sport-related concussions (concussion symptoms) resolve over days and weeks (most within three weeks), a subset of sport-related concussion patients may not resolve in this expected time frame and have persistent post-concussion symptoms, or be seen as developing post-concussion syndrome/disorder. Diagnostically, according to the International Classification of Diseases, post-concussion syndrome occurs after a head trauma (which may include a loss of consciousness), and includes at least three of the following symptoms:

  • Headache
  • Dizziness
  • Fatigue
  • Irritability
  • Difficulty in concentration and performing mental tasks
  • Memory impairment
  • Insomnia
  • Reduced tolerance to stress, emotional excitement and alcohol.  

Symptoms of depression or anxiety resulting from loss of self-esteem or fear of permanent brain damage are seen as adding to the original symptoms.

Treatment/management of sport-related concussion is often based on self-reported symptoms, and these symptoms may reflect other conditions and/or factors not related to concussion, but more with post-traumatic stress disorder. Thus, based on the nonspecificity of symptoms, there is some controversy about the validity of a “post-concussion syndrome.” In general, when athletes continue to be significantly symptomatic (or worsen) beyond the three- to four-week recovery period, the symptoms could be more influenced by psychological factors than the original physiological factors associated with the acute injury.

Following a sport-related concussion, athletes are told initially to observe relative physical and cognitive rest. Reducing physical activity for an active student-athlete can be a difficult and stressful adjustment. A prescribed reduction in cognitive demands often involves reduced class time or assignments and is described by some as “cognitive or brain rest.” These restrictions and reductions appear appropriate in the initial week of recovery, but may become harmful later in recovery, as other stressors may emerge with falling behind in school (making up and keeping up demands upon return) and concern over training/conditioning effects.

As student-athletes recover and are cleared, they begin a return-to-play protocol that incrementally increases the physical exertion level, and ultimately the risk of re-injury over days, leading to a return to full practice and participation. Student-athletes must complete each stage without emergence of symptoms. Similar “return to learn” approaches have been proposed for academic re-entry.  

Strong somatic focus, hyper-vigilance to symptoms, sleep disturbance (often due to mental activation or worry), general stress/rumination behaviors, or a pattern of maladaptive coping styles may also be factors associated with prolonged or persistent symptoms. Family or social network/support problems, which include negative/nonsupportive responses or reactions from teammates, coaches or other primary relationships can result in more emotionally based symptoms.

During sport-related concussion recovery, if significant mood swings, depressed mood, or increasing anxiety or panic symptoms arise, they are indicators for referral to clinical or counseling psychologist/sport psychologist or other health care providers with expertise in these management areas.

Most concussed student-athletes recover symptomatically relatively quickly and return to their sport and academic activities. However, some have persistent symptoms, or delayed symptom resolution, which often impacts their athletics, academic, social and emotional functioning.

In addition to the basic approach of monitoring symptoms over time, interventions aimed at sport-related concussion education, management of recovery expectancies, symptom attributions and addressing emotional issues have been positive factors in recovery from sport-related concussions.

Ideally, management and treatment of sport-related concussions should include opportunities to evaluate and address the psychological impact and emotional responses that can be activated in student-athletes in varying degrees. When student-athletes are unable to practice or train, or when they feel significant physical, cognitive or emotional vulnerability, they often perceive/feel challenges to their identity – particularly their athletics identity, self-esteem, and in some cases, their future plans or goals.

Discussion of sport-related concussion as an injury with varying degrees of concurrent neurophysiological and psychological components appears to be the most effective approach with student-athletes. It helps avoid concussion being seen with the false dichotomy of the athlete having physical or mental issues. Referrals to licensed health care providers or counseling centers can help the student-athlete deal with those challenges, as well as the fear of re-injury, and address potential concerns over long-term consequences of concussions.

David Coppel is a professor in the department of neurological surgery and the director of neuropsychological services and research at the University of Washington Sports Concussion Program. He is a clinical professor in both the department of psychiatry and behavioral sciences and the department of psychology at Washington, where he has provided clinical supervision to graduate students, psychology residents and postdoctoral fellows for more than two decades.  Since 1996, Coppel has been the consulting neuropsychologist and clinical/sport psychologist for the Seattle Seahawks. His work at the Sports Concussion Program continues his strong involvement in the evaluation of the cognitive and emotional aspects of sport concussion, research regarding the sports concussion recovery factors, and the role of neurocognitive factors such as attention, concentration and focus in sports performance.

