CHAPTER 7
Prevention and Training
This book would not be complete without a chapter devoted to school-based concussion prevention efforts. These may include initiatives such as safety measures, sessions to train student athletes to recognize signs of concussion in teammates, and strategies for disseminating concussion information to school staff, families, and community members.
Engaging in sports and recreational activities has innumerable benefits for youth and it is not reasonable to expect we could prevent all brain injuries. However, some basic safety guidelines can make a significant impact in preventing them.
SCHOOL-BASED CONCUSSION PREVENTION PROGRAMS
Safety Measures
School personnel can conduct regular safety reviews of play areas, including both playgrounds and sporting areas. This includes making sure there is a soft surface to cushion falls under playground equipment, that there are railings around bleachers, and that the playing fields are well maintained. The physical space of the school should also be evaluated: Are there crosswalks to ensure safety of students who walk to school? Are there signs that indicate when floors are wet to prevent falls?
It is also important to provide adequate staffing to monitor recess and sporting events. These individuals must be trained not only in concussion recognition and response, but also in strategies for diffusing fights, managing risk-taking behaviors, and summoning help when needed. Officials monitoring youth sports need to call penalties when players break the rules. Otherwise, players will believe they can aggressively go after other players, executing moves that can endanger their opponents.
Both in recreational activities and in sports, there should be guidelines and enforcement of rules. Techniques used in sports should be age appropriate. For example, body checking is prohibited in many primary-age youth sports organizations. In sports that do allow physical contact, players should be proactively instructed in safe body alignment and techniques. They should also be encouraged to increase their awareness of what is going on around them, which can help reduce unexpected body hits that can cause concussions.
Some youth sports organizations have a “hit count,” which is a limit to the number of head contacts a player experiences over a given time period. While such a policy makes good intuitive sense, it is also an example of a safety measure that still needs more scientific study to clarify its validity as a policy or recommendation.
Physical education programs should include lessons that emphasize safety, including the need for safety equipment, the correct use of such equipment, and rules of play. A director of physical education should provide leadership in class instruction, competition, and activities that are part of the school physical education (PE) program and ensure that safety measures are followed during such classes.
There are also recommendations for safety measures that are not currently required in a number of youth sports. Such reforms recommended by Dr. Robert Cantu, author of the 2012 book Concussion and Our Kids include:
No tackle football before age 14
No body checking in youth hockey before age 14
No heading in soccer until age 14
For youth baseball, require chin straps and restrict head-first slides
The age of 14 is not necessarily a “magical” age, but it is used for a few reasons. By age 14, a child’s neck is stronger and the body is better able to keep the head steady during a body slam. The brain is also more mature; the fatty myelin coating on the nerves in the brain more effectively protect it from damage. At the age of 14, youth are also better able to make decisions for themselves related to what sports they want to play and what risks they want to take.
Safety measures can also be put in place related to the amount of contact expected during practice drills, as many concussions are sustained not only in competitive games, but during practices and scrimmages.
Carly
In reviewing their playground safety measures, Carly’s school administrators found some areas for improvement. While everyone agreed that free play time—including climbing on age-appropriate equipment—was important, they determined that a softer surface needed to be installed below the climbing equipment. There was also a need for better training opportunities for playground aides and office staff in concussion recognition and response.
Protective Gear
Student athletes of all ages need adequate protective gear, such as helmets and mouth guards. However, contrary to what some individuals may believe, there is no research supporting the use of mouth guards to prevent concussions. And while helmets can protect against more severe brain injuries and fractures, they do not prevent all concussions (see Concussion Myths and Misconceptions in Chapter 1).
In recent years, the use of soft headgear products in sports that do not require helmets, such as girls’ soccer, has become popular. The National Federation of State High School Associations (NFHS) Sports Medicine Advisory Committee (CMAC) developed a position statement (2013) regarding these products to address misperceptions regarding their performance in preventing concussions.
The statement indicates that soft or padded headgear products are not considered effective equipment for preventing concussions. Wearing such headgear is not scientifically or medically supported, thus it should not be considered as a valid way to decrease concussion incidence or expedite the return to play process. Further, wearing soft or padded headgear in non-helmeted sports may provide a false sense of security in athletes, parents, and coaches, thereby minimizing their focus on the importance of avoiding head impact and reporting concussion symptoms.
It is important that athletic gear be appropriately fitted. This includes ensuring that footwear fits appropriately and is the right type for the activity at hand. Young children who cannot tie their shoes well should have Velcro closures or have an adult double-knot their laces.
