Transcripts For CSPAN2 Conference On Student Athlete Health Safety - Part 2 20240714

Its my honor to introduce our next speaker, colonel francis oconnor, m. D. , whos the professor and chair of military and emergency medicine. If you never been there actually worth a visit here francis took me around and its really a great place where we have training, medical training for those are going to be serving in our country and providing service to the men and women who serve in a country. Hes also a leading voice for exertional illness, sickle cell trait. Hes leading a major study and internist and really sicklecell trait even better and he certainly has been a mentor and a friend to john and me and others at the ncaa and trying to guide us to go in the right direction. So thank you for coming here today. Well, thank you. Its an absolute honor to be here to honor derek sheely. As a father of three sons im still shaken. Ms. Sheely, listening to your words and your passion, i will not forget. I will not forget. Im going to be moving away from cardiac and we will talk about some and other entities of exertion illness. As brian also stated i am with the department of defense and all the opinions i have today are those of myself and not to be construed with the department of defense uses or cases. August 2001, cory stringer, practicing full gear, outofstate here in the midwest, heat index 110. Stringer vomited three times, walked to an airconditioned shelter, start to complain of distance and became dizzy and began breathing heavily. Darrell boyd and a Football Player, 19, 2006 collapsed on the field in texas after exerting himself. He and his teammates as very common football ran 16 consecutive 100yard sprints, almost a full mile. Early on you showing distress picket difficulty breathing, complaining of leg tightness, trouble standing, subsequently collapsed. Michael, Football Player, west point. First day of Ranger School at fort benning. Falls ill in his first day. He just completed a vigorous training session, gone to dinner when he fell out ill. Doug brenner, january 2017, university of oregon. There were trash cans lined up for the players to throw up in. Im sure so swollen i couldnt take off my own shirt without help. I could not even eat. So my objectives here in the next 2530 minutes we will talk about injury prevention, quickly identify some ideologies and focus on four entities that are exertional. Heatstroke, sickle cell trait, hypernatremia, with a specific focus on how to prevent these things from occurring. This is one of the leading models for sports injury prevention and as you see it as it moves around clockwise number one establish the extent of injury. Whats the perspective, severity, mortality . Try to establish how does this occur, what are the entry mechanisms. Entered is an injury prevention measure and then of course the soared and assess are we making a difference. What we try to layer on particularly military is prevention and the receipt three different forms of prevention, primary, make sure you dont give the flu. Secondary can interrupt or detect the disease before it becomes automatic. Check blood pressure. Tertiary come , limit the conses of symptomatic disease. Youre having a stroke to get to the Stroke Center to decrease the effects. This carries right honorable friend to sports. This was alluded to. You can see this is the largest cohort of death in athletes, and you see the 56 is cardiovascular that are others as we know derek sheely. What im going to talk about are the others, heatstroke, sickle cell traits. When we get back to cory stringer on the fateful day we all know this was exertional heat stroke. What we know about it . For us in military where we have 1 million men women under arms activeduty and reserve its a big deal. Big deal. Big numbers because we need a force that is ready. This was data from 2013, 324 heat strokes. We tend to know it tends to be the men over the women that have heatstroke to do one. Tends to be young, the young we predispose to these loads and in or sign up in the United States military asianpacific islanders at twice the rate of heatstroke and other cohorts. As dr. Hainline talked about these things are common. I quoted 325 in 2013 but in 2013 but we had 418 in 2015 and last year 470. Our numbers continue to climb but we dont have people dying because of some of the preventive measures im going to talk about. What about football its the sad read. Since 199554 reported Football Player but that was a heatstroke. 54. You take a look at it, its largely predictable. Most of these are in august, 60 . Onethird occurred more than two hours into the practice session. Most of us in room converted to. Interestingly enough, you take a look at the exertion heat illness rate in football, 11 times greater than all of the sports combined. Its football. You could argue this and i would make a strong stance you that exertional heat stroke is the most common cause of preventable nondramatic exertion sudden death american sports. Cardiac is very difficult to prevent. Heatstroke we should prevent. As is pointed out by mr. Sheely, we want investigations. The Israeli Defense defense fos at every single death excruciatingly and here in this publication that took a look at heatstroke deaths and they found two items present in 100 of cases. Number one, the physical effort was unmatched to physical fitness. You could predict it. And number two and most important, absence of proper medical training. Emergency action plan was not ready to go. Take a look at some the risk factors from the early model. Many of these were described by dr. Hainline. We talk about for physical fitness. Real problem with American Youth is they enter military service or the start these transition periods as dr. Hainline talked about. Lack of acclimatization. We talk about not only environmental acclimatization but also exercise acclimatization. We talk about obesity. Dr. Hainline talked about sleep. This is emerging as a powerful variable. In my expense as a military provider illness, how many kids are sick on that particular day, till the drill sergeant im up and get up to the company and feel very good. Or Marine Corps Marathon is coming up. Drugs i will talk about in a minute and the equipment. We take a look at what soldiers where this is not exactly something you have an easy time in the heat with. Also difficult time. Obesity, we have found this to be an extremely powerful risk factor for predicting heat illness. This one study done in fort bragg, overweight, three times more likely in the first 90 days of service to have exertional heat illness. We know this is a problem in the military. Take a look at football. We know a lot of the kids out there are running around are going to be very predictable for exertional heat illness. Beds come a lot of kids on medications meds. Medication allergies but anything that will affect your cardiac output, to sweat. These are Major Concerns that we need to be aware of as providers as these kids go forward, particularly and august 42 a days. What i would argue the most interesting to me as a military physician is this. Supplements, many of these do not have thirdparty certification to what you see is a soldier had an exertional death and asked the aniston and this is what they pull out of his locker. God knows what the combination is of this group of supplements. Primary prevention, what do we do . We want to make sure a place like the military or football training if you go off to aside that her condition is leveraged but acclimatization is hydration, cooling that we need to leverage primarily to keep kids cool. In the military, another thing mr. Schumer talk about, accountability. Theres accountability to the commanders to adhere to this table you see. What you see is a work rest water consumption table. Everyday temperatures measured. Work is classified and from that work within calculus appropriate work rest cycles and how much water should be provided. If you start of heat strokes and people are going down in large cohorts, the commanders will be held accountable. Did