NCAA reaches proposed settlement in concussion lawsuit

The NCAA will provide $70 million for concussion testing and diagnosis of current and former NCAA student-athletes as a part of its agreement to settle claims in several consolidated concussion-related class actions.

NCAA responds to NY Times editorial on concussion guidelines

A July 12 editorial states that recently released National Collegiate Athletic Association guidelines are “An Inadequate Response to Concussions.” These guidelines address medical care for college student-athletes and concussion diagnosis...

Athletics Health Care Administration Best Practices

The NCAA Sport Science Institute and leading scientific and sports medicine organizations have developed recommendations for athletics departments and athletics health care providers to use in the delivery of care for college athletes. These recommendations serve as an update from 2014 guidance and reflect Division I Independent Medical Care (IMC) legislation that defines the athletics health care administrator.

Best Practices

Institutional line of medical authority should be established in the sole interest of student-athlete health and safety.  An active member institution should establish an administrative structure that provides independent medical care and affirms the unchallengeable autonomous authority of primary athletics health care providers (team physicians and athletic trainers) to determine medical management and return-to-play decisions related to student-athletes. 

In addition to an administrative structure that assures such authority of primary athletics health care providers, an active institution should designate a director of medical services to oversee the institution's athletic health care administration and delivery.

Note: Upon the suggestion of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, the term 'Director of Medical Services' has been changed to 'Athletics Health Care Administrator' in the legislative language.  This intent of this proposed terminology is to stress the administrative nature of this position, with no change otherwise in the function of this position.

Background

Diagnosis, management and return-to-play determinations for the college student-athlete are the responsibility of the institution’s primary athletics healthcare providers (team physicians and athletic trainers). Even though some have cited a potential tension between health and safety in athletics, collegiate athletics endeavor to conduct programs in a manner designed to address the physical well-being of college student-athletes (i.e., to balance health and performance). In the interest of the health and welfare of collegiate student-athletes, a student-athlete’s healthcare providers must have clear authority for student-athlete care.  The foundational approach for independent medical care is to assume an “athlete-centered care” approach, which is similar to the more general “patient-centered care,” which refers to the delivery of health care services that are focused only on the individual patient’s needs and concerns. The following 10 guiding principles, listed in the Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges, are paraphrased below to provide an example of policies that can be adopted that help to assure independent, objective medical care for college student-athletes:

  1. The physical and psychosocial welfare of the individual student-athlete should always be the highest priority of the athletic trainer and the team physician.
  2. Any program that delivers athletic training services to student-athletes should always have a designated medical director.
  3. Sports medicine physicians and athletic trainers should always practice in a manner that integrates the best current research evidence within the preferences and values of each student-athlete.
  4. The clinical responsibilities of an athletic trainer should always be performed in a manner that is consistent with the written or verbal instructions of a physician or standing orders and clinical management protocols that have been approved by a program’s designated medical director.
  5. Decisions that affect the current or future health status of a student-athlete who has an injury or illness should only be made by a properly credentialed health professional (e.g., a physician or an athletic trainer who has a physician’s authorization to make the decision).
  6. In every case that a physician has granted an athletic trainer the discretion to make decisions relating to an individual student-athlete’s injury management or sports participation status, all aspects of the care process and changes in the student-athlete’s disposition should be thoroughly documented.
  7. Coaches must not be allowed to impose demands that are inconsistent with guidelines and recommendations established by sports medicine and athletic training professional organizations.
  8. An athletic trainer’s role delineation and employment status should be determined through a formal administrative role for a physician who provides medical direction.
  9. An athletic trainer’s professional qualifications and performance evaluations must not be primarily judged by administrative personnel who lack health care expertise, particularly in the context of hiring, promotion and termination decisions.
  10. Member institutions should adopt an administrative structure for delivery of integrated sports medicine and athletic training services to minimize the potential for any conflicts of interest that could adversely affect the health and well-being of student-athletes.

The unchallengeable, autonomous authority of primary athletics healthcare providers to determine medical management and return-to-play decisions becomes the linchpin for independent medical care of student-athletes.  Importantly, this linchpin in college sports is the team effort of both physicians and athletic trainers, with ultimate medical reporting authority being the team physician. The NCAA Sports Medicine Handbook’s Guideline 1B opens with a charge to athletics and institutional leadership to “create an administrative system where athletics healthcare professionals—team physicians and athletic trainers—are able to make medical decisions with only the best interests of student-athletes at the forefront.” Multiple models exist for collegiate sports medicine.  Primary athletics healthcare providers may report to the athletics department, student health services, the institution’s medical school, a private medical practice or a combination thereof.  Irrespective of model, the answer for the college student-athlete is established medical decision-making independence for appointed primary athletics healthcare providers.

