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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.
The NFL and NFLPA have conducted reviews of the application of the Concussion Protocol in the September 8th Panthers-Broncos game and have determined the following. In the fourth quarter, Mr. Newton incurred a helmet-to-helmet hit which drew a penalty. Mr. Newton was slow to get up following that hit. The Panthers medical staff and the Unaffiliated Neuro-trauma Consultant (UNC) were positioned together on the sidelines monitoring the game and were unable to see the point of contact and decided to review the play via the sideline video replay system. In order to facilitate the video review, the team physician and UNC initiated radio contact with the Booth ATC and asked to view the video. Under the current application of the Protocol, once contact between the Booth ATC and the club’s medical team occurs, the Booth ATC’s responsibilities end (including the ability to call a medical time out). The time it took to actually receive the video following this request was prolonged due to a technology glitch. After reviewing the replay and observing Mr. Newton from the sideline, the Panthers’ medical staff and the UNC agreed that no further evaluation of Mr. Newton was necessary as they did not observe signs or symptoms of concussion.
The parties also conducted a review of the application of the Protocol in the September 15th Bills-Jets game. That review showed Bills quarterback Tyrod Taylor sustain a big hit that included helmet-to-helmet contact. Mr. Taylor seemed to be unsteady on his feet. Prior to any actions by the club physician, Booth ATC Spotter and/or UNC, referee Ed Hochuli directed Mr. Taylor to the sideline for the required sideline examination. The club medical team and UNC reviewed the video and conducted the required examination, cleared Mr. Taylor and returned him to the game.
Collaboration between the Team Physician and the UNC, who is jointly appointed by the parties, is a critical aspect of the Concussion Protocol and therefore bears emphasis. In both instances, the reviews of the NFL and NFLPA determined that the club physicians and UNCs worked closely together to review the plays at issue and jointly made medical determinations regarding evaluation and diagnosis; in each instance, the medical determination made revealed that neither player had sustained a concussion. The Team Physicians and UNCs involved in each instance worked closely together to provide medical care for the players involved and their team work should be emulated across the League. Similarly, Mr. Hochuli’s decision to send Mr. Taylor to the sideline for evaluation after spotting an observable sign of possible concussion, demonstrates a conservative and therefore appropriate application of the Concussion Protocol.
The NFL and NFLPA, in conjunction with our medical advisors and the NFL Physicians Society, have also taken several steps to further clarify and enhance the Concussion Protocol in an effort to ensure that it is being applied uniformly in all NFL games and that everyone involved in its application understands their roles and responsibilities. Some of the agreed upon enhancements are set forth below.
The Concussion Protocol has been adopted by the parties in order to establish a conservative standard of care and ensure that competitive considerations do not influence healthcare outcomes. The objective of this Protocol is to provide medical staffs responsible for the care of NFL players with a standardized process for identifying and managing potential concussion. The parties recognize that concussion diagnosis and management is often a difficult and complex exercise, compounded by hectic game conditions. Accurate diagnosis and management of concussion requires experienced physicians coordinating with others on the sideline and within the field of play, each acutely aware of his or her responsibilities and all committed to the strict application of the policies implemented in order to protect players.
2016 CONCUSSION PROTOCOL ENHANCEMENTS
- Concussion Protocol to require the Booth ATC Spotter to remain in contact with the club medical team and provide video support until the medical team confirms that a concussion evaluation has occurred;
- The NFL Head, Neck and Spine Committee, together with the NFLPA Medical Director will conduct a conference call with all UNCs to review changes to the Concussion Protocol;
- The NFL, in consultation with the NFLPA, will use Referee Ed Hochuli’s actions in Buffalo as an example of the appropriate application of the Concussion Protocol and proactive officiating in this realm as part of its continuing training of game officials;
- The NFL and NFLPA are reviewing the merits of supplementing the Booth ATC program with a Booth UNC program as part of their continuing evaluation of the Protocol to ensure the best possible care of our players.
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.”