you follow the guidance to keep people safe sex data just produce a hydration guidelines. I was a part of this document in terms of making sure with adequate water but not too much. Very important point coming out of this document was to avoid fluid balance problems, drink when thirsty. That seemed to be the most powerful recommendation. For elite athletes they mean need more and more file into sports performed because drinking to thirst may not keep them at the edge. The most important thing is this right here. Individualization. Oftentimes we fall into the military or football team, one strategy for everybody. Thats not going to work because people are different and we need to recognize that. Dr. Hainline alluded to this ethically developed but this ts a high School Document to leverage acclimatization so we can change that trajectory of 54 deaths since 1995. Very carefully thoughtout, recognizing this vulnerable transition day one through five we see right here. No two days. No uniforms. Acta should not exceed three hours. You cannot walk too but you need a threehour period to recover. The cory institute is trying to propagate this across all states to ensure its safety of the show Football Players. Its also clear outside of football in athletic medicine literature this is from europe for one of want to really bring your attention to is that a conversation strategy here. Its one to two weeks. It takes time. Its not two days. You would have to be careful with this vulnerable transition period military with tremendous interest in keeping people cool because we need to keep people in the fight. Take a look youre just three little strategies not only keeping cool when battling prevent heat illness but may enhance performance. Simple things can you see a warrior and a humvee with a vacuum called twice for his hand. The military is very involved and look at the microclimate cooling devices all the way down to the underwear. And simple things like slush is what many foreign militaries will leverage to try to keep people cool so they can go forward and exercise. Very important, sometimes as physicians we need to jump in and say not going to be a good day. This is a sign from the chicago marathon back in i believe 1996 race overcome three hours. They had so many strokes at the time and ran out of water and had to stop the race. Two years ago in washington the army ten miles the race had to stop as well, had 30 heat strokes which was unprecedented. This is a paper that says theres a way to determine a do not start temperature that maybe we live to fight another day. This is what medical directors, physicians need to jump in, follow the data as dr. Hainline talked about, develop plans that say maybe we go tomorrow. Maybe we keep you in a fight for a future marathon. Secondary prevention, i was also moved by mr. Healy, this is what we leverage the military were so misses johnny does not look right. Bring them to a medic. Thats perhaps our most important sector prevention measure. Looking at signal cases when you see things pop up on one particular to our unit. They are having a bad trend over here. Something stuck right. The other thing we do in the military is with leverage what we call heat dumping. Every opportunity where kids are hot come , here you see in the l again leveraging a hand coding device. In the military at fort benning we leverage showers, cool shows, run kids do these all the time. The other thing we do is we now have these cooling systems filled with cold water and the skids moved from training site they rode their sleeves, put their arms in to keep themselves cool throughout. Tertiary prevention means you are ready. When someone drops Everybody Knows the plan. Here you see a picture down at fort benning. We have barrels filled with cold ice sheets so if a soldier goes down, this drill sergeant knows wrap this kid in this ice brito and call 9 11. This intervention alone will help say that young mans life. The other thing in addition to this drill sergeant being in action is we need Rapid Intervention as dr. Hainline alluded to being prepared. Military can we use little different technique. We have a governing here suspended over ice water and would bring up and over to complete cold water immersion. Just a brief picture here from the Marine Corps Marathon. Get out of the way. Get out, get out, get out. A little loud but that being said, its a heat attack. Its a heat attack. If we dont act a young man will die. Thats a team that is hactivist and ready to go. They had 100 heat strokes last summer. Everybody walks away because theres a good plan and execute it and they practice it. Field treatment here very common. Dr. Hainline talked about it, emergent cooling. Were preparing to treat onsite with preparations for transfer but its all about a plan, attics the plan and executing the plan. They avoid them dale lloyd was thought to be a benign condition. However, its very clear in the literature. This is the american medical journal of medicine. Here you see faces of Nine American Football Players who all died as a result of sickle cell trait associated crisis. The military said the publication 1987 establishes very clear if youre africanamerican and her sickle cell trait positive you have nearly 30 times the risk of sudden death event in the first year compared to being africanamerican and sickle cell trait negative. University of washington looked at a cohort and established or also established this risk is about the same. Africanamerican sickle cell trait positive have higher relative risk of sudden cardiac death. She determine if your African American sickle cell trait Football Player, you have an absolute risk of one in in 185f sudden death in. Going back to the original construct, sickle cell trait falsity of the category. Dr. Emery talked about lightning strikes thats commonly using that analogy but the sickle cell trait rooted confiscations and deaths are rather rare. We need to have the right balance here in the right narrative when we committed to africanamerican athletes on what is the risk and what is not the risks . What do we know about these deaths . Most electron from case reports as an ncaa athlete who died in 2014 and an offseason training work out at cal berkeley. Generally unconditional military recruits or deconditioned athletes in that transition period thats when this generally happens. Repeated intense bows limited time for recovery and unlike a cardiac death most of these deaths are conscious. The athlete will go done complaining of weakness, i cant walk there still alert at least initially. This is a very detailed slide taking a look at how does sickle cell trait cause death . In many thoughts theres a local environment here, hypoxia acidosis, increased interest that may cause signaling with an explosive rhabdomyolsis but this is a hypothesis being worked out but that is the leading thought somehow we are precipitating a sickle cell trait crisis, excuse me, a sickle crisis in someone who is sickle cell trait. This is controversial. A lot of different thoughts. He believes its all a all the hydration, hydration is a key variable in leading to the sickle cell trait crisis. Doctor iker was in oklahoma, you see is, too, he is no more a trigger for exertional sickly dentist alta to come athlete, or a reckless coach. Truly believes intensity is the key variable. As dr. Hainline alluded to wear very interested in this, very interested in the genomics. Because i know the mr. Speaker sickle cell trait positive africanamerican your risk of dying in the first year is one in 3000. Im interested as i exploited dr. Hainline in the 2000, 999 what exact same boat as to why they dont die. That is interesting to us and my bottom line up front and what we are trying to uncover and explore is that maybe all sickle cell trait athletes are the same. There might be Something Different in some that predisposes you might be able to find it, stratus report and provide better advice. Terms of primary president xis dr. Hainline talked about their screen out division thats recommended. You can wave out if you