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UK Multidisciplinary Team Presents First of its Kind Protocol for Traumatic Brain Injuries in Equine Sports
Health providers, researchers and other professionals from the University of Kentucky who work in the area of traumatic brain injury developed and presented the Saddle Up Safely Concussion Assessment Tool and Return to Riding Protocol for Concussions in Equine Sports at the 5th International Consensus Conference on Concussion in Sports in Berlin, Germany, this past fall.
The conference was hosted and organized by Fédération Internationale de Football Association (FIFA), International Ice Hockey Federation (IIHF), International Olympic Committee (IOC), World Rugby, and Fédération Equestre Internationale (FEI) and has evolved into the world’s most influential process for policy makers on concussions in sport.
Representing UK at the conference were Dr. Dan Han, associate professor of Neurology, Neurosurgery, and Physical Medicine & Rehabilitation at the UK College of Medicine, Bill Gombeski, senior advisor at UK HealthCare, Fernanda Camargo, associate extension professor at the UK College of Agriculture, and Carl Mattacola, professor in the Athletic Training Program at the UK College of Health Sciences. Also playing a major role in the development of the concussion tool but unable to attend the conference were Dr. Erika Erlandson, assistant professor of Physical Medicine & Rehabilitation at the UK College of Medicine, and Jill Stowe, director of Equine Programs at the UK College of Agriculture. The multidisciplinary effort represented Saddle Up Safety (SUS), the Kentucky Neuroscience Institute (KNI), the Sports Medicine Research Institute (SMRI), the Spinal Cord and Brain Injury Research Center (SCoBIRC), Physical Medicine & Rehabilitation (PM&R), the Equine Program, and UK HealthCare.
The UK team identified key questions that needed to be addressed in advance, identified and reviewed relevant articles, and developed early recommendations which they presented to conference attendees.
“It was clear that in the area of equestrian sports concussion and return to riding protocol, that UK is one of the world leaders,” Gombeski said. “Individuals attending the conference from around the world discussed the work that the UK group shared and to learn more about using the concussion assessment tool and return to riding guidelines that members of the Saddle Up Safely program created.”
The Return to Riding Protocol for Equine Sport is the first of its kind for equine specific head injury. Presentations (5 in total) by the UK team members will be published in the May 2017 issue of the British Journal of Sports Medicine. The conference recommendations created this year will come out online in February.
Researchers at Seattle Children’s Research Institute published a study in the journal Pediatrics showing a new intervention for adolescents with persistent post-concussive symptoms that improved health and wellness outcomes significantly. The approach combines cognitive behavioral therapy and coordinated care among providers, schools, patients and families.
“We were pleased to find that using an approach that adds a psychological care component to treating concussions and providing coordination of care in areas of the patient’s life significantly improved outcomes,” said Dr. Cari McCarty, a psychologist and researcher at Seattle Children’s Research Institute who led the study. “This new approach aims to improve the quality of life for patients who were otherwise left to deal with unrelenting concussion symptoms.”
A fall off a horse causes a persistent concussion
Carmen Einmo, 16, loves to ride horses. In November 2014, she fell off her horse and broke her arm. At first, she didn’t complain of typical concussion symptoms, but after a few weeks it became clear something was amiss.
“I developed really bad headaches and became very sensitive to light,” Carmen said. “I started having memory issues and would forget words in the middle of a conversation.”
As her symptoms persisted over a couple months, Carmen’s doctor at Seattle Children’s, Dr. Elaine Tsao, suggested she sign up for McCarty’s study. The family was excited to have found another treatment option to pursue.
“A lot of Carmen’s schoolwork had to be done on an iPad, and spending long amounts of time on it hurt her eyes and head,” said Diana Einmo, Carmen’s mom. “Some of the teachers didn’t understand that Carmen couldn’t spend a lot of time on an iPad, and they didn’t know what to make of how long her symptoms had been going on.”
Carmen’s grades had started to slip and she worried about how the persistent symptoms got in the way of schoolwork.
“I entered my second year of high school ready to start off strong, but the concussion set me back,” she said. “My PE class was especially challenging because I couldn’t run, so I would walk, and I got penalized for it in my grade.”
