Taking Care of Those
Who Take Care of Us
Recognition and Management of
Concussion for Law Enforcement
Training Academies: A Learning Tool
Nancy C. Burke, MS, ATC, VATL
Public Safety Athletic Trainers’ Society
Overview
Rationale
Purposes of This Educational Tool
Scope of Concussion in Law Enforcement Academies
What is a Concussion / Traumatic Brain Injury?
What happens in the Brain with Concussion / TBI?
Recognition of Concussion
Treatment of Concussion
Sideline (On-Site) Assessment
Recommendations
References
Resources
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Overview
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• Awareness for police academy personnel of the risks of
concussions in training and the need for appropriate response
and management.
• To provide information for staff training on the recognition of
signs and symptoms of head injuries.
• To outline best practices for preventing concussions in training
exercises.
• To assist institutions in the development of protocols for
response to concussion injuries, medical follow-up, injury
management and rehabilitation.
4
Rationale
5
• Law enforcement recruits take on the challenge “To Protect and
Serve” the citizens of their area.
• As a result of a variety of influences, those who break or defy
the law are becoming more violent and aggressive.
• Increasingly, police officers are attacked by violent assailants -with and without weapons.
• The risk of violent attacks makes them potentially deadly.
• For their own safety -- and to prevent a tragedy -- police
officers have to learn to defend themselves and to take control
of the offender with aggressive defensive preparation.
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• Recruits must be prepared, both mentally and physically, to
protect themselves and their weapons and then subdue violent
assailants.
• Training routinely calls for recruits to learn defensive techniques
in simulated attacks -- including how to fend off simulated
“blows” from fellow recruits, role players or instructors.
• A small mistake or unexpected movement by recruit or role
players can jar the brain and turn simulation into reality in a
matter of seconds.
• The result: Simply learning how to ward off attack can cause
life-threatening concussions.
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• With the stakes so high, careful precautions are required.
• Everyone involved in training new officers -- recruits, instructors,
role players and staff -- deserve the safest-possible learning
environment, including...
* Safe and appropriate equipment for all participants.
* Trained observers who can determine if a recruit is responding
adequately or is injured and cannot protect himself/herself.
* Onsite healthcare professional evaluate and respond to injuries.
* Staff training in concussion awareness and appropriate medical
follow-through.
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Purposes of This Educational Tool
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• To assist in planning an academy’s immediate response to
concussion.
• To assure that experienced health care professionals -- such as
certified athletic trainers with expertise in injury diagnosis and
management, or other trained medical professional – are
present during training sessions.
• To encourage follow-through with appropriate medical care by a
physician.
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Scope of Concussion
in
Law Enforcement
Academies
11
• Injuries occur during law enforcement physical and defensive
tactical training.
• Incidence and severity of brain and other injuries are difficult to
ascertain:
– There is no state, regional or national injury database for
documentation on the incidence and severity of injuries for
public safety academies.
– Knowledge of catastrophic injury is usually revealed by the
media.
– Recruits are reluctant to report injury for fear of recycle or
outright dismissal.
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Strategies to
Improve Safety
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• Insist that each training scenario has a specific purpose that is
clearly understood by all participants.
• Manage scenarios to avoid deteriorating into unrehearsed
conduct and increased injury risk.
• Assure that every training exercise has observers on hand to
protect recruits, role players and instructors.
•
Observers have the power to stop an exercise at any time.
• Make certain that everyone -- participants, observers, other
recruits -- knows they can and should take action if they think a
trainee isn’t responding normally or could be injured.
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• Develop or review emergency care plans for unexpected
catastrophic injury.
• Develop a confidential medical history tool, including
concussion episodes, for all participants and staff.
• Review training timetable to allow make-up training for recruits
who miss classes after short-term injury.
– The threat of recycle is devastating. Depending upon the
training missed and the time loss projected, develop tools to
make-up missed training.
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What is a Concussion/Traumatic
Brain Injury?
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The most common head injury in athletic activity is
concussion, an injury to the brain. Concussion may also
be referred to as “Traumatic Brain Injury.”
Intracranial hemorrhage (bleeding of the brain) is the
leading cause of brain death in sports. Making rapid
initial assessment and appropriate follow up mandatory
to prevent a catastrophic outcome .
17
What Happens in the Brain with
Concussion/TBI?
Subdural
Hematoma
Robert C. Cantu, Alisa D. Gean. Journal of
Neurotrauma. September 2010, 27(9): 1557-1564.
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Contre Coup Concussion
The brain “floats” in a liquid cushion of
cerebrospinal fluid.
Upon impact, the brain slams forward and
contacts the front (blue) of the skull.
The brain then rebounds to a second
Impact with the rear of the skull (red).
Head Injury Society
of New Zealand
Both blows cause trauma to the soft tissue
that may result in bruising, bleeding and
swelling.
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Subdural Hematoma
The bleeding of small blood
vessels in the brain causes a pool
of blood to form.