want different athlete but screening is mandated. The dilemma for physicians is just as dr. Hainline came out in the ncaa recommends screening there some people like the American Society of hematology the came up and said we opposed this screening. Your screen for genetic variation. This has the potential, student athletes, and may create a false narrative. This is a tough issue especially when youre getting outside of the ncaa with High School Athletes or athletes in the military on what to do. But most and this is a guidance on the ncaa, this this is a con sense kind i give also to parents of high school. Ive emboldened some of the key things, slow gradual preseason conditioning. Again recognizing that transition period the excuse from a performance test such as serial sprint is a saw in darrell lloyd. Stay well hydrated. Refrain if youre ill and seek prompt medical care. It speaks to universal common sense guidelines and a clear recognition of transition period secondary prevention, and again dr. Hainline new document emphasizes all these points, or have a punitive exercise. This is where people get naked trouble. Recognize and athlete who are struggling. As we heard with ms. Sheely this morning and when they are down, to help them up your most importantly. And finally develop adequate Emergency Action plan that is rehearsed, practiced and ready to go. Sector prevention includes hydration. My read of the literature, the single most important thing in African American athletes to do in addition to harmonization is leverage hydration and stay hydrated. Tertiary prevention, war fighters, we give a brief to edwin come in they are aware of the risk but most important we have detailed Emergency Action plan on what to do if an athlete goes down and everybody from a coach to the trainer, drill sergeant is aware of this so we can execute it weekly. This is just an education tool ill show you quickly to share this with dr. Hainline but with different beta tapes we produce in the department of defense to give to the contrary, tradespeople, to the doctors were going to mansion these problems come into the soldiers. I wont belabor this in the essence of time but were trying to produce these tools to get them to the right people. Bottom line, try to be prepared. Michael, Football Player at west point, first date of Ranger School, first day had just graduated. He was an excellent associate hyper death. Unfortunately those deaths happen cleanly. What are your best to mitigate this but its been a real problem. This is cynthia, 2002 died in the Boston Marathon with this became an issue. His athletes who present who are normal temperature but they are cloudy, mental status changes. This is a person working at an event needs to be aware of no normal temperature, excess associate needs to be rolled up. What we know from the literature . A couple things. Not all that common, like. 3 1 interest for those people with with longer finishing times, people at the longer on the course can have a greater risk and i think most important here is vomiting was only clinical sign different chin from conditions. When theyre down and vomiting the answer is not drink more, get up and run. The entries you have a problem, sit back at embassy was going on. Hillary died within the medical tent that they not too far from here at the Marine Corps Marathon, 36 years old, nine months postpartum. She was vomiting. She was given water. Primary prevention, our table and our water intake in the military has been dialed down. We give less water at this point in time to try to avoid hyponatremia and you see that and more case races across the country are increasing water stops to avoid this complication. The hydration guidelines ive alluded to. Singable sport think this guideline is you have to know yourself and jeff to recognize that people are different and there are different loads, that will create different stresses. Secondary prevention, use no more and more at races medical wayans. This is from the hawaii ironman. You should not gain weight when youre exercising. And if you are gaining weight, thats a tipoff that you may be of hyponatremia competition. Tertiary, out at fort benning, dana recognize of this. Last case, doug brenner. And, of course, this is exertional rhabdomyolsis. A major issue for in a military. We are seeing an increasing number, between 20132016 our numbers almost went up 50 . This may be the training for ot may be the pool of fitness of individual come in the military but this affects our ability to train and to be ready. Its not just the military. This was interesting published by a colleague of mine. Offseason training again emphasis from dr. Hainline, iowa players described described grueling times workouts. 100 squats, a good way to put a lot of people in the hospital, which they did. Also military cohort study, 44 cadets who are doing whats called the murph, one mile run, 100 polyps, two and a push ups, 300 squats and the one mile run. All these kids attend before. They never had a problem and in some decided to put a clock to it. 40 of kids went to the hospital when you put a clock on it. Rhabdo is complex. Its not just exertional rhabdo and providers need to be alert. It can be the flu. It can be ecstasy or cocaine, a number of things can contribute to rhabdo. So as a physician you need to have your thinking hat on. But for exertional rhabdo it usually when a perfect storm comes together and this can be exercise factors. Again whos coming in, whats the transition time, whats the intensity, are we leveraging exercise acclimatization early on . There are many not exercise factors. Again i will dovetail again with dr. Hainline here. Illness, not sleeping well, sickle cell trait, drugs, statins, supplements. But i would strongly agree with the think what mr. Sheely tried to point out, the most important thing i see as measured by providers looking at these cohorts, leadership. Whether its heatstroke or rhabdo, these kids will do what you ask. It is leadership. Primary prevention, i i take ts slide whatever i can. I think this is a very powerful guides dr. Hainline put out in general 2019 identifying the vulnerability of the transition period and Holding People accountable. Strength and conditioning workouts, exercise based. Work to rest ratio of one to four. The workout should be documented, documented in riding and what of the best riding these programs. I thought a very powerful statement that we certainly push it. In terms of secondary prevention, rhabdo is no joke. It is no joke. When youre in the hospital for three to nine days, whatever it may be fighting for kidneys or ending up on dialysis. In terms of tertiary prevention we published guidelines on this at this point in time. We have detailed guideline here we use in the United States military that walks providers all the way through on how to manage this so we can get troops back to duty and avoid complications. I want to conclude, again, an honor for me to be here to speak on behalf of derek sheely. I think exertional illness is largely preventable at this point in time. I think, since recommendations as we heard from dr. Hainline, acclimatization of Emergency Action plans are the best way ahead, as was in the military. Again echoing mr. Sheely, i truly believe remains the key risk factor for exertional injury that i described and is most important variable for improvement. Thank you. [applause] well, thanks dr. Oconnor its number pleasure to introduce doctor harvey or tardiness was a director of the Barrow Concussion and brain injury center, chair of the Arizona Interscholastic Association Sports Medicine Advisory Committee. He is really a leader in the American Academy of neurology engines of helping to advance all of the neurologists understanding of concussion, traumatic brain injury but just a little side note that you may not be aware of. It wasnt until i believe three years ago that concussion training became a mandatory part of a neurology residency training. It was always assume neurologists were the most knowledgeable in concussions, when i was trained as a neurologist