Recognition and Management of Concussion for Law Enforcement Training Academies: A Learning

Tool

Nancy C. Burke, MS, ATC, VATLPublic Safety Athletic Trainers’ Society

Taking Care of Those Who Take Care of Us

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OverviewRationale

Purposes of This Educational ToolScope of Concussion in Law Enforcement Academies

What is a Concussion / Traumatic Brain Injury?What happens in the Brain with Concussion / TBI?

Recognition of ConcussionTreatment of Concussion

Sideline (On-Site) AssessmentRecommendations

References Resources

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Overview

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• Awareness for police academy personnel of the risks of concussions in training and the need for appropriate response and management.

• To provide information for staff training on the recognition of signs and symptoms of head injuries.

• To outline best practices for preventing concussions in training exercises.

• To assist institutions in the development of protocols for response to concussion injuries, medical follow-up, injury management and rehabilitation.

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Rationale

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• Law enforcement recruits take on the challenge “To Protect and Serve” the citizens of their area.

• As a result of a variety of influences, those who break or defy the law are becoming more violent and aggressive.

• Increasingly, police officers are attacked by violent assailants -- with and without weapons.

• The risk of violent attacks makes them potentially deadly.

• For their own safety -- and to prevent a tragedy -- police

officers have to learn to defend themselves and to take control of the offender with aggressive defensive preparation.

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• Recruits must be prepared, both mentally and physically, to protect themselves and their weapons and then subdue violent assailants.

• Training routinely calls for recruits to learn defensive techniques in simulated attacks -- including how to fend off simulated “blows” from fellow recruits, role players or instructors.

• A small mistake or unexpected movement by recruit or role players can jar the brain and turn simulation into reality in a matter of seconds.

• The result: Simply learning how to ward off attack can cause life-threatening concussions.

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• With the stakes so high, careful precautions are required.

• Everyone involved in training new officers -- recruits, instructors, role players and staff -- deserve the safest-possible learning environment, including...

* Safe and appropriate equipment for all participants.

* Trained observers who can determine if a recruit is responding adequately or is injured and cannot protect himself/herself.

* Onsite healthcare professional evaluate and respond to injuries.

* Staff training in concussion awareness and appropriate medical

follow-through.

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Purposes of This Educational Tool

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• To assist in planning an academy’s immediate response to concussion.

• To assure that experienced health care professionals -- such as certified athletic trainers with expertise in injury diagnosis and management, or other trained medical professional – are present during training sessions.

• To encourage follow-through with appropriate medical care by a physician.

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Scope of Concussion in

Law Enforcement Academies

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• Injuries occur during law enforcement physical and defensive tactical training.

• Incidence and severity of brain and other injuries are difficult to ascertain:

– There is no state, regional or national injury database for documentation on the incidence and severity of injuries for public safety academies.

– Knowledge of catastrophic injury is usually revealed by the media.

– Recruits are reluctant to report injury for fear of recycle or outright dismissal.

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Strategies to Improve Safety

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• Insist that each training scenario has a specific purpose that is clearly understood by all participants.

• Manage scenarios to avoid deteriorating into unrehearsed

conduct and increased injury risk.

• Assure that every training exercise has observers on hand to protect recruits, role players and instructors.

• Observers have the power to stop an exercise at any time.

• Make certain that everyone -- participants, observers, other recruits -- knows they can and should take action if they think a trainee isn’t responding normally or could be injured.

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• Develop or review emergency care plans for unexpected catastrophic injury.

• Develop a confidential medical history tool, including concussion episodes, for all participants and staff.

• Review training timetable to allow make-up training for recruits who miss classes after short-term injury.– The threat of recycle is devastating. Depending upon the

training missed and the time loss projected, develop tools to make-up missed training.

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What is a Concussion/Traumatic Brain Injury?

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The most common head injury in athletic activity isconcussion, an injury to the brain. Concussion may also be referred to as “Traumatic Brain Injury.”

Intracranial hemorrhage (bleeding of the brain) is the leading cause of brain death in sports. Making rapid initial assessment and appropriate follow up mandatory to prevent a catastrophic outcome .

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What Happens in the Brain with Concussion/TBI?

Subdural Hematoma

Robert C. Cantu, Alisa D. Gean. Journal of

Neurotrauma. September 2010, 27(9): 1557-1564.

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The brain “floats” in a liquid cushion ofcerebrospinal fluid.

Upon impact, the brain slams forward and contacts the front (blue) of the skull.

The brain then rebounds to a secondImpact with the rear of the skull (red).

Both blows cause trauma to the soft tissuethat may result in bruising, bleeding andswelling.