As there is no escape for the
blood, pressure from the fluid
causes a compression of the brain
tissue.
Until the bleeding stops and/or the
pressure is relieved, cells will
continue to die.
Healthtree.com
20
Second-Impact Syndrome
Second Impact Syndrome (SIS) is a result of second
concussion which occurs while the brain is still healing
from a previous concussion.
Second impact syndrome is a major cause of serious
head injuries in adult athletes. (1)
Repeated mild brain injuries occurring within a short
period (i.e., hours, days, or weeks, even months) can be
catastrophic or fatal. (3)
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SIS is a life-threatening emergency and will require surgery to
prevent further damage to brain tissue.
SIS may be preventable by removing concussed persons from
training until their symptoms have gone away and they have
been cleared by a health-care professional. (3)
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Recognition of Concussion
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Classification
No longer is there a classification of concussion as Grade 1, Grade
2, Grade 3.
New terminology for concussion is:
Simple – recovery is within 7 to 10 days.
Complex – those who are slow to recover ( > 10 days).
Second International Conference on
Concussion in Sport, 2005.
HOWEVER
Concussion recovery is dependent upon the resolution of symptoms,
not any given timeline. (8)
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A PERSON WITH A HEAD INJURY SHOULD
NEVER BE LEFT ALONE.
Symptoms may appear right away. Some may go away and
reappear once a person becomes more active -- especially
when resuming demanding physical activity.
Individuals with head injuries should be monitored for the next few
hours in case their condition deteriorates.
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Immediate concussion symptoms may include:
Disorientation
Headache
Vacant stare
Poor balance
Nausea/Vomiting
Agitation
Sensitivity to bright light
Tinnitus “ringing in the ears”
When symptoms are reported assume a concussion unless proven
otherwise.
With hits to the face, jaw, nose, eye orbit, one should suspect
concussion as a secondary injury.
26
This chart from the CDC indicates symptoms of
concussion.
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Sideline (On-Site) Assessment
Participant is removed from training and the following considerations
are made:
1. Evaluation of signs and symptoms of concussion,
2. Evaluation of mental status,
3. Determine to activate EMS or refer to physician.
These evaluations should be performed only by those who are
properly trained in the use of a sideline assessment tool.
No matter what the Sideline Assessment reveals, the participant
should be removed from training and not returned that same day.
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Sample Side-Line Assessment
Mental Status.
–
Orientation: time (within 1-2 hours, place - where are they?),
person (name a person indicated), purpose (why are they
there, what happened?)
–
Concentration: months of the year in reverse order; backward
digits (3-2-1; 4-8-1-5; 6-4-8-2)
–
Memory: recall of recent news events; details of injury event
(moves, opponent, etc).
(cont’d)
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Exertion:
–
5 push-ups; 5 sit-ups; 5 jumping jacks; 5 knee bends; sprint
(30-40 yds).
–
Purpose is to induce symptoms (loss of balance, headache,
dizziness, etc.)
Neurologic:
–
Coordination: finger-nose-finger
–
Balance: Romberg (eyes closed, feet together, arms out to
side, head back); finger-nose (eyes closed)
(Based on Sideline Assessment of Concussion
©Brain Injury Association, Inc. 1997
McCrea, Kelly Randolph)
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Treatment of Concussion
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Diagnosis of concussion and return to play decisions should be
made by licensed physicians only. Initial assessment of head injury
should only be administered by trained individuals.
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When to Refer to Physician
• When a person sustains a blow to the head, is conscious and
exhibits signs or symptoms, the decision to refer to a physician
shall be made by the onsite healthcare professional. (2)
• Monitor the individual at 5-minute intervals from the time of the
injury until the symptoms completely clear or until referred to a
physician. (2)
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• If concussion is suspected but a physician or other trained
healthcare professional is not available, the academy
instructors primary role is to ensure the person is seen by a
physician. (2)
• Anyone with a concussion should be referred to a physician on
the day of the injury if he or she lost consciousness,
experienced amnesia lasting longer than 15 minutes, or has
lingering symptoms.
• WHEN IN DOUBT, DO SOMETHING. Seek the next level of
medical care if there is any uncertainty about whether or not a
brain injury has occurred.
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Return-to-Duty:
This decision shall be made by agreement of the treating
physician and the academy onsite healthcare professional.
Individual should be gradually returned to activity to reduce the
likelihood of return of symptoms – headache and loss of
balance.
Decision Criteria:
•
Thorough clinical evaluation by treating physician or
neurologist if applicable.
•
All symptoms have resolved especially headaches and
balance/stability.
•
Neurocognitive follow-up testing if baseline test is available.
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Return – To – Play Protocol (Adapted for
Academy Training)
The current recommendation is a gradual progression of activity,
with increasing activity if the participant remains free of symptoms.