i have no formal training in concussion. So its not part of neurology residency curriculum, and leadership have helped get us there. Hes also an independent physician for the National Football league, and thats been i think an interesting and good experience where he believes that there is than been Real Transparency on the field. So dr. Cardenas will talk about traumatic injury and sport. Thank you for coming here. Dr. Hainline, thank you thay much. Im honored to beer and present on this topic to the she lease, thank you as well. Greatly happy to do this. I will also disclose that it will be talking about traumatic brain injury which of course derek died from, and if so whether its the slides or stories are some of my own patients become upsetting, i apologize in dance if you have to step away. All right. A bit of those disclosures. As you heard already from dr. Hainline indeed, my involvement in this particular area spans all ages, from youth to the professionals, and this in my opinion allows me to get a good understanding of how things are different at each level but also how there can be changes. The change is not going to be necessarily unidirectional. Its not always going to come from the top down. There are many things that can be shared in both directions. When we are looking at catastrophic sports injuries as you already heard, there are a significant number of them. The majority of them occur actually in high school. 33 fatal, 14 nonfatal and 50 series. Most of these occur in a competition but some in practice. Football has the greatest representation of catastrophic sports injuries. Once again this date is primarily from high school with 55 represented versus esquivel, soccer, baseball and other sports. The entity that its tracking this is National Center for Catastrophic Sports Injury Research in north carolina, chapel hill. This is indeed a reporting system. It is a voluntary system but over the years they have been able to get more accurate data because of social media, and they can reach out to different people and organizations and ask for the data to be provided. This was established in 1982, and i know that many times coaches get a bad rap especially when comes to football, pushing people through it which indeed may be the case but, in fact, this was established by coaches who are attempting to analyze how these catastrophic injuries were occurring. Now, a few definitions that youre going to want to know. Fatality which is selfevident. Nonfertility is a permanent but severe injury pics of this may be neurological injury. A serious injury may not be severe ear so, for example, or may not have a permanent deficit. Somebody who suffers a spine fracture but does not suffer a spinal cord injury. Then the mechanisms, direct, of course from participation in the sport and then indirect occurred while participating in the sport but not necessarily directly from the sport. As you heard today and as you are learning about the three ages are the key when it comes to catastrophic sports injuries. Heat, heart and head to california 80 of these injuries. Some of the outcomes if we look at the direct outcomes, 20 are fatal, 33 nonfatal, 43 serious. Majority once again if we look at direct injury occur and again. Some in practice. The mechanisms of which for a direct injury are neck 37 , brain 33 and once again football is represented with the greatest number of direct injuries. With respect to indirect injuries, 42 that are fatal. If you look at gain versus practice in condition use somewhat of an inversion of the numbers compared to the direct injuries. And in the mechanisms are also different. Heat, heart however once again as you heard earlier football is indeed representative with the most number of indirect injuries as well. The National Center for Catastrophic Sports Injury Research also is a subset dedicated specifically to football, and once again emphasizing these definitions direct, indirect and nonexertional related, which some of this is to gather data outside come off the field if you will, for example, if somebody suffers a cardiac arrest in their sleep sometime after a sporting event. And this is the data most recently published for 2018. We will go over some of that. If we look at participation, football does represent the highest number of High School Participants as well as youth. 1. 1 million at the High School Level. In 2018 there were two direct football fatalities, two in high school, nine in college. The fatality rate is at. 095. They both occurred in a competition. One was a brain injury and one was a cervical spine cord injury. Compare that of course with the indirect the top of these, three in high school, one in middle school and one in college. Once again for the 2018 year. Over time we see the direct and indirect fatalities broken up by five years and you could see they have come down over time. With our most recent data, 20152018, indeed a shorter period of time in terms of the data specifically looking at head and cervical spine fatalities, once again you see a decrease in these the tablet is. One could argue that when it comes to fidelity from a brain injury spinal cord injury that perhaps advancements of medicine have contribute to that reduction rate. But additionally, you can also achieve at some of the interventions and policies for that reduction. Looking at cervical spinal injury fatalities specifically in football, three in 20152018. 127 over 73 years. Most of them occur in a competition. Most occur while playing defense. Tackling is the most common activity and then the position defensive back, 35 , kickoff 9 , linebacker 9 9 . Once again looking at both cervical spine and head injuries, you could see that over time these numbers have gone down in both cervical spine and head injuries. This is just an analysis of the fatalities from 2018. Once again a small number represented. Look at traumatic brain injury vitalis. It would tend between 20152018. 20052014 was 31. Approximate 560 since 1945 and most are helmet to helmet hits now, football is not the only sport in which we can have catastrophic injuries and, in fact, this is an opportunity to emphasize that there are cheerleaders and women sports that have sears risk factors attributed to them, specifically cheerleading. This is the data from cheerleading in high school looking at direct catastrophic injuries. You can see for telling numbers of course are low but nonfatal and serious injuries are pretty high. This is in direct catastrophic injuries, and youll see actually basketball is represented here as having the highest number. Moving on to college, female catastrophic injuries, once again cheerleading is at the top. If we took all female sports combined and look at catastrophic injuries they would not equal the number of catastrophically injuries we see in chile alone. This is true not just at the High School Level, but also at the College Level in terms of a catastrophic injury. A few studies we are citing. This one was published in 2003 looking at injuries between 19822002. They were able to investigate specific injuries, 29 out of the 39 entries that we were reported at the time. 27 women were injured. Of course men and women participate. In college there was a five times greater risk. The activities that were most at risk of course was the pyramid and the basket toss. Theres a pyramid and theres a basket toss. 17 of these were head injuries, 13 fractures, two of them died. Eight had cervical spine fractures three spinal cord injuries and then one was listed as having multiple head and neck injury. Another study looking at ideas for prevention. 66 of the catastrophic injuries in High School Athletics were attributable to cheerleading. So once again an emphasis that if you look at overall injury rates by itself, cheerleading does not have that many injuries. Injuries. However, if you look at just catastrophic injury rates you can see it clearly outnumbers all of the other womens sports. The mechanisms by which people are injured is stunting. The majority of them, the base or spotter accounts for 23 . Tumbling, 14 and 26 to a fall up to 25 . 