Head Injury Society of New Zealand

Contre Coup Concussion

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The bleeding of small blood vessels in the brain causes a pool of blood to form.

As there is no escape for the blood, pressure from the fluid causes a compression of the brain tissue.

Until the bleeding stops and/or the pressure is relieved, cells will continue to die.

Healthtree.com

Subdural Hematoma

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Second Impact Syndrome (SIS) is a result of second concussion which occurs while the brain is still healing from a previous concussion.

Second impact syndrome is a major cause of serious head injuries in adult athletes. (1)

Repeated mild brain injuries occurring within a short period (i.e., hours, days, or weeks, even months) can be catastrophic or fatal. (3)

Second-Impact Syndrome

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SIS is a life-threatening emergency and will require surgery to prevent further damage to brain tissue.

SIS may be preventable by removing concussed persons from training until their symptoms have gone away and they have been cleared by a health-care professional. (3)

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Recognition of Concussion

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Classification

No longer is there a classification of concussion as Grade 1, Grade 2, Grade 3.

New terminology for concussion is:

Simple – recovery is within 7 to 10 days.

Complex – those who are slow to recover ( > 10 days).Second International Conference on

Concussion in Sport, 2005.

HOWEVER Concussion recovery is dependent upon the resolution of

symptoms, not any given timeline. (8)

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A PERSON WITH A HEAD INJURY SHOULD NEVER BE LEFT ALONE.

Symptoms may appear right away. Some may go away and reappear once a person becomes more active -- especially when resuming demanding physical activity.

Individuals with head injuries should be monitored for the next few hours in case their condition deteriorates.

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Immediate concussion symptoms may include:

Disorientation Nausea/VomitingHeadache AgitationVacant stare Sensitivity to bright lightPoor balance Tinnitus “ringing in the ears”

When symptoms are reported assume a concussion unless proven otherwise.

With hits to the face, jaw, nose, eye orbit, one should suspect concussion as a secondary injury.

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This chart from the CDC indicates symptoms of concussion.

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Sideline (On-Site) Assessment

Participant is removed from training and the following considerations are made:

1. Evaluation of signs and symptoms of concussion,2. Evaluation of mental status,3. Determine to activate EMS or refer to physician.

These evaluations should be performed only by those who are properly trained in the use of a sideline assessment tool.

No matter what the Sideline Assessment reveals, the participant should be removed from training and not returned that same day.

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Sample Side-Line Assessment

Mental Status.– Orientation: time (within 1-2 hours, place - where are they?),

person (name a person indicated), purpose (why are they there, what happened?)

– Concentration: months of the year in reverse order; backward digits (3-2-1; 4-8-1-5; 6-4-8-2)

– Memory: recall of recent news events; details of injury event (moves, opponent, etc).

(cont’d)

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Exertion:– 5 push-ups; 5 sit-ups; 5 jumping jacks; 5 knee bends; sprint

(30-40 yds).– Purpose is to induce symptoms (loss of balance, headache,

dizziness, etc.)

Neurologic:– Coordination: finger-nose-finger– Balance: Romberg (eyes closed, feet together, arms out to

side, head back); finger-nose (eyes closed)

(Based on Sideline Assessment of Concussion©Brain Injury Association, Inc. 1997

McCrea, Kelly Randolph)

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Treatment of Concussion

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Diagnosis of concussion and return to play decisions should be made by licensed physicians only. Initial assessment of head injury should only be administered by trained individuals.

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When to Refer to Physician

• When a person sustains a blow to the head, is conscious and exhibits signs or symptoms, the decision to refer to a physician shall be made by the onsite healthcare professional. (2)

• Monitor the individual at 5-minute intervals from the time of the injury until the symptoms completely clear or until referred to a physician. (2)

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• If concussion is suspected but a physician or other trained healthcare professional is not available, the academy instructors primary role is to ensure the person is seen by a physician. (2)

• Anyone with a concussion should be referred to a physician on the day of the injury if he or she lost consciousness, experienced amnesia lasting longer than 15 minutes, or has lingering symptoms.

• WHEN IN DOUBT, DO SOMETHING. Seek the next level of medical care if there is any uncertainty about whether or not a brain injury has occurred.

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Return-to-Duty:This decision shall be made by agreement of the treating physician and the academy onsite healthcare professional.

Individual should be gradually returned to activity to reduce the likelihood of return of symptoms – headache and loss of balance.

Decision Criteria:• Thorough clinical evaluation by treating physician or

neurologist if applicable.• All symptoms have resolved especially headaches and

balance/stability.• Neurocognitive follow-up testing if baseline test is available.

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The current recommendation is a gradual progression of activity, with increasing activity if the participant remains free of symptoms.

