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  1. #1
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    Exclamation Second Impact Syndrome & Return to Play

    Here's an excerpt from a NC television news report (WRAL) regarding the deaths of 3 high school football players, just in the last couple of months. This is what so many here on the forum have discussed regarding rider injuries so I thought you might be interested to read it:

    CHAPEL HILL, N.C. — A panel of sports medicine experts said Thursday that any high school athlete suspected of suffering a concussion must be cleared by a physician before he or she can play or practice. The moves come in the wake of the recent deaths of three North Carolina high school football players, two of whom died from head injuries. "We need to err on the side of caution. Keep them out. Get them referred to a physician," said Dr. Kevin Guskiewicz, chairman of the Department of Exercise and Sport Science at the University of North Carolina-Chapel Hill and a committee member.
    The committee received reports outlining the deaths of Atlas Fraley, 17, of Chapel Hill High School, Juquan Waller, 17, of J.H. Rose High School in Greenville, and Matt Gfeller, 15, of Reynolds High School in Winston-Salem.
    Waller, a junior running back, left the field after being tackled in a game and then collapsed on the sideline. He was taken to Pitt Memorial Hospital, where he was placed on life support. He died on Sept. 20. He had been hit in practice two days before the game and suffered a mild concussion, and a medical examiner determined the cause of death to be "second-impact syndrome," where a person receives two or more blows to the head in a short period.
    Gfeller died Aug. 24, two days after a hit that he took in a game against Greensboro Page High School led to cranial bleeding.
    The committee's recommendation requiring written permission from a physician before a player can resume practice and game play after suffering a suspected concussion is effective immediately, members said.



  2. #2
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    Excellent.

    Reed



  3. #3
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    Thanks for posting this!

    The USEF/USEA really needs to come up with a responsible return-to-play policy. IMO, we need more than simply 'cleared by a physician.'

    So sad to hear about these kids. No one wants to see a young life end like this.



  4. #4
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    Horrible. Those poor kids.

    Doesn't mean diddly to the rider being discussed here recently. He had doctors that "cleared" him. Still it's nice to see the topic being addressed and perhaps there will be more robust guidelines with actual "teeth" to come out of these tragedies.
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  5. #5
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    Second impact syndrome has long been established and is on the fore front of the minds of every Athletic Trainer and Sport Physical Therapists who make return to play decisions. The NCAA has strict guidelines about return to play after concussions based on severity and frequency of injury. These could be easily implemented in the eventing world. The NHL has also developed guidelines and the NFL is on track as well.
    The difference here is these athletes are under the constant supervision of medical professionals and are required to pass a baseline physical in order to begin the season.
    There is a 6 month set down period after the resolution of symptoms (that means no headache, confusions, memory loss ect) before an athlete can return to contact sports. It's not unreasonable for a rider to have to wait a minimum of 6 months after symptom resolution before return to what is essentially a contact sport.
    I have suggested this to the USEA but have yet to get a response. I wonder if Medical Mike has any thoughts???
    It takes a good deal of physical courage to ride a horse. This, however, I have. I get it at about forty cents a flask, and take it as required. ~Stephen Leacock



  6. #6
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    Default More research

    Hey, I'm finally able to post again!

    There was a great article in this Monday's Boston Globe about "back to play" evaluations. Apparently, an increasing number of high school and college athletes are undergoing a mental skills evaluation proactively. The test is described as resembling a simple video game, but involves short term memory, pattern recognition and speed of reaction. I think it's called IMPACT.

    If an athlete suffers anything that might be construed as a brain injury, they have to take the test and achieve a score comparable to their pre-injury test before they can be cleared to return to play. While the cost was not specified, they noted that for a fairly large local high school, the parents' sports club had donated the $1500 or so it was going to cost to do the baseline test for the school's athletes.

    It was also noted that studies are beginning to show that brain injuries in high school students have much more severe effects than in college students, and that cumulative injuries are the worst.

    I don't know if you have reviewed any of this Reed. I wonder if any of it can be applied to eventing?
    They don't call me frugal for nothing.
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  7. #7
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    Quote Originally Posted by frugalannie View Post
    I don't know if you have reviewed any of this Reed. I wonder if any of it can be applied to eventing?
    blackwly, is really the expert in this area. JER, deltawave and Medical Mike are probable are probably the better person to comment on this from the medical POV. I'm just a bone geek.

    There would be no way to proactively develop a baseline test. WE ALL ARE CRAZY, would be the baseline.

    silverpine, keep bringing it up! Many of us have hammered on your very same points to the USEA and USEF before. It is possible the but the glacier of governance could be moving. We just need to keep pushing.

    While many of us grew up riding without helmets, breaking young horses and chasing stone walls 4' tall, the rules of competition must protect the youngest and lowest levels. RTP policies would force various entities to act like the mentors and role models they claim to be, and would engender a culture of consideration and safety throughout the sport.