Stage 1: Light aerobic exercise: walking, swimming, stationary
cycling, heart rate to less than 70% of max; and no
resistance exercise;
Stage 2: Training related exercise, no contact, no head impact;
Stage 3: Non-contact training drills, progress to more intense and
complex;
Stage 4: Full contact work, following medical clearance, normal
training activities;
Stage 5: No restrictions. Caution about repeat head trauma. (4)
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Return – To – Play Protocol (cont’d)
If any concussion symptoms re-appear, the participant is returned to
the previous level of activity and may try to progress again after 24
hour period of rest.
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Key Considerations
1.
Those who exhibit any signs or symptoms of concussion when at
rest, or after exertion for at least 20 minutes, should be
disqualified from training on the day of the injury.
2.
Brain activity such as television, computer, video games, texting,
should be discouraged while the brain heals.
3.
More conservative waiting periods may be appropriate for those
with a history of concussion. (2)
4.
If assessment tools are not available, then a 7-day symptom-free
waiting period before returning to full training is recommended.
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The cornerstone of concussion management is:
1.
Physical and cognitive rest until symptoms resolve, and
2.
Graded program of exertion prior to medical clearance and
return to training. (4)
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Recommendations
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1. Protective headgear shall be approved by the American Society
for Testing and Materials (ASTM) for blunt impact.
2. Recruits, role players and staff shall wear a mouthguard when
participating in combative or defensive tactical training. A
custom-fit laminate mouthguard available from a dentist is
preferred.
3.
A healthcare professional trained in the recognition and
management of concussion should be onsite whenever
combative or defensive training is conducted.
4. Establish professional relationships with local physicians and
neurologists for concussion management.
41
The American Academy of Neurology in it’s October 2010 “Position
Statement on Sports Concussion” recommends:
“A certified athletic trainer should be present
at all sporting events, including practices,
athletes are at risk for concussion.” (8)
Athletic trainers are specialists in concussion assessment, cognitive
testing and management.
42
The focus of the IACP/SACOP SafeShield Project is that all officers
should go home everyday: “zero officers killed or injured.” (8)
Academy staff, recruits and role players should be an fundamental
component of this same principle.
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For more information about athletic trainers, concussion
recognition and management, contact:
Kathryn Moore, National Athletic Trainers’ Association
kathrynm@nata.org
1-800-879-6282 ex. 138
www.nata.org
Nancy Burke, MS, ATC, VATL
Nancyb@PSATSociety.com
703-629-2038
www.PSATSociety.com
Center for Disease Control
www.cdc.gov/concussion
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References
45
1.
British Journal of Sports Medicine, Head Injuries in Sport, Cantu,
R. 1996, December, 30(4): 289-296.
2.
Journal of Athletic Training, National Athletic Trainers’
Association Position Statement: Management of Sport-Related
Concussion, Guskiewicz, Bruce; S, Cantu, R; Ferrara, M; Kelly,
J; McCrea, M; Putukian, M; Valovich McLeod, T. 2004, 39(3):
280-297.
3.
University of Washington School of Medicine – Concussion,
http://uwmedicine.washington.edu/concussion
4.
Journal of Clinical NeuroScience, Consensus Statement on
Concussion in Sport – the 3rd International Conference on
Concussion in Sport, Zurich, 2008. McCrory,P; Meeuwisse, W;
Johnston, K; Dvorak, J; Aubry, M; Molloy, M; Cantu, R.
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5.
McCrory, P, Johnston, K, Meeuwisse, W., Aubry, M., Cantu, R.,
Dvorak, J. et al. “Summary and Agreement Statement of the 2nd
International Conference on Concussion in Sport; Nov. 2004,
Prague, Czech Republic.
6.
Makdissi, M., Is the Simple versus Complex Classification of
Concussion a Valid and Useful Differentiation?”. British Journal of
Sports Medicine, 2009, 43: i23-i27.
7.
SafeShield Project, www.theiacp.org.
8.
American Academy of Neurology, “Position Statement on Sports
Concussion,” October 2010 (Policy 2010-36).
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Resources
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Information:
CDC “Heads Up” online training course. Directed at youth athletes
however with good basic information.
http://www.cdc.gov/concussion/HeadsUp/online_training.html
NCAA Concussion Webinar. Reviews concussion, physician
management, athletic trainer management directed to universities, still
applicable.
http://s3.amazonaws.com/ncaa/web_video/health_and_
safety/concussion/webinar.html
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Concussions: Don't Hide It, Report It, Take Time to Recover (NCAA).
Directed at the collegiate athlete has clear implications for brain injury
for adults.
http://s3.amazonaws.com/ncaa/web_video/health_and_safety/
concussion/concussion.html.
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For training in the recognition and management of head injury
including concussion, seek out an athletic trainer.
Contact your local university, high school or the National Athletic
Trainers’ Association at: 1-800-879-6282.
Appreciation for review and critique is extended to: BJ Phillips, Philadelphia, PA; Basic Staff of the Fairfax County
Criminal Justice Academy.
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