Testimony on House Bill 2038
House Public Health
By: Theodore Spinks, MD
March 30, 2011
Chair Kolkhorst and members of the committee, I am Dr. Theodore Spinks, a pediatric neurosurgeon here in Austin and co-director of the Dell Children’s/Seton Hospitals Concussion Program. I am speaking “on” House Bill 2038 on behalf of the Texas Medical Assocation, the Texas Pediatric Society, and the Texas Academy of Family Physicians. Together our organizations represent nearly 48,000 physicians and medical students in our state. I also serve on the TMA Ad Hoc Comitttee on Student Athlete Concussions, which has reviewed this and other concussion-related proposals.
While we are unable to support the current version of the legislation, we would like to thank Representative Four Price for addressing a serious health concern facing Texas’ young athletes and their families in HB 2038. Even with the current media focus on concussions, they are still underreported and often unrecognized. Concussions often do not produce dramatic symptoms such as a loss of consciousness. They may be easily missed by someone untrained in their recognition, including the athletes themselves. Unfortunately, a concussion sensitizes the brain to repeat injury. An athlete who is symptomatic from a concussion can be reinjured by seemingly minor insults. These reinjuries can severely worsen or prolong symptoms, and can even put the student at risk for rapid brain swelling and sudden death. Researchers are also now finding there are long-lasting effects of concussion as well as cumulative effects of multiple concussions. In addition, newer studies have shown that younger patients may recover from concussions more slowly than adults. This means Texans in our middle and high schools are particularly vulnerable. Because their brains are still developing, they need to be carefully managed as they return to sports and to school.
The most authoritative consensus statement on concussion management is developed by a panel of international experts, and it is revised every few years. The panel currently recommends a multidisciplinary treatment team that develops individualized return-to-play and return-to-school guidelines for each patient. HB 2038 was clearly written with this plan in mind, and for that reason, it is laudable for promoting state-of-the-art management over older, “rule-of-thumb” type guidelines. However, our understanding of concussions is still evolving, and has changed markedly over the past several years. Because of this, one of the greatest challenges at the state level is to create a system that is flexible enough to incorporate new scientific guidelines as they develop. Thus, placing anything in statute on this situation is concerning to physicians.
The Texas University Interscholastic League’s (UIL’s) Medical Advisory Committee has developed a new policy for the next school year that is appropropiate and contains solid strategies for managing concussion risk and treatment among student athletes. Additionally, we know the UIL committee includes strong sports medicine expertise. The committee also has demonstrated a commitment to implementing solid, evidence-based recommendations. This UIL committee is well-positioned to react to new scientific evidence, and appropriately and expediently change its recommendations to achieve the best care for our young athletes. We pledge to continue working with UIL and its Medical Advisory Committee during the interim to identify issues and solutions.
Because of the seriousness and frequency of these head injuries, we appreciate the attempt at a comprehensive approach to concussion management laid out in HB 2038. We strongly support the inclusion of an education component and language to ensure to adequate concussion training is available. Athletes, parents, coaches, school staff, and health care professionals all must be part of the strategy that includes training and education about concusssions, recognition and assessment on the field, referral to a physician or delegate, and proper management of the concussion. This comprehensive approach helps ensure that there is a standard across all school districts, and that each young athlete is equally protected. The cornerstone of this approach is education. It is unclear, however, that a continuing education requirement should be codified in law. TMA opposes specific, legislatively mandated continuing medical education. These educational guidelines might best be left to UIL as part of its concussion management recommendations. A requirement for UIL to develop and offer education to members of the concussion management teams may be a better option. It still would ensure that the physicians and other health care providers involved be kept abreast of this evolving field.
We would also like to remind the committee that a concussion can be caused by a jolt or shake, and not necessarily an impact. The altered mental state could be in the form of physical, cognitive, emotional, or sleep-related symptoms. A concussion may or may not result in loss of consciousness. TMA suggests this definition of “concussion: “Concussion means a complex pathophysiological process affecting the brain, which may include temporary or prolonged altered brain function, that is caused by a traumatic physical force or jolt to the head or body and that results in physical, cognitive, emotional, or sleep-related symptoms and may or may not involve loss of consciousness.” This language is similar to what UIL uses in its recommendations, and it is derived directly from the most current consensus statement on concussion management.
Another concern is that the proposed legislation allows only a coach, athletic trainer, or physician to remove a student from a game for a suspected concussion. If the physician is not present at the practice or game, and there is not an athletic trainer on staff, the only person who can remove the student from the game is the coach. Parents, teachers, or other school staff present should also be encouraged to point out possible concussion incidents and get athletes the appropriate evaluation. Again, this underscores the importance of appropriate education of all these involved parties.
Many physicians who are working with school districts and athletic programs are doing so in a voluntary capacity. Because of this, we have asked for additional liability protection for them and acknowledgment through a consent form by affected families.
We know that sports activities add to the quality of life in our communities, and we certainly applaud the engagement of more students in physical activity. Thus we must be wary of erecting policies that school districts cannot meet nor maintain. We appreciate Representative Price’s commitment to protecting student athletes, and we look forward to working with all parties involved to help ensure our student athletes can continue to safely participate in healthy competition.
82nd Texas Legislature Testimonies