    No, we should not coddle folks when the fall off. Hell, my 70 year old mother still falls in the hunters and gets right back on, thus I have NO excuses. But a rider's toughness can be TEMPERED with considered thought and insight gained through observation of the actions of top riders.

    The new method of data collection in the USEF and USEA has to be utilized and followed to find out if what a minor head bump resulted in death or impairment but was never reported because the competitor left the show grounds. The cases presented are terribly sad but can serve as excellent examples to the gatekeepers that they manage a sport and can not abdicate responsible and reasoned safety efforts.
    Reed



  8. #8
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    Would it be possible for there to be a list of riders available to organizers/secretaries of riders with previous injuries? Kind of like the "watch list" they're proposing for dangerous riding that will be distributed to TDs. The way I see it working would be: If a rider falls at Event #1 and the EMTs look at rider and determine head injury (even if it's mild), they could submit their name to this list. Then at Event #2, when the rider goes to check in, the secretary can hold their packet until the rider shows them a doctor's notice that was obtained clearing the rider to compete.

    Just an idea ...
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  9. #9
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    Quote Originally Posted by mythical84 View Post
    Would it be possible for there to be a list of riders available to organizers/secretaries of riders with previous injuries? Kind of like the "watch list" they're proposing for dangerous riding that will be distributed to TDs. The way I see it working would be: If a rider falls at Event #1 and the EMTs look at rider and determine head injury (even if it's mild), they could submit their name to this list. Then at Event #2, when the rider goes to check in, the secretary can hold their packet until the rider shows them a doctor's notice that was obtained clearing the rider to compete.

    Just an idea ...
    It is a good idea but that gets into the difficulty of HIPPA. The diagnosis of the rider at Event #1 becomes part of the medical record that can not be made public. Given the EMT's can not diagnose the rider will need to be seen by a doctor before a definitive answer can be given. This then can not be given out.

    You can say that any rider with a fall, regardless, needs a doctor's note. Or, the USEA/USEF can have various doctors assigned to over see clearing riders. Similar to team doctors in the major sports.



  10. #10
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    The ImPACT Test group has a good website with lots of links and info. The front page has recent news items, like the Globe article frugalannie referred to.

    ImPACT website

    I also want to add that the return-to-play policies in major concussion sports leagues like the NFL and NHL are not particularly good. The NFL had a policy that was implemented last year -- but this came after the NFL commissioned some marvelous 'studies', like the one that said it was usually ok for a player to return to the game in which he was injured. The NHL and its view of head injuries is best illustrated by this knock-out two-part series in the Dec 07 Toronto Star: "Hockey Concussions Take a Toll" Part 1 Part 2

    (Don't miss the Star's sidebars and videos -- good stuff there.)

    IIRC, both the NHL and NFL put too much weight on whether the player was unconscious. This is not the most significant criteria for a TBI. Any kind of amnesia (anterograde or retrograde) is more important.

    Finally, I think this program -- in which elite athletes are donating their brains to science -- is very interesting. Any riders want to sign up?



  11. #11
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    Quote Originally Posted by JER View Post

    ...

    IIRC, both the NHL and NFL put too much weight on whether the player was unconscious. This is not the most significant criteria for a TBI. Any kind of amnesia (anterograde or retrograde) is more important.

    ....

    Well, yeah! Players are commodiites and resources. They lose value if they sit off the morket for extended periods. Forget protecting the player. Protect the income!

    It is funny to note that the powers that be in the NHL sound a lot like certain "safety" people in eventing. I wonder if any realize how idiotic they sound?

    Reed



  12. #12
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    Quote Originally Posted by RAyers View Post
    It is funny to note that the powers that be in the NHL sound a lot like certain "safety" people in eventing. I wonder if any realize how idiotic they sound?
    Nope. The problem is, they're only listening to their own voices. It's hard to recognize idiocy in a vacuum.

    This is why eventing needs to be looking outward, not just inward, for safety solutions.



  13. #13
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    Default NCAA

    NHL and NFL are dealing with issues similar to workers comp when injuries occur, not to mention there are contract to consider from the players point of view. It's not the best incentive to be honest about your symptoms.
    The NCAA have much more stringent guidelines. The table in the article below outlines some current return to play based on a number of factors.

    http://www.aafp.org/afp/990901ap/887.html

    Eventing has trouble here because there is no regulation of participants (no MD clearance required) and no system in place to determine if an individual has meet the criteria. I think at the lower levels implementing something like this would be next to impossible but at the upper levels where the numbers are much fewer it might be feasible.

