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TRANSCRIPT
Concussion�
• Part�of�the�RFU�“Don’t�be�a�HEADCASE”�concussion�awareness�and�education�programme�� Launched�Jan�2013
• Superseded�previous�campaign�– “Use�your�head”�launched�in�2007.
For�more�information�visit�� www.englandrugby.com/headcase.�
For�resources�email�– [email protected]
Follow � @EnglandRugbyCoach and@RugbySafe
Welcome
Concussion�– the�landscape�has�changed
Zachary�LysadtLaw
RFU�Survey�09/10�of�16�– 18�year�olds
• Regarding�personal�concussion�history:–66.2%�of�this�group�did�not�leave�the�field�after�a�concussion;–37.9%�did�not�report�their�concussion.�–Only�9.8%�of�concussed�players�waited�the�stipulated�3�weeks�before�returning�to�play.���
• Coaches�=�key�source�of�information
Players’�Source�of�Information�on�Concussion
0%
10%
20%
30%
40%
50%
60%
70%
80%
Teammate26.3%
Coach�68% Parent�24.6% First�aider30.9%
Dr/Physio25.7%
Other�7.4%
RFU�Concussion�Risk�Management�Strategy�– Summary�
EducationPrevention� Management� Research Communication
Evidence�based,�independently�reviewed,�and��effectiveness�evaluated�
Across�communities�of�practice�(Priority�=�coaches)
What�is�concussion?�
• The�brain�is�injured�as�a�result�of�a�blow�to�the�head�or�body• It�is�a�traumatic�brain�injury• ?�Functional�disturbance�– routine�brain�scans�are�normal�• Variable�impact�threshold�• Loss�of�consciousness�in�only�10�� 15%�of�cases• Recognition�can�be�difficult• Symptoms�may�be�delayed�up�to�72�hours• Usually�expect�complete�recovery��• Repetitive�concussions,�particularly�before�full�recovery�can�
have�potential�for�serious�and/or�long�term�consequences
What�have�we�started�to�understand?
• Concussion�takes�longer�to�resolve�than�previously�thought– Microscopic�injury�rather�than�functional�disturbance
• The�brain�is�more�vulnerable�to�further�injury�immediately�after�and�during�recovery�from�a�concussion:– Risk�of�further�concussion�– likely�to�be�more�severe�and�prolonged�– Other�injury�� slowed�reactions�and�poor�coordination�– Further�brain�injury�– very�rare�but�fatal�brain�injury�in�young�players�
(second�impact�syndrome)
• Repetitive�concussions:– Increase�the�risk�of�prolonged�concussion�symptoms�– May�cause�early�onset�cognitive�and�memory�impairment�in�latter�life– Potential�association�with�degenerative�brain�disease�in�latter�life.�
Short�term�effects�� a�bit�of�science
Symptom�Recovery
Source:�McCrea�et�al.,�2013,�p.�26.
GSC�– Graded�Symptom�Checklist
Where�do�head�injuries�occur?�
• Road�traffic�collisions�e.g.�cars,�cyclists• Falls�e.g.�playground�or�around�school�• Assaults�e.g.�Saturday�nights�out!• Sport�and�recreational�activities
Concussion�Rates�
Sport Concussion�rate�per�1000�player�hours
Horse�racing�(Amateur) 95
Horse�racing�(Jumps) 25
Horse�racing�(Flat) 17
Boxing�(professional) 13
Australian�football�(professional) 4�� 20
Rugby�union�(professional) 7�– 11
Ice�Hockey�(NHL) 1.5???
Rugby�Union�(Youth) 1 – 2
Rugby�union�(amateur�adult) 1�– 1.5
Soccer�football�(FIFA) 0.4
NFL�football�(NFL) 0.2???
