April 24, 20131 Maryland State Board of Education Lillian M. Lowery Ed.D.

Superintendent Maryland State Department of Education 200 West Baltimore Street Baltimore, MD 21201 Re: MSDE Concussion Task Force Report: Recommended Forms Dear Dr. Lowery and Members of the Maryland State Board of Education, I am from Montgomery County, Maryland and am the parent of two high school students involved in sports. I appreciate the effort reflected in January 22, 2013 report of the Maryland State Department of Education (MSDE) Concussion Task Force2 and in the decision by the Maryland State Board of Education (State Board) to propose a permanent regulation based on the emergency concussion regulation adopted in July 2012.3 I am concerned, however, by Recommendation number 3 in the Task Forces report regarding forms that school systems are required to use for: (1) notifying parents when a sports concussion is suspected; and (2) documenting a physicians or other healthcare providers clearance for a symptom-free student to begin the gradual return-to-play steps. The Task Force recommended deleting the notification form adopted in 2011 without recommending a replacement form. The Task Force also recommended that the medical clearance form, also adopted in 2011, be modified in a way that removes important elements. The Maryland Public Secondary School Athletics Association (MPSSAA) implemented this recommendation in December 2012 and has deleted the notification form and substituted the medical clearance form on its website. The recommendation regarding forms conflicts with other recommendations by the Task Force so it is likely that the recommendation was an oversight that resulted from the tight time deadlines under which the task force was asked to complete its report.

1 2

This letter replaces a substantially similar letter submitted on April 22, 2012.

http://www.scribd.com/doc/132212487/01-22-2013-Md-St-Dept-of-EdConcussionTaskForceReport
3

http://www.scribd.com/doc/132212955/Md-State-Bd-of-Ed-Proposed-Sports-ConcussionRegulation-Comments-Due-04-22-2013

I respectfully request that Dr. Lowery instruct MSDE staff to restore the 2011 forms to include the previous two forms pending final action by the State Board, after consideration of this and other public comment. When the proposed concussion regulation is adopted in final form, I recommend that the forms be included as appendices to the regulation. I also request that the State Board incorporate into its final regulation a requirement that return to play be conditioned on a full return to academic life, that is, on a return to learn, and direct staff to include return-to-learn in the form used to document clearance for return-to-play. Background While high school sports can generate many benefits, they represents the schoolsponsored activity that poses the most serious risk of personal injury to students while being the one that is most remote from the school systems sole purpose of academic education. One injury common in high school sports is a concussion. Data about the incidents of sports concussion throughout Maryland public high schools does not appear to be available. Howard County Public Schools, however, collects such data and reported for 261 sports concussions for the 2012 school year.4 The Massachusetts Department of Health asks high school students as part of its 2011 biennial Youth Health Survey whether they have ever had a blow to the head playing high school sports that resulted in a headache, nausea, dizziness. In response, 21 percent of Massachusetts students surveyed answered yes to questions posed about "blows to the head" with concussion-like symptoms. While the popular conception is that 80 percent of concussions resolve completely within two 2 weeks, recent studies using functional imaging indicate that a student can experience altered brain functions for months after the student no longer has symptoms.5 And a students recovery can be further delayed if they get a second trauma to the brain before fully recovering from the first one.

http://www.scribd.com/doc/124077961/Howard-County-Md-Public-Schools-Athletic-Director-AnnualReport-to-Bd-of-Ed-Re-High-School-Sports-Program-p-15-Concussion-Stats-by-Sport-p-1 at p. 15.
5

http://www.purdue.edu/newsroom/research/2012/120202NaumanFootball.html (Functional imaging (fMRI) showing altered brain function in high school football players lasting after symptoms have resolved.); http://blogs.edweek.org/edweek/schooled_in_sports/2012/12/concussions_alter_childrens_brains_ for_months_after_injury_study_finds.html (University of New Mexico study showing brain changes in children with concussions lasting months after a child reports being symptom-free.).