    I'm off to take Reed's advice and petition the USEA once again.
    It takes a good deal of physical courage to ride a horse. This, however, I have. I get it at about forty cents a flask, and take it as required. ~Stephen Leacock



  14. #14
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    Quote Originally Posted by RAyers View Post
    It is a good idea but that gets into the difficulty of HIPPA. The diagnosis of the rider at Event #1 becomes part of the medical record that can not be made public. Given the EMT's can not diagnose the rider will need to be seen by a doctor before a definitive answer can be given. This then can not be given out.
    .
    I will admit I have not looked closely at HIPPA recently but I cannot imagine that it does not permit the patient/subject to waive privacy of certain information- thus if USEA requires you to do this in order to play, HIPPA should not come into play.

    we don't have to look to other sports for return to play rules- BE has them. I believe if you want to return to competing in less than some designated period of time after a head injury at an event, you have to pass a set of cognitive tests meant to assess brain injury (don't think it is IMPACT because I don't think there needs to be a baseline test to compare it to but I could be wrong, my knowledge on the Brit requirements is a bit sketchy)
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  15. #15
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    HIPAA, not HIPPA. Pet peeve. Sorry. Back under my rock.
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  16. #16
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    I've been really busy with a bunch of things, but I have begun to compile a list of the basic threads and I have posted them onto the "threads & posts" page of the "Eventing Going Forward" web site (egf.black-forest-design.net/). I wil be adding this thread to the threads page.

    I also will be adding the USEA new rules page link.

    I am slow.

    Deltawave, nice to see you came out from under your rock.

    Frugalannie, glad to see you're back. I will be adding your summary for the Darren thread to the web site fairly soon. I have it on disk.



  17. #17
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    Default from the sports medicine sideline side.....

    My comment at the safety summit was "I do not think that ImPact testing is a good solution. The mechanical coordination and skills required to ride a horse, IMO far outweigh the "thinking" that must go on when navigating a course. Football players are not "smart", but are movement geniuses'. A better estimation of their "normalicy" involves as much physical testing as mental testing."

    JER, ....."NFL put too much weight on whether the player was unconscious". Maybe in years past, but not now. The NATA guidelines are pretty much the standard teams use.

    Granted there are exceptional cases, but the vast majority do follow updated guidelines.

    As for Second Impact Syndrome as an entity......There is some feeling that folks with this condition have a genetic disposition to it. There is something that makes these folks susceptible to trauma and subsequent bleeding from the lesser blow.

    As for organizing it, while I see it being problematic on paper, I do not think it would be that difficult to do even with regards to hipaa.
    The interpretation I have been given to work by states that any individual involved in the immediate care/supervision process following an injury can know what the injury is/might be.

    I see no difference here.

    Goes back to another point from the conference....Everyone knows who the athletes are that have sponsorship and show up. In any other sport you can name, the sponsors know EVERYTHING about that athlete. If there is a question of their ability to perform, they are replaced. Yes, I am aware of the horse being the X-factor.

    Don't care. Start at the top, let anyone get some performance parameters on these folks, then it would be easy to make decisions in cases such as this.

    Regards,
    Medical Mike
    equestrian medical researcher
    www.fitfocusedforward.us



  18. #18
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    Quote Originally Posted by medical mike View Post
    As for Second Impact Syndrome as an entity......There is some feeling that folks with this condition have a genetic disposition to it. There is something that makes these folks susceptible to trauma and subsequent bleeding from the lesser blow.
    But what about this?
    A University of North Carolina study reported in 2005 that retired NFL players faced a 37 per cent higher risk of Alzheimer's than similarly aged U.S. males. It also found repeated concussions significantly raised the chance they'd suffer dementias such as mild cognitive impairment later in life.
    (from Toronto Star article on NHL and concussions)

    Quote Originally Posted by medical mike View Post
    Start at the top, let anyone get some performance parameters on these folks, then it would be easy to make decisions in cases such as this.
    Which suggests to me that ImPACT testing might be a good place to start as it is an existing system. A research grant to do a pilot program for riders would probably be a good idea. And really, there's no reason why the eventing safety big guns can't sit down and talk with motorsport orgs like F1 and IRL to ask about their experiences with ImPACT as riders and drivers do have a few things in common.



  19. #19
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    Cognitive abilities are vastly more important in the big picture, especially for non-professional athletes, than the fine-tuned skills required to complete a challenging athletic task. If the cognitive "stuff" is NQR after a head injury, that will be a far bigger handicap to the athlete in the future.

    It's not just about getting back in the saddle or on the field.

    However, I also think that some sort of motor skills testing is reasonable, too.
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  20. #20
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    F1 is geting more careful, depending on how serious the impact was, they will suspend drivers.
    There were several drivers in the last 5 years that had sever impacts, some of them lost form, never came back to pre impact, most notably Ralf Schumacher, after his huge accident at Indi. He never regained his pre accident form.
    His brother Michael had a accident in Silverstone/GB, several years ago, broke a leg and did not come back for the rest of the season, because he did not feel right, he was laughed at, but I guess that guy had real good Docs and was smart enough to listen and when he came back he was good enough for 5 or so World Championships.
    That guy the FEI, USEF has to talk to
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