25 . Some of the risk factors include the bmi of the athletes, history of a previous injury specifically head or neck injury. The stunting themselves and a very key point, the surface of which the athlete lands. In fact, this was a publication of just last october analyzing an intervention that came in and 20062007 academic year, and that is a change in our will. So looking between 20022017, the idea was to find out whether not this rule change, this policy change made a different injury. This was the policy became thee out from the National Federation from high school association, specifically that the basket toss was not going to be permitted unless there was a soft padding, unless there was a soft surface for them to land. They found they were 3. 6 catastrophic injuries per year, 2. 2 per million cheerleaders. Most occurred in a practice setting. Head injury accounted for 50 of them. Neck 30 at once again the basket toss 35 of them. If you look at the injury rate lead up to the policy and will change, it was 1. 5 per 1000, versus afterwards,. 4 per 1000 once again looking at the data, taking that data, making a policy change and then seeing the result, which is always key. Of course these things can occur in wrestling as you have heard from dr. Hainline. It is also an aggressive contact sport. This date is from 8199 looking at 35 incidents. Most in high school. 80 occurred in a match. Youll see the trend of course is that competitions to be a pretty high risk. Defensive position for a takedown, so this was the athlete was taken down, 74 , 23 in a deposition and a very small percentage in a line position to 27 at a cervical spine fracture, four with iceland contusions. 11 ended up being delos movement of the arms and legs with six paraplegic, just legs, and three brain injuries and one of these athletes died. Catastrophic injury in poll vaulters pick once again this is an example of looking at interventions to see how interventions can impact outcomes. So between 8298 there were two catastrophic injuries per year. Looking at where these athletes landed, most of them landed off the side or back of the landing pad. A small number landed in the vault box there was a rule change in 2003 expanding the dimensions of the pad. And then the data was then analyze between 20032011. Same number of catastrophic injuries. However, most of them landing in the vault box, 24 landing on the side or back of the pad. So here is an illustration, even though the pictures sidebyside look like theyre the same size. In fact, this is a larger padding. You can see it encompasses the areas where the poll sits, and so the arrows represent what athletes had fallen off versus the injuries within the vault box. Based on this information there were 19 catastrophic injuries in that second step of groupings. There were spine fractures, pelvic fractures included those as catastrophic. The rate because of participation had actually increased during this time was 1. 0 in the original study and. 22 in the new study so decrease in the fertility rate for poll vaulters. Rugby, in an analysis, granted this is a while ago, rugby is a sport that is now reevaluating their head and spine injuries. At this time they found that there were more spines, specifically cervical injuries, compared to head injuries in other sports such as american football. Having higher rates of head injury and neck injury. Another sport that can have a significant number of catastrophic injuries, thinking of not just all the team sports but also individual sports in which you can have these injuries. In this study between 20032010 looking at 72 injuries, 30 head, some have subdural hematomas, 15 of them died. Some were significantly injured and persistent vegetative state, and six were disabled. 19 of them were neck injuries of that total. Some had complete paralysis versus incomplete, and others had a full recovery. 90 or less than 20, so these are young people that are suffering these injuries. Now, as i mentioned earlier i would be talking that one of my patients. Ironically, this young mans first name is derek. He and his mother just and we knows have given me permission to talk about him and his case. This young man was a 17yearold senior at the time of that picture, and in late or mid october of 2012 he suffered a head injury in a game. He complained of headaches but only to his girlfriend picky did not mention this to his coaches, his mother, or his teammates. He suffered another injury on october 26. Took a hard hit. It was pretty obvious. He was motion to come off the field. He didnt. When he did come off the field he started to have a seizure. He was airlifted to my institution at barrow and this is a picture his mother took and shared with me in the intensive care unit. He had a bleed, a subgroup subdl hematoma but clearly the biggest concern was the swelling and shift of the brain to the side. Because this is a potentially lifethreatening event. He did not require surgery, however. He did demonstrate some permanent changes on a subsequent mri. He required, about a month of inpatient neurological rehabilitation. As you can see here hes actually about 62. He is righthanded, not lefthanded, and the therapist has them by app built because he was not coordinated on his right arm and leg. And then he had about a year afterwards of outpatient neurological rehabilitation that included physical as well as speech cognitive therapy. So what does this represent . This may represent second impact syndrome which is a rare consequence suffering a second injury before recovering from the first it has clinically been described as somebody who collapses. They have rapidly dilating pupils. They lose their eye movements. They stop breathing. And then the brain swells very quickly. This is distinct from having a big bleed within the skull. The second hit itself might be minor and i included a presumed pathology because this is under great debate and there is not an animal model or another model to find out exactly whats going on. There is presumed blood flow from the first injury and then after second injury theres vascular engorgement and then herniation of the brain. It carries with it a 50 tablet and 100 morbidity. This is not an new entity. It was first described in 1973 by dr. Schneider republished head and neck injuries in football. This publication recommended the use of football helmets materials, so hard materials that you heard about earlier from dr. Hainline as well, as well as a ban in speeding because is look at the neck injuries as well. The term second impact syndrome which came from doctor harbaugh when you publish a 1984 article in 1984. It was popularized by bob cantu who is seen here when you published an article on boxers, of which there were five allmale all young, all had two impacts. One of them was a car accident, the others were boxing injuries. They all had symptoms after the impact in the second impact was anywhere between six hours and two days from the first, considered to be minor. That all collapsed they all died. They all lead cerebral edema and two had very small bleeds. Now, the National Center data from National Center was utilized to look at potential cases between 198093, a base of the state if they felt there were 19 confirmed second impact syndrome cases and they felt this is distinct from a delayed diffuse cerebral swelling which is a different entity altogether also not as malignant brain edema center. It has its own set of controversies at the thought is theres a single impact and from the single impact there is something inherent in the individual that caused them to have unusual swelling of the brain due to this cascade. However, this is not to be contested. Doctors analyzed the same 17 cases under these or mac criteria. The first was a medical review after a witness impact, meaning that were both impacts indeed witnessed versus simply reported. And there were five probable cases. The 12 cases were primarily excluded because only one impact being witnessed they felt was do to swelling. If you look at the 5 cases they call