Stage 1: Light aerobic exercise: walking, swimming, stationary cycling, heart rate to less than 70% of max; and no resistance exercise;

Stage 2: Training related exercise, no contact, no head impact;

Stage 3: Non-contact training drills, progress to more intense and complex;

Stage 4: Full contact work, following medical clearance, normal training activities;Stage 5: No restrictions. Caution about repeat head trauma. (4)

Return – To – Play Protocol (Adapted for Academy Training)

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Return – To – Play Protocol (cont’d)

If any concussion symptoms re-appear, the participant is returned to the previous level of activity and may try to progress again after 24 hour period of rest.

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1. Those who exhibit any signs or symptoms of concussion when at rest, or after exertion for at least 20 minutes, should be disqualified from training on the day of the injury.

2. Brain activity such as television, computer, video games, texting, should be discouraged while the brain heals.

3. More conservative waiting periods may be appropriate for those with a history of concussion. (2)

4. If assessment tools are not available, then a 7-day symptom-free waiting period before returning to full training is recommended.

Key Considerations

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The cornerstone of concussion management is:

1. Physical and cognitive rest until symptoms resolve, and

2. Graded program of exertion prior to medical clearance and return to training. (4)

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Recommendations

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1. Protective headgear shall be approved by the American Society for Testing and Materials (ASTM) for blunt impact.

2. Recruits, role players and staff shall wear a mouthguard when participating in combative or defensive tactical training. A custom-fit laminate mouthguard available from a dentist is preferred.

3. A healthcare professional trained in the recognition and management of concussion should be onsite whenever combative or defensive training is conducted.

4. Establish professional relationships with local physicians and neurologists for concussion management.

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The American Academy of Neurology in it’s October 2010 “Position Statement on Sports Concussion” recommends:

“A certified athletic trainer should be present

at all sporting events, including practices, athletes are at risk for concussion.” (8)

Athletic trainers are specialists in concussion assessment, cognitive

testing and management.

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The focus of the IACP/SACOP SafeShield Project is that all officers should go home everyday: “zero officers killed or injured.” (8)

Academy staff, recruits and role players should be an fundamental component of this same principle.

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For more information about athletic trainers, concussion recognition and management, contact:

Kathryn Moore, National Athletic Trainers’ Associationkathrynm@nata.org1-800-879-6282 ex. 138www.nata.org

Nancy Burke, MS, ATC, VATLNancyb@PSATSociety.com703-629-2038www.PSATSociety.com

Center for Disease Controlwww.cdc.gov/concussion

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References

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1. British Journal of Sports Medicine, Head Injuries in Sport, Cantu, R. 1996, December, 30(4): 289-296.

2. Journal of Athletic Training, National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion, Guskiewicz, Bruce; S, Cantu, R; Ferrara, M; Kelly, J; McCrea, M; Putukian, M; Valovich McLeod, T. 2004, 39(3): 280-297.

3. University of Washington School of Medicine – Concussion, http://uwmedicine.washington.edu/concussion

4. Journal of Clinical NeuroScience, Consensus Statement on Concussion in Sport – the 3rd International Conference on Concussion in Sport, Zurich, 2008. McCrory,P; Meeuwisse, W; Johnston, K; Dvorak, J; Aubry, M; Molloy, M; Cantu, R.

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5. McCrory, P, Johnston, K, Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J. et al. “Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport; Nov. 2004, Prague, Czech Republic.

6. Makdissi, M., Is the Simple versus Complex Classification of Concussion a Valid and Useful Differentiation?”. British Journal of Sports Medicine, 2009, 43: i23-i27.

7. SafeShield Project, www.theiacp.org.

8. American Academy of Neurology, “Position Statement on Sports Concussion,” October 2010 (Policy 2010-36).

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Resources

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Information:

CDC “Heads Up” online training course. Directed at youth athletes

however with good basic information.

http://www.cdc.gov/concussion/HeadsUp/online_training.html

NCAA Concussion Webinar. Reviews concussion, physician

management, athletic trainer management directed to universities, still

applicable.

http://s3.amazonaws.com/ncaa/web_video/health_and_

safety/concussion/webinar.html

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Concussions: Don't Hide It, Report It, Take Time to Recover (NCAA).

Directed at the collegiate athlete has clear implications for brain injury

for adults.

http://s3.amazonaws.com/ncaa/web_video/health_and_safety/ concussion/concussion.html.

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For training in the recognition and management of head injury including concussion, seek out an athletic trainer.

Contact your local university, high school or the National Athletic Trainers’ Association at: 1-800-879-6282.

Appreciation for review and critique is extended to: BJ Phillips, Philadelphia, PA; Basic Staff of the Fairfax County Criminal Justice Academy.