Forms Play an Important Role in Managing Sports Concussions So it is important that school systems establish strong policies and procedures to follow when a concussion is suspected and when allowing a student who has had a concussion to return to play. An important element of strong policies and procedures is a strong recordkeeping system under which important milestones are documented. Standardized forms play an essential role in recordkeeping. Just as important, forms provide important information to students, parents, and even health care providers about concussions at a critical juncture: when a student is suspected of having one. Forms are particularly important for Maryland school systems that dont have athletic trainers on staff at their high schools.6 In those schools, students and families go it alone, and forms with good health information content can reduce the knowledge gap at schools without athletic trainers. The 2011 Concussion Forms In August 2011, MSDE adopted forms for school systems to use to document sports concussion as part of its Policies and Programs on Concussions for Public Schools and Youth Sports Programs (MSDE Concussion Policies and Programs Document).7 The document was developed by the Concussion Review Committee set up by MSDE and MPSSAA in the wake of Maryland enacting a sports concussion statute in May 2011. The document included recommendations for coaches training, parent and student awareness, and removal from play/return to play procedures. The 2011 MSDE Concussion Policies and Programs Document also included two recommended forms: one for notifying parents when their child is suspected of having sustained a concussion and for documenting the initial diagnosis by a health care professional (2011 Notification Form).8 The other form was for documenting a physicians or other healthcare providers clearance of a recovered student to begin the 5stage gradual return to play protocols before being cleared for return to full contact athletics (2011 Medical Clearance Form).9 The August 2011 MSDE Concussion Policies and Programs Document also included charts for documenting a students progression through each of the five stages of the
6

http://www.scribd.com/doc/120598273/Map-Athletic-Trainers-at-Maryland-Public-High-Schools

7 http://www.scribd.com/doc/94516532/MSDEPoliciesProgramsConcussions2011-2-3 8

http://www.scribd.com/doc/127338994/Maryland-High-School-Notification-of-Probable-HeadInjury-MPSSAA-August-2011
9

http://www.scribd.com/doc/127339303/Maryland-High-School-Medical-Clearance-for-GradualRTP-MPSSAA-August-2011

students gradual return to play, with customized charts for students returning to football and soccer (2011 Gradual Return-to-Play Charts). The 2011forms had previously been developed by Gerry Gioia, PhD, a member of the 2011 Review Committee and the 2012 Task Forces, in conjunction with athletic trainers and Mike Williams, the athletics director for Howard County Public Schools. Dr. Gioia directs the sports concussion clinic at Childrens National Medical Center in Washington D.C. and has developed similar forms under a grant from the CDC that are used in Fairfax County, Virginia and elsewhere for documenting concussions. Forms similar to the 2011 forms had been in use in school systems in Howard and Carroll Counties, Maryland, and elsewhere since 2008. The Recommendation Forms The Task Forces recommended forms are located at Exhibit G of the Task Forces January 22, 2013 Report and are attached and at the link at this footnote.10 While it is commendable that the Task Force looked for ways to make existing forms more useful, the recommended forms represent a troubling step backwards. No Parent Notification Form Significantly, MPSSAA has removed the 2011 Notification Form and has not included any new form for notifying parents when a concussion is suspected. The 2011 Notification Form documented the symptoms that cause the suspicion of a concussion and other related details. The 2011 Notification Form also provided parents with a list of symptoms to expect and to watch out for if their childs condition deteriorates. Contact information with school personnel was also included. Importantly, the 2011 Notification Form urged parents to seek a physicians care, urgently if certain symptoms emerge. The form also underscored that blows to the head can also cause other serious injuries such as a neck injury and a brain bleed. Finally, the 2011 Notification Form indicated that it should be shared with the school nurse and athletic director. Documenting injuries and maintaining written records of them is a critical aspect of managing sports concussions and other injuries. MPSSAA has removed this 2011 Notification Form from the 2011 MSDE Concussion Policies and Programs document at its website and has not replaced it. The Task Force action seems to conflict with the Task Forces recommendation that a local school system provide parents with a written notice as well as an oral notice when a concussion is suspected.

10

http://www.scribd.com/doc/127525600/Md-Concussion-Task-Force-2013-Recommended-NewForms