probable i would like to highlight that all of them had ongoing symptoms so for those of us who care for individuals who sustain concussions and monitor them afterwords, it is critically important in doing so. These are the most recent publications with sudden infant death syndrome. On the left side in terms of age and gender, attendyearold american Football Player, a female, from first injury to second industry, 32 and all had ongoing symptoms. Mcquarries publication. And and and in these cases this is a 15yearold, and in a kick return. And he went to see his pc pay and thank goodness. There is the subdural hematoma, and did intensive cognitive testing and was very successful. There is a 60yearold male who was in a wrestling tournament who suffered his first injury on 21 september, and i only found out when a teammate of his later told me he suffered an injury and didnt tell anybody else. The following day during the tournament, he continued his match. He had a bad headache. For the third match, his headaches continued. s mother took her to the Emergency Department where ct scans showed a subdural hematoma and swelling and required neurosurgical intervention. Removal of bonus, also demonstrated the change in imaging and survived this particular injury. This is a 17yearold in 2013. From a Rural Community in which they had access to medical care but also no athletic trainer available, he suffered a hit shortly before the competition and then he was told to take it easy and there were state turn them ins and in the Fourth Quarter he had a legal hit and played for two more plays and collapses. This is his ct scan. You notice massive brain swelling and bleeding. This is the mri, the temporal lobe and frontal lobes, significant damage and succumbed to his injuries on the 11th in 2013. Now this is the most recent publication of second impact syndrome case in which there was an injury after the first step and then the other. This is a 17yearold who took a hematoma hit. His pcp, had headaches, normal exam, ordered a ct scan and told them he should not participate in the ct scan which was read as normal. Five days after the injury he did return despite the recommendation. He was slow to get up and said he couldnt feel his legs, collapsed, was taken to the hospital and had severe subdural hematomas. This is his subsequent ct scan after the second hit. There is some herniation and an injury on imaging and two months later you see significant atrophy after his injury. The one we are looking at, risk reduction, one of the interventions we can do. You know the story of zachary who in 2006 suffered multiple head injuries, ultimately collapsed at the end of the game and was airlifted and required neurosurgical intervention. He was the inspiration for the 2009 washington state. This is him at his washington graduation. You see he is in a wheelchair and limited cognitive speech abilities but this set the stage for education, removal from play and a second concussion and return to play after seeing a licensed healthcare provider. This is the model legislation of which every single state in the nation and dc has a concussion log but for the most part covers those three illnesses. Who can tell me what is wrong with this particular image and why it might be a problem . The chinstraps . This is an issue we felt was a problem at the High School Level because before instagram this is a picture the High School Athlete would post on their locker and we were concerned it would be an issue of keeping them off. We made a rule at the Advisory Committee level that stated if the helmet comes off during play they had to go to the sidelines to be. And this is somewhat risky the Interscholastic Association changed a rule on the National Federation of high schools, presented the National Federation and not long after that there was a release recommending allstate associations have a little. Dont know if his direct correlation of this is the time doctor carson came to the ncaa but the ncaa not long after also released a bull about helmet displacement where the play, other issues with respect to injury, this represents football compared to other sports. When we are looking at contact practice in 2013 we wanted to limit concussions as well as exposure to head impacts. We recommended a bull during the preseason, during the regular season no more than a third of the time could be contact practices and we defined what contact was in order to see what is clear. And and implemented limits contacting this is from the National Federation of high schools as well. In arizona we have a limit on the amount of heading practice, specifically that can be done during the preseason, regular season and how many days a week you can do so. This is to reduce the professional injury but also exposure to head injury. There are other ways to address this making sure every athlete is covered by a policy, not just for catastrophic injury but other injuries, looking at other means of prevention, preparticipation physicals. And conditioning as we heard earlier is critical, having an athletic trainer and Emergency Action plan. And not being involved in medical decisions is not being supported and supporting the referee, based on safety. Sports specific recommendations keeping head out of the game. And limiting sliding at first. This is the concussion protocol checklist. All institutions are required to have it. It covers preseason education. And and identifying signs and systems identified by concussion. Managing the injury is on the field and for return to play but also just as importantly returned to learn, students before athletes and reducing exposure to head trauma and lastly just reinforces of brian hainlines document regarding catastrophic injury and death and the six points for keeping all of our athletes. Thank you, javier cardenas. The speakers from this morning john parsons will moderate the Panel Discussion and we will be inviting questions from the audience. Good morning. My name is john parsons, managing director of the Sports Science caa and im proud to moderate the discussion this morning. We will entertain questions. The microphones are now active. Give you a chance to organize your questions and ask that you approach the mic and i will recognize you and while you are preparing your questions, i will get started on one. Many of not only the cases and the data we talked about today but also the policies across multiple levels, high school youth, etc. I wonder if you might comment on what you see as the policy relationship between the organization is there a trickledown effect at the ncaa or the professional level . Talk about your experience in the direction of policy. I will start by talking about the relationship between the ncaa and the relationship the high school association. Those who have come to indianapolis, the building next door is for the National Association of State High School associations. We have a close working relationship, raise your hand, bob, part of the senior leadership, we actually sit on their committees. Bob is always at our meetings, the committee on competitive safeguards so there is a relationship. Importantly the ncaa is an association, National Federation, they can put out guidance. Not allstate are part of it, the states as they too but there is a trickledown effect there. And the landscape is wide open. We have representatives from usa football here but doesnt oversee the youth landscape of football. It is not even under the auspices of either of those organizations so there is a breakdown in the youth sport level. We may be talking this afternoon about the committee in 1978. They were empowered by congress to oversee all of the youth sports. The 1978 sports apps. But there was not funding for that so at the Grassroots Level there is not that double oversight and that is where i see the biggest thing. Indeed there are policy implementations and the complete breakdown at the youth level. What is important about all of that is that they are driven by the data. There are epidemiologists gathering data, each of the sports whether it is the