Athletics healthcare administration is one of the strategic priorities of the NCAA Sport Science Institute. Athletics healthcare administration refers to the manner in which healthcare services are delivered within the athletics department of a member institution.  Even if there is an extraordinary medical team in place, medical healthcare delivery will suffer if such care does not have an efficient and well-rehearsed delivery system.  To help provide oversight in efficient and well-rehearsed delivery of medical care, member schools should designate a director of medical services.  This individual will be generally responsible with administrative oversight of the delivery of student-athlete health care and will ensure an administrative structure that provides independent medical care to student-athletes.  This individual should be familiar with healthcare administration but does not need to be a licensed physician.  This administrative role may include assuring that schools are compliant with all pertinent NCAA health and safety legislation and with interassociation consensus statements that impact student-athlete health and safety.  Because this position is administrative in nature, it does not reflect the normal medical-legal hierarchy of healthcare practitioners.  Healthcare practitioners can have dual roles.  For example, athletic trainers deliver healthcare under the direction of a licensed physician; however, an athletic trainer could concomitantly serve as the director of medical services in a purely administrative role.

 

Year-Round Football Practice Contact Recommendations

The NCAA Sport Science Institute and leading scientific and sports medicine organizations have developed recommendations for athletics departments and coaches to use as they plan their year-round football practice sessions. These recommendations serve as an update from 2014 guidance and include additional recommendations for pre-season, inseason, postseason and spring practice.

To download the full Year-Round Football Practice Contact Recommendations interassociation consensus document, click here.

Recommendations

Preseason practice recommendations

Two-a-day practices are not recommended.  A second session of no helmet/pad activity may include walk-throughs or meetings; conditioning in the second session of activity is not allowed.

The preseason may be extended by one week in the calendar year to accommodate the lost practice time from elimination of two-a-days, and to help ensure that players obtain the necessary skill set for competitive play.

In any given seven days following the five-day acclimation period:

  • Up to three days of practice can be live contact (tackling or thud).
  • There should be a minimum of three non-contact/minimal contact practices in a given week.
  • A non-contact/minimal contact practice should follow a scrimmage.
  • One day should be no football practice.

Difference from the 2014 guidelines:

  1. Recommendation to discontinue two-a-day practices.
  2. Recommendation to allow an extension of the preseason by one week. This requires a legislative change if the pre-season begins one week earlier.
  3. Recommendation to reduce weekly live contact practices from four to three.
  4. Non-contact/minimal contact practice recommendations have been added.
  5. Non-contact/minimal contact practice recommendation the day following a scrimmage has been added.
  6. One day of no football practice recommendation has been added.
  7. Legislation 17.10.2.1. would need to be updated if the pre-season practice time begins one week earlier.
Inseason practice recommendations

Inseason is defined as the period between six days prior to the first regular-season game and the final regular-season game or conference championship game (for participating institutions).  In any given week:

  • Three days of practice should be non-contact/minimal contact.
  • One day of live contact/tackling should be allowed.
  • One day of live contact/thud should be allowed.

Difference from the 2014 guidelines:

  1. Recommendation to no longer allow two live contact/tackling days per week.
  2. Non-contactminimal contact recommendations have been added.
Postseason practice recommendations

NCAA Championships (Football Championship Subdivision/Division II/Division III), owl (Football Bowl Subdivision)

  • If there is a two week or less period of time between the final regular season game or conference championship game (for participating institutions) and the next bowl or postseason game, then inseason practice recommendations should remain in place.
  • If there is greater than two weeks between the final regular season game or conference championship game (for participating institutions) and the next bowl or postseason game, then:
    • Up to three days may be live-contact (two of which should be live contact/thud).
    • There must be three non-contact/minimal contact practices in a given week.
    • The day preceding and following live contact/tackling should be non-contact/minimal contact or no football practice. 
    • One day must be no football practice.

Difference from the 2014 guidelines:

  1. Current guidelines do not differentiate postseason/bowl practice from inseason practice.
Spring practice recommendations

(Divisions I and II)

Of the 15 allowable sessions that may occur during the spring practice season, eight practices may involve live contact (tackling or thud); three of these live contact practices may include greater than 50 percent live contact (scrimmages).  Live contact practices should be limited to two in a given week and should not occur on consecutive days.  The day following live scrimmage should be non-contact/minimal contact.

Difference from the 2014 guidelines:

  1. Non-contact/minimal contact practice recommendation the day following live scrimmage.

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