Source�– 4th Int Concussion�Conference�Presentation�– Dr�M�Turner��+�subsequent�publications�
Prevention
ALL�have�a�part�to�play
BUT�– Coaches�have�the�key�role�because:• Primary�source�for�concussion�information�for�players• Set�culture�within�the�team/squad/club• Develop�players:– Techniques�– Influence�behaviours– Provide�information/education�
• Select�who�plays�and�plan�training�sessions• Often�first�or�only�adult�on�scene• Manage�replacements�
Prevention
• Reduction�in�head�trauma�is�key:– Tackle�technique– Player�behaviour�in�contact– Zero�tolerance�of�foul�play:
• Collision�“tackles”• High�tackle• Tip/spear�tackle• Taking�out�player�in�the�air• Targeting�head�in�contact�and�punching�
– Playing/training�ground�conditions�
Injuries�by�Event�� Youth
On�Field�Management
TAKE�CONCUSSION�SERIOUSLY�RECOGNISE�– know�the�symptoms�and�signs�of�concussion.� Remember�you�do�not�need�to�be�knocked�out�to�have�a�concussion.�REMOVE�– any�player�with�suspected�concussion,�right�away.�Continuing�to�play�increases�their�risk�of�more�severe�injury,�and�longer�lasting�concussion�symptoms,�as�well�as�increasing�their�risk�of�other�injury.RECOVER�– take�time�to�fully�recover�as�you�would�with�any�other�injury.�
RETURN – all�players�must�follow�a�step�wise�Graduated�Return�to�Play�(GRTP)�and�must�not�go�back�to�rugby/sport�until�they�have�been�cleared�to�do�so�by�a�doctor
For�more�information�visit�� www.englandrugby.com/headcase
RECOGNISE
• Obvious:– Actual�or�suspected�loss�of�consciousness– Convulsion�or�posturing�– Loss�of�coordination/balance– Vomiting– Confusion–Memory�loss– Clearly�dazed
RECOGNISE
• Less�obvious:– Nausea– Drowsy– Irritable– Emotional– Fatigue/low�energy– Anxious/nervous– Poor�memory– Neck�pain
– Headache/pressure�in�head
– Dizziness– Blurred�vision– Sensitive�to�light/noise– Difficulty�concentrating– Feeling�in�a�fog– “Don’t�feel�right”
RECOGNISE�
REMOVE
1. First�Aid�principles��2. Head�injury�+�reduced�conscious�level�+/� neck�pain�
=�treat�as�NECK�INJURY�and�DO�NOT�move.���3. Concussion/suspected�concussion�=�REMOVE4. NO�RETURN�5. If�in�doubt�sit�them�out6. Player�to�be�assessed�by�healthcare�professional
Danger�Signs
• Danger�Signs�=�dial�999– Deteriorating�conscious�level– Increasing�confusion��or�irritability– Severe�or�increasing�headache– Repeated�vomiting– Unusual�behaviour– Seizure/convulsion– Double�vision�of�deafness–Weakness/tingling/burning�in�limbs
What�to�do�next�– CHILDREN?�
• Injury�event�but�no�suspected�concussion�or�other�injury:– Assess�and�observe– BUT�“if�in�doubt�sit�them�out”
• Suspected�concussion�but�no�LOC,�no�seizure,�no�significant�memory�loss,�no�danger�signs:– REMOVE– Notify�parents/carer�and�provide�HI�instructions�– Player�to�be�assessed�by�a�doctor�(school�nurse�if�not�possible)�that�day
• Any�LOC,�seizure,�significant�memory�loss,�danger�signs,�or�concerned:– REMOVE�(if�safe�to�do�so,�if�not,�do�not�move�and�wait�for�ambulance)– Dial�999�for�ambulance�service�– Notify�parents/carer
RECOVER�&�RETURN�� RTP�Guidelines���
RECOVER�&�RETURN
• RECOVER:�– Rest:
• Initially�avoid�TV,�computers,�reading,�load�noises/flashing�lights• From�exercise��e.g.�PE,�sport�training�sessions��(no�different�from�ankle�sprain!)���
• May�require�a�few�days�off�school/work��� usually�only�one�or�two�if�symptoms�e.g.�headache,�dizziness,�fatigue.�
• RETURN:– To�academic�activities�before�return�to�sport�– Graduated�Return�to�Play– Medical�clearance�to�return�to�play��
Graduated�Return�To�Play
Stage� Rehabilitation�Stage�
Exercise�Allowed� Objective�
1 Rest Complete�physical�and�cognitive�rest�without�symptoms� Recovery�
2 Light�aerobic�exercise Walking,�swimming�or�stationary�cycling�keeping�intensity,�<70%�maximum�predicted�heart�rate.�No�resistance�training.�
Increase�heart�rate��and�assess�recovery
3 Sport�specific�exercise�
Running�drills.�No�head�impact�activities.�
Add�movement�and�assess�recovery
4 Non�contact�training�drills�
Progression�to�more�complex�training�drills,�e.g.�passing�drills.�May�start�progressive�resistance�training.�
Add�exercise�+�coordination,�and�cognitive�load.�Assess�recovery
5 Full�Contact�Practice� Normal�training�activities� Restore�confidence�and�assess�functional�skills�by�coaching�staff.�Assess�recovery�
6 Return�to�Play� Player�rehabilitated� Safe�return�to�play�once�fully�recovered.�
Note:• Must�be�symptom�free�after�each�stage�before�progression• Students�must�return�to�academic�work�symptom�free�before�return�to�play�
Example�RTP�Pathway�� SchoolDay�� Rehabilitation�Stage� Exercise�Allowed� Notes��
1�– 14� REST� Activities��of�daily living Return�to�academic�studies�
Sun Stage 2�Light�aerobic�exercise�
PE��lessons�or�own�run/swim/cycle�–low�intensity�Mon Clearance�by�GP Recommended�
TueStage�3�+�4
Sport specific�– non�contact�
Normal�PE�Lessons�+�rugby�training�sessions�Non�contact�Progressive�increase�in�complexity,�intensity�and�decision�making
Monitor�symptoms�using�PCRT�(SCAT�3�for�HCP)
Review�techniques�and�high�risk�behaviours
Wed
Thu
Fri
SatOwn�run/swim/cycle – high�intensity�
Sun
MonStage�5� Full�Contact�Practice�
Clearance�by�GP��
Tue
Wed Stage�6 Return�to�Play�
Note: • Must�be�symptom�free�after�each�stage�before�progression• Students�must�return�to�academic�work�symptom�free�before�return�to�play�
Example�RTP�Pathway�– Club�(Youth)
Day�� Rehabilitation�Stage� Exercise�Allowed� Notes��
1�– 14� REST� Activities��of�daily living Return�to�academic studies
Mon
Stage 2��+�3�Light�aerobic�exercise�+�
Sport specific�– non�contact�
PE��lessons�Own�run/swim/cycle�– progressive�intensity�School/�Club�rugby�training�sessions���non�contact�
Clearance�by�GP Recommended�
Tue
Monitors�symptoms�using�PCRT�(SCAT�3�for�HCP)
Review�techniques�and�high�risk�behaviours
Wed
Thu
Fri
SatStage�4�
Non�contact��training�Progressive�increase�in�complexity,�intensity�and�decision�makingOwn�run/swim/cycle – high�intensity�
Sun
MonStage�5� Full�Contact�Practice��at�school/club
Tue Clearance�by�GP��
Wed Stage�6 Return�to�Play�
Note: • Must�be�symptom�free�after�each�stage�before�progression• Students�must�return�to�academic�work�symptom�free�before�return�to�play�
Repeated�Concussion�Guidance
Second�concussion�in�a�12�month�period
Must�be�assessed�by�GP�(referral�to�concussion���specialist)
If�cleared�� Conservative�RTP�
Technique/Behaviour�Modification��
HEADCASE�Website
"Having�reviewed�the�RFU's�HEADCASE�resource�as�an�independent�expert,�I�think�that�it�is�an�excellent�source�of�information�for�those�involved�with�rugby.�It�is�an�accurate,�thorough�and�appropriate�source�of�information,�based�on�the�most�up�to�date�medical�consensus. The�RFU�should�be�applauded�for�making�this�available�in�such�an�accessible�format.“�� Dr�Richard�Greenwood,�Centre�for�Neurological�Diseases,�Queens�Square�Hospital,�University�College�London.�
Questions?
EnglandRugby.com/[email protected]
• Prevent�head�trauma�
• 4�Rs =�Recognise – Remove�–Recover�– Return
• Majority�recover�without�problems��BUT�follow�the�guidelines�for�management�and�RTP�to�protect�your�players�and�yourself
EXPERTS�AGREE�BENEFITS�OF�RUGBY�OUTWEIGH�RISKS�
Summary