nfl or Major League Baseball and there can be policy changes based on that at the ncaa, there is a body collecting the data that is there as well and the nhs there is the Surveillance Program and i mentioned these things because it is important to make sure these policy decisions are made based on the best Scientific Evidence and that is specific to these groups because there is going to be data present at the professional level that isnt going to be present at the college or the use or i school level however it can clearly be informative and some of the benefits from those policy changes, whether it is leadership, the conceivable way making a change where the nca tests follow suit because it is clearly safety but that is where those are. Questions from the audience. My name is lita and im a physiologists but i also worked at the National Academies of science and engineering. Thank you for sharing this data, very evidence based institution. I want to remark on the New York Times article on the university of colorado at boulders program. I was trained as an anesthesiologist and i work by the football field every morning, fantastic Sports Medicine program there. The news is interesting because two regions voted against the new football coach hire, university of colorado, because of this increasing awareness of acknowledgment of head trauma in football and we are seeing this at the national academy, widespread occurrence where leadership at the University Level are starting to be more hesitant about supporting programs. A lot of fallout which is the university of maryland who recently said he was going to resign as a result of the football investigation. I want to ask you, all of you, what you think the implications of data of these measures is going to mean for the future of football at universities, a very risky perception from university leadership. We at the National Academies are concerned with this and the state of our Research Institutions and want to make sure the integrity and missions of the universities are carried out and not by some of these institutes. Im being invited to address those but thank you for the question and it is an important issue and there is no clearcut answer. I will answer in a couple of different ways. One is we have to be data informed. What the ncaa did is we got to be partnered with the department of defense because this isnt about just football. It is as much about cheerleading for football or bicycle riding or anything and how do we really understand what is going on . Is concussion the issue we need to be addressing a repetitive head impact or Something Else . We know for example our military service men and women in afghanistan that there have been consequences of traumatic brain injury and other injuries so to try to understand this, we joined together a cooperative Research Agreement and we are studying all 24 sports in the ncaa. The largest perspective longitudinal study ever performed in history by many many faculty and we arent just looking at concussions. It is the only study in history that is comparing concussions to repetitive head impact exposure to training s an elite level. Not only that but it is the only study in history that is looking at those 3 issues and not just looking at them clinically but object objective markers. Very high risk. Womens soccer, womens lacrosse, mens football, ice hockey, mens lacrosse, mens soccer. What are those factors . Look at womens ice hockey and there is a higher rate. We need to understand all of these things and the consequences. And those high risks, accelerometer data, we are getting genetic tests. Doctor oconnor talked about potential risk factors, wiser 1999 people do not have a sicklecell problem and the risk is one in 2000. What is unique genetically . We understand there may be genetic risk factors for recovery and repetitive head impact or concussion and we are looking at blood biomarkers. What is real risks . We understand this in blood tests and for brain mri it used to be thought concussion was a functional problem but is it an anatomical issue . Now with this study we are starting to piece apart where are the risks, what are they . If you have a brain on the line that shows a change on the brain and people say you play football you have a change in the brain, theres proof it causes brain trauma, irreversible. We are starting to understand that is not irreversible. They can shift over time. We are in our fourth year, we look at 45,000 athletes from the Sports Service academy, with 30 nca member schools look at all 24 sports we gather data from 45,000 individuals and track over 4000 concussions. A large study before this. We are starting to understand what the date are telling us, we moved from phase i to face to the looking at persistent or cumulative repetitive head impact and we developed a methodology, the board of governors provided half of the funding for the next 35 years of the study. And what is unique is we are going to be studying the ncaa and the Service Academy and these 35 year plans, we are going to access the veterans medical records, and say this is about repetitive head impact or some other lifestyle and so some say you wait 35 years to make a change. From this data we made important policy changes, we are limited to is a practice in football, changed last year the kickoff rules of football because we understand most of the injuries were occurring on a single play before the end zone and the 25 but what we dont know, i will state this clearly there is a book that was just published on sports neurology, a handbook called the handbook of clinical neurology. It is externally peerreviewed. Robert stern, with the encephalopathy center, and put together a handbook. That addresses all of the issues that are implicated in the question. There is a final chapter called future directions, doctor stern and i write the following. We dont know the Natural History of concussions, we dont know neurobiological recovery, we dont understand what the disclosure means. We dont know if encephalopathy is a progressive neurodegenerative condition. We dont understand if it is specifically related to any sport. We dont know if it can happen in a general population, but we understand it is described in the general population of individuals with absolutely no exposure through any head trauma whatsoever. This is the final chapter of our book cowritten by doctor stern and myself. It is a chapter that has as many questions as it does answers. It is a chapter that says we must come to understand these issues in a scientific manner, a consensus driven manner and a manner that says we need to make policy changes when we understand the data or have come to understand there may be Something Better but we also make a difference between changes in the weather and changes in the climate. It is important to understand that. I dont have all of the answers to your question because one question right in front of us is should football be banned as a sport . We ban youth tackle football because when papers is the risk is higher for people under the age of 12. That one paper that was published in the New York Times, the authors themselves said we have to reconsider that paper so that wasnt published. The New York Times is something i wake up every morning and the first newspaper i read and go to the editorial pages because that is where i get my information but im not certain theyve got all the information correct with regards to football and encephalopathy but what they take seriously this discussion needs to happen publicly and needs to happen in a manner with everyone addressing all sides and i want to be part of that and im open to the criticism of where we need to go moving forward and i will end by saying the board of governors are ncaa says with regard to the study in this study i have no access to the data. I have no access to the publication. The head of the nih, one of the members overseeing the study and the president of Georgia Tech University bud peterson said wherever the study goes there must be ncaa. I believe we are addressing it. This