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Thursday, July 05, 2012

How New York Fumbled the Ball on Concussion Management

Below is a copy of a letter I sent today to Deputy Commission Ken Slentz at the Office of P-12 Education at the NY State Education Department (SED). The letter concerns opposition to aspects of the Concussion Management and Awareness Act.


The letter also addresses opposition to aspects of the concussion management regulations published by the State Education Department (SED) due to concerns that the safety and well-being of children are being put at risk, despite the best of intentions. The law excludes psychologists with expertise in concussion management and evaluations (e.g., neuropsychologists) from making return to play decisions in children who have suffered concussions. The subsequent regulations do not do enough to recognize the important role that neuropsychologists play in concussion evaluation and management.

If you are as concerned as I am about this issue, parents, students, health care professionals, and others should a) forward this letter to others, b) spread the word via social media and other media sources, and c) contact Senator Kemp Hannon, Assemblywoman Catherine Nolan, and those copied at the end of this letter to voice your opposition and advocate for the amendments to the law and regulations listed below.

Historical background:

Since 7/12/10, the New York State Association of Neuropsychology (NYSAN) and other state and national psychological/neuropsychological organizations have been in contact with multiple sponsors (i.e., Senators Hannon and Stachowski, Assemblypersons Nolan and Benedetto) regarding the Concussion Management and Awareness Act. Through these contacts, we advocated for reverting to the language in an earlier draft of the bill (S07572) that specifically allowed for “a licensed health care provider trained in the evaluation and management of concussions” to make decisions about return to competitive play and physical activity after a known or suspected concussion (mild traumatic brain injury). This would have allowed for our profession to continue in this role, which helps ensure the safety and well-being of children.

Despite our repeated advocacy and educational efforts, the bill states that only physicians are allowed to make return to play decisions after concussion, thus removing part of a psychologist’s scope of practice in New York and creating unnecessary health risks for children (see below). Ironically, the profession (i.e., neuropsychology) that has contributed the most research on understanding the effects of concussions, developed the cognitive assessment tools and symptom checklists now promoted by SED, and led the way in operationally defining a mild traumatic brain injury* is now not legally permitted to pull or return athletes from play in New York after suffering a known or suspected concussion. Meanwhile, physicians whose primary area of expertise is not directly related to neurological functioning (e.g., cardiologists and pulmonologists) are performing cognitive evaluations of such patients and provide return to play clearance.

NYSAN raised the above concerns with the Governor's Office before Governor Cuomo signing the bill into law but the office was non-responsive to our concerns. Senator Hannon (sponsor of the bill) informed me (and others) before the bill was passed that psychologists might be added through an amendment but after the law was passed it is our understanding that there are no such plans at this time. It was suggested to us through Senator Hannon’s and Assemblywoman Nolan’s office that psychologists could have a role in developing the regulations that were published by SED on the practical implementation of the law.

Opposition to Aspects of Current  SED Regulations:

Dr. Dominic Carone served as the New York State neuropsychology representative to SED (by their request) regarding the development of their concussion regulations, but the feedback and edits provided about adding neuropsychology more prominently in the document were essentially ignored and removed. The edits were not intended to change the law regarding who could provide return to play clearance (which we hoped to do with an amendment) but were designed to recognize the important role of neuropsychologists in concussion management and evaluations.

In the final version of the regulations, which were not released to us before they were finalized, new language was added stating that it is a role of school nurses to provide neurocognitive baseline evaluations and similar assessments with concussion patients to aide the physician in understanding the status of the child. This was the only profession specifically singled out to perform these evaluations. While a for-profit test company may provide a certificate to various health care professions to use such tests, this does not equate to the training and education on concussion management and evaluation provided through formal education and professional training in the neurosciences. The most qualified health care providers to provide this service are neuropsychologists due to their formal education and training in cognitive assessment, neurosciences (e.g., neuropathology, neuroanatomy), statistics, emotional pathology, symptom validity assessment, and other factors that are crucial towards interpreting test scores and patient presentations.

While NYSAN agrees with many aspects of the legislation and regulations, we believe that they unintentionally place children at risk of harm due to the problems noted above. As such, Dr. Carone requested that his name be removed as an advisor to these regulations and the request was granted. Neurocognitive evaluations can easily be misinterpreted by those who do not have formal expertise in this area, causing children to be cleared to return to play too early which risks further neurological injury. Another risk, which is rarely discussed in the media but often encountered in clinical circles, is withholding players from most physical activity and/or school for excessive periods of time, resulting in emotional pathology, declining academic performance, over-medication, and development of the sick role.

Action Points:

Our organization strongly recommends an amendment to the state law and regulations to be inclusive of our profession. Legally, this means broadening the language as we originally requested to be consistent with that of so many other states. In terms of regulations, this means specifically recognizing the important role of psychology/neuropsychology in the Concussion Management Team. Please note that neuropsychologists are included on the staff of NHL and NFL teams to aide in making return to play decisions after concussion. In addition, the National Athletic Trainers' Association recommends that a neuropsychologist should ideally be part of the sports-medicine team when evaluating players who have sustained a concussion (Guskiewicz, et al. 2004).Why would New York State not afford children that same layer of safety, protection, and expertise that are afforded to professional athletes?

I have copied Senator Hannon and Assemblywoman Nolan and request a personal meeting (separately or together) to discuss ways to move forwards on an amendment process. I will be happy to discuss this information further and my contact information is listed below.

*Note: Dr. Thomas Kay, a New York neuropsychologist, was the senior contributor of the American Congress of Rehabilitation Medicine’s operational definition of mild traumatic brain injury used throughout the world today. See the attached document for more contributions of neuropsychology. 

Reference: Guskiewicz, et al. (2004). National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion.  J. Athl Train. 39: 280-297

Sincerely,
Dominic A. Carone, Ph.D., ABPP-CN
Diplomate, American Board of Clinical Neuropsychology
NYSAN Past-President

cc: Mr. Ken Slentz, Deputy Commissioner,Office of P-12 Education,NYS Education Department, 2M West EB,89 Washington Avenue,Albany, NY 12234
The Honorable Senator Kemp Hannon, The Capitol Room 420, Albany, NY 12247
The Honorable Assemblywoman Catherine Nolan, 836 Legislative Office Building, Albany, NY 12248
Doug Lentivech, Esq., Deputy Commissioner, Office of the Professions, New York State Education Department, 89 Washington Avenue, Albany, NY, 12234

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