A coordinated approach to concussion care
As a participant in the study, Carmen got support from a research team member that created a coordinated care plan for her. The researcher worked with the school and family on a plan that would allow Carmen to continue school with accommodations as she recovered. The plan included a homework priority list, allowing her more time to finish work and access to another room if she became tired from light and sound in class.
In addition, Carmen received cognitive behavioral therapy that involved her parents and sister.
“Cognitive behavioral therapy involves changing both behaviors and thinking patterns,” McCarty said. “In our study that included relaxation techniques, teaching coping skills and offering pain management. We found that incorporating a psychological care component improved health outcomes and quality of life for these kids.”
Only 13% of patients who received the coordinated care and psychological intervention in the study reported high levels of post-concussive symptoms after six months, compared to 42% of patients who received standard concussion care. In addition, 78% of patients who received the specialized care reported reduction in depression symptoms, compared to just 46% of patients who received standard care.
Getting back in the saddle
Carmen is feeling more like herself now and has been cleared to ride horses again. She and her mom say one of the most important things they learned during this experience was to take concussions seriously, especially because the effects and symptoms might not be apparent right away.
“It’s especially challenging when a teenager gets a concussion because it’s hard to tell if a change in behavior is because of a concussion, or because a teenager is going through a growth and development phase,” Einmo said. “We found the therapy to be especially helpful in figuring some of this out.”
Carmen adds that having a plan and realistic expectations with school helped immensely.
“I would tell young people struggling with a concussion to stick up for yourself and what you need,” she said. “Take it one day at a time and do your best, and ask for the help you need.”
The British Horseracing Authority (BHA) has announced a series of enhancements to its concussion management protocols, in order to ensure that riders are better protected and prevented from riding while under the influence of a concussive injury.
The enhancements, which come into effect from 1 August 2016, are being implemented across the full concussion management process, from baseline cognitive testing, trackside diagnosis and care through to post-injury follow-up, assessment and treatment and return-to-riding clearance. Their implementation follows a review of the existing concussion management protocols led by the BHA’s Chief Medical Adviser Dr Jerry Hill, in consultation with relevant stakeholders, including most crucially the Professional Jockeys Association (PJA).
The headline elements of the enhancements include:
* Extension of trackside screening test to ensure all riders who are involved in a fall are assessed for testing with symptom scores, balance and short and long-term memory (previously only memory was tested)
* Doctors will be given authority to test riders who were involved in a heavy fall a second time, approximately 25-30mins after the initial test, even if the rider passed the initial screening test, in case of late-onset concussion
* Involvement of other members of the racecourse team in encouraging potentially concussed jockeys to attend for (re)-testing with the medical team both doctors and nurses.
* Further research and development of an active rehabilitation programme for riders who have suffered concussion, on top of the existing enforced period of rest
* Ensuring riders are asymptomatic before submitting themselves for return-to-riding tests.
* Enhancement of “Cogsport” baseline testing to ensure all baseline tests are reviewed and evaluated to ascertain any tests which may need repeating for technical or clinical reasons
* Inclusion of IJF almoners in baseline testing process in order to make testing more convenient for riders
In addition to these enhancements, further improvements to the process are planned for the near future. These include a rewrite of the “Head Injury Instructions” guidance given to jockeys who are diagnosed with concussion, enhancements to the “helmet bounty” system whereby jockeys are given a stipend in exchange for returning the helmet they wore when suffering a concussion, and an extension of the administrative support around the concussion process in order to accommodate all of these enhancements.
In the longer term the BHA is working on a program of education which will be designed to inform not only jockeys but any relevant individuals who work within the sport about how to diagnose concussion and the risks of continuing to ride when suffering from concussion.
Dr Jerry Hill, Chief Medical Adviser for the BHA, said:
“For some time British Racing has been recognised as pioneers when it comes to concussion management, as you would expect from a sport which carries an above average risk of concussion injury.
“However, it is essential that a sport should not be complacent about the management of such a serious issue as concussion. It is my intention that in British Racing we provide our jockey athletes with the appropriate guidance, treatment and care. This is why I am personally putting a renewed focus on the support these athletes receive in injury management as well as wellbeing, nutrition and mental health.
“The enhancements to our concussion management protocols will help reduce the risk of jockeys continuing to ride while suffering from a concussion. It will also aid their safe return to riding following a concussion injury.”