group of esteemed panelists. We understand the potential risks and we understand some sports need to be looked at differently than other sports but we are all in this together and we will make some decisions. Just a brief comment. The country right how is in an department of defense by next year in 2020, less than one in 5 high schools and will be picked for military service. We have a real problem of inactivity, of concussion, sudden cardiac death, sicklecell we need to get the medical narrative right and not put fear into patients either. Iq this all the time, and context and perspective, exercise is a good thing. It is an obligation to make sure the narrative is correct. I listened carefully, 6 points, not one of them was tackle football. There were other errors that led to his death because he loved the game and that is what we need to listen to to correct those problems. My name is ken fine, an orthopedic surgeon, doctor barry bowdens are references, a lot of research, thank you for your excellent talks. One thing many of you talked about are the rule changes, guidelines to reduce injury risks. My question is something doctor bowden noted what occurred specifically are related to abusive coaching, there are some rule changes. Do you think it is realistic to purchase guidelines about training to avoid overtraining. So many coaches, and doing Dangerous Things is what they are talking about. And improve function and performance without performing. Colleagues address it as well. With regard to football coaches, it goes beyond that and irrational training. Really talking about in direct data injuries. The document i reference at the beginning has been endorsed by organizations. It is not only going to be widely disseminated. It specifically addresses the volume, the work to rest ratio, great detail in the transition period, what they elaborated on even more. Without having a punitive exercise and importantly, it is important to understand what you mean and most of these nontraumatic injuries that occurred, strength and conditioning specialists. Under the guidance of strength and conditioning, we dont use that term. And for the first time what they are reporting on should not be to the head football coach or any should be into the Sports Medicine and the diplomacy division. Not just the ncaa saying this but the medical and Scientific Organization for all the data. That is going to go to the next logical question. A separate step in the process and that also is being discussed at the National Level but my strong feeling is the policy. Many times coaches volunteering, and incredible turnover. And Education Needs to be educating for those coaches. Finding those leaders, and overtax their athletes dont hit multiple times in a week to be successful in one game where that is going. You have tremendous respect most of that time for the coach. Looking at the influence coach, couldnt be involved in medical decisions and when their athlete is injured there is value acknowledging the industry from the coaches perspective that they need to get better so it can return in a healthy state and participate. I am from the university. Two questions along the same lines. You mentioned guidelines and recommendations that dont hold a lot of weight if they are not enforced. Are there discussions around setting up possible Enforcement Mechanisms to ensure all season guidelines are followed. The second part of the question is, is the conversation moving towards state and federal legislations to prevent catastrophic injuries, where is that advocacy taking place and what role do you see the ncaa playing link everything from the youth sports through the usoc. Thank you for the question. If we look at a few things, i talked about the Association Process and the Association Process led to the diagnosis and what happens when that came out was i didnt say the ncaa was a Representative Democracy accept 65 high schools and those are the autonomy conferences and sometimes they are nicknamed the power five. Studentathlete welfare independent of the organization because they felt sometimes the concerns about infrastructure and so forth didnt allow them to move where they wanted to. And concussions, legislation which is enforceable. The rest of the division i into that. The autonomy we are going to follow that division ii. Across the entire membership, concussions safety legislation specifically refers to a checklist. And every member of the protocol is in place and must follow a there is a mechanism for enforcing that. And the autonomy five, and it would be to that. It is possible, it is an association wide politics. It is taking a giant sidestep so that is a tennis term. We talk about Mental Health best practices document endorsed by Sports Medicine, Sports Science organizations and the autonomy 5 january said every school must provide Mental Health in keeping or alignment with this best practices document and im confident that may be opted in and association wide legislation. The process is taking place and being led by the interAssociation Process and representatives from American Medical Society for Sports Medicine and the American College of cardiology are part of the process for legislative changes. I will comment a little bit about legislation and advocacy. Take a step aside and look at actual State Government legislation particularly how it relates. As you saw from my talk theres a lot of controversy in cardiac screening and that puts it mildly. There have been a couple states notably texas on several occasions to introduce legislation to mandate screening for every youth athlete. What does that mean . I dont know. That is the question. If you dont have the workforce or the understanding of what to do you create chaos and that is what the legislation screening is likely to do to create more controversy and label thousands of Young Athletes with what they dont have and that has as much powerful impact with misguided legislation. There is no training in sports cardiology. This training in neurology. There is no training in sports technology, no cardiology fellow in training confide about exercise. Its not about physiology or nutrition. There is no formal training process but a handful of people in the field of sports cardiology. I can screen every single athlete. I do think screening has a role and can be done well on the right hand dont have enough hands yet. When we talk about legislation and cardiac screening, we do more harm than good in legislative fashion. I had to write down my question. Trying to make evidence based data to support legislation, it is still concerning to know the policy recently passed with competitive safeguards. For issues of student Athletes Health and safety when we are trained my question is how can we prevent stuff like that . I missed what slipped through the cracks. Move your microphone a little bit. The football redshirt rule. Through competitive safeguards. You are talking about the legislation that extends eligibility. The response ability on staff, the safeguards right to the point of that example of the governance process. It is an important step for health and safety. The organization of that size, the legislative government process to occur but i am very comfortable in telling you we have identified a problem and we have taken procedural and policy steps to make sure it doesnt happen again. So many who i know watch what is coming out and see changes, for example the frequency of the committee so that it can be better aligned with important timelines that play into the legislative process. The association is everchanging and the role in the deliberative process even though the committee has been around for decades is different today than it was at the time five years ago. Staff, membership all have to watch, monitor in real time to make sure the gaps dont open up. I am confident in this particular case. Thank you for your time and attention. We are up against our lunch break. If you are staying with us, there is a complimentary lunch on the second floor. 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