It may be that the Task Force intended a coach to give a parent the medical clearance form at the time of the concussion is suspected and that this would satisfy written notification requirement that the Task Force proposed. The medical clearance form, however, does not contain any of the essential information in the 2011 Notification Form, except the fact that an injury has happened. New Combined Clearance Form The Task Force recommends abandoning the 2011 Medical Clearance Form in favor of the clearance form for documenting medical clearance for gradual return to play be updated as reflected at Appendix G of its report. The recommended form combines the initial medical evaluation for a concussion (which was previously located on the 2011 Notification Form) with the medical clearance to begin gradual return to play steps. Unlike the previous form, the initial evaluation part of the new form does not orient the health care professional to check for other injuries that can occur when a concussion is suspected or to document the evaluation for these other injuries. The 2011 Medical Clearance Form provided a checklist for a health care professional to document the basis for clearing a student to begin the 5-stage gradual return to play:11 1. No symptoms at rest/no medication use to manage symptoms (e.g., headaches) 2. No return of symptoms with typical physical and cognitive activities of daily living 3. Neurocognitive functioning at typical baseline 4. Normal balance and coordination 5. No other neurological/medical/complaints/findings The new Form at Appendix G provides no such checklist. It appears to be assumed that the form will always be in the hands of a physician or other healthcare provider who is highly familiar with the management and treatment of sports concussions. As Task Force member Gary Dix, M.D., an Anne Arundel County neurosurgeon, explained to the State Board at the January 22, 2013 meeting, there are too many troubling anecdotes of physicians and other health professionals being unaware of the best practices reflected in the previous clearance form. The recommended clearance form indicates that the initial diagnosis and the clearance for gradual return to play may be performed by a physician, a physician assistant, an athletic trainer, a nurse practitioner, or a psychologist trained in neuropsychologist. As explained in a separate comment letter, the State Board should leave to the relevant health occupation oversight boards the issue of which licensed health care provider is authorized to provide medical clearance for a student to return to play after sustaining a concussion.

11

http://www.scribd.com/doc/127339303/Maryland-High-School-Medical-Clearance-for-GradualRTP-MPSSAA-August-2011

New Gradual Return to Play Chart The 2011 Gradual Return to Play Charts provided a way to document a students progression through the 5 stages of gradual return-to-play, with sport-specific charts for football and soccer. While it is useful to get the gradual return to play steps on one page, the chart (at page 50 of the Task Forces Report) would be more useful if it contained lines for the students name, dates of each step, and the name of the person who is supervising the gradual steps. The charts attached to the 2011 MSDE Concussion Policies and Programs Document were organized in this fashion and should be maintained. Return-to-Play Only After Return-to-Learn It is important that the clearance forms incorporate the recommendation of the 2012 Zurich Consensus Statement on Sports Concussions that no student return to play until after he or she has returned to full academic participation. It was agreed by the panel that no return to sport activity should occur until the child/adolescent athlete has managed to return to school successfully.12 A full return-to-learn, without the need for any accommodations, would appear to be relevant to a physicians diagnosis of whether the student who no longer reports concussion symptoms has, in fact, recovered from the concussion. The 2011 clearance form addressed this issue, albeit indirectly, by including in the checklist for beginning GRTP a requirement that a student have no return of symptoms with typical physical and cognitive activities of daily living. The return-to-learn prerequisite needs to be included so that a school official certifies that the student has returned to full academic participation and no longer needs academic accommodations to do so. An excellent resource for managing return-to-learn has been developed in neighboring Pennsylvania. I encourage the State Board and Dr. Lowery to ask MSDE to review the BrainSTEPS program. http://www.brainsteps.net/_orbs/about/index.aspx BrainSTEPS was developed in 1997 by the Brain Injury Association of Pennsylvania, through funding from the Pennsylvania Department of Educations Bureau of Special Education, and the Pennsylvania Department of Health. Conclusion While the MPSSAA has already added the new concussion forms to its website, to date, it does not appear that any Maryland school system has adopted them. All Maryland
12

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 http://bjsm.bmj.com/content/47/5/250.full

school systems, except Montgomery County, use the 2011 forms, and none appears to have moved to abandon them despite the Task Forces recommendation.13 The State Board charged the Task Force with continuing to work on remaining issues. I strongly urge you to ask the Task Force to include in its unfinished business evaluating the 2011 concussion forms for improvement. For example, the Task Force reviewed the form recommended by the Utah High School Athletics Association, which achieves many of the same ends as the MPSSAA August 2011 forms, but with a different layout.14 The Task Force should evaluate when it should recommend this form or borrow from it to update the 2011 MPSSAA form. In the meantime, I respectfully request that MPSSAA restore the 2011 forms to the 2011 MSDE Concussion Policies and Programs Document at its website until the State Board takes further action regarding the forms. Thank you for your attention to this important public health issue. Sincerely, /s/ Tom Hearn

cc: Edward Sparks, Executive Director of MSDE Athletics /Executive Director, Maryland Public Secondary School Athletics Association (MPSSAA), Co-Chair of the MSDE Concussion Task Force Alicia Mezu, MSDE Health Service Specialist, Co-Chair of the MSDE Concussion Task Force

13

http://www.scribd.com/doc/120603284/Map-of-Maryland-Counties-Where-Public-SchoolSystems-Use-Concussion-Forms-Recommended-by-MSDE-and-MPSSAA
14

http://www.scribd.com/doc/127339653/Utah-High-Sch-Ath-Ass-n-Concussion-Release-Form