Because helmets can offer some protection against certain types of concussive blows, their addition can be helpful in sports that do not currently require helmets, such as field hockey and girls’ lacrosse (Cantu & Hyman, 2012). Many girls participating in these sports sustain facial injuries, skull fractures, and other types of brain injuries. While some leagues have safety rules, such as no sticks above the knees, violations of this rule happen in most games and can, of course, result in concussions and other injuries to the head and face.
Athletic Programs
School districts’ athletic programs can implement a number of safety measures to help make school sports safer for all participants. Preseason/beginning-of-year baseline testing, such as ImPACT, can provide preinjury measurement of cognitive abilities (see Chapter 4 for a discussion on this and other computerized neurocognitive tests) and help coaches, athletic trainers, medical personnel, and parents determine when a child is ready to safely return to athletic play.
Coaches can also be better trained in exercises that help strengthen their athletes; they can also conduct drills to enhance players’ awareness of what is going on around them. Girls’ coaches can explore the benefits of neck strengthening exercises for female athletes and better understand the type of exercises that can achieve this goal.
Further, a recent study indicated that only 70% of responding public high schools provided athletic trainers at sports competitions and practices and only 37% of public high schools had a full-time athletic trainer (Pryor et al., 2015). Not all high school associations require that a trainer be present at athletic competitions. This is often due to the high cost.
Changing the Culture
Increasing rates of concussion reporting will be an uphill battle as long as athletes continue to be immersed in a culture that praises “playing through the pain.” It is crucial that players themselves be taught both how to prevent injuries as well as how to recognize and respond to known and suspected concussions. Student athletes need to see the signs not only in themselves, but also in their teammates. A person with a brain injury is notorious for lacking judgment—it’s one of the defining features—but a teammate who saw a concussive blow that a coach may have missed, or who heard the student complaining of dizziness in the locker room, can be tremendously helpful in getting that injured teammate the necessary medical care.
Unfortunately, many athletes would rather have their injured teammate play through a game if it means the difference between a win and a loss. School professionals can help change the concussion culture by encouraging the reporting of known and suspected concussions to responsible adults who can then connect with the concussion team leader.
Students need to learn self-advocacy as well. The term health literacy applies to one’s understanding of one’s own health condition or injury in order to make appropriate health decisions (Manganello, 2008). If students better understand their injuries, including how symptoms can affect their academic performance, emotional well-being, and physical condition, they might better advocate for their own needs. Thus, children and adolescents should be educated on the importance of disclosing a head injury and following concussion-management recommendations.
TRAINING GUIDELINES
In addition to safety measures, education can help reduce concussions. Even when concussion management procedures and return-to-play guidelines are in place, many high schools do not provide frequent concussion education to their athletes. Without concussion education regarding how students’ injuries may affect their daily activities, athletes and nonathletes alike often return to the academic demands of school prematurely.
Schools—particularly middle and high schools—should require coaches of youth athletic activities to complete a concussion recognition education course each year. Such training should also be required of volunteer coaches at club and recreation facilities, as well as athletic leagues that sponsor youth sports. This training can include information on signs and symptoms of concussion, how to obtain medical attention in the event of a suspected concussion, risk factors of untreated concussions, and how to properly return an athlete who has sustained a concussion to athletic activity.
It is also important to keep in mind that many students’ concussions were not sustained in athletic activities. Therefore, training is recommended for all school staff who supervise play and recreation. This includes teachers (particularly physical education teachers), aides, office staff, related service personnel, administrators, and nursing staff. Such training should include information on both recognizing and responding to known and suspected concussions, guidelines for participating in a school-based concussion team, and ways to make adjustments to the school environment to meet students’ needs upon return to school.
Leaders of such trainings can provide resources such as this book or they can turn to reputable online training sources, such as the Centers for Disease Control and Prevention (www.cdc.gov/concussion) or the Brain101 “Concussion Playbook” (http://brain101.orcasinc.com), which has videos and resources for coaches, educators, parents, and students. Those conducting school-based trainings might construct a child-based concussion scenario based on their work or personal experience and walk participants through appropriate response steps. They can also have participants engage in small group role plays. In these groups, each participant would assume specific roles (e.g., student, teacher, parent, school psychologist, nurse, administrator, coach) and act out a concussion response scenario, such as determining appropriate adjustments to the school environment upon the child’s return after sustaining a concussion.
Damien
Damien’s school had no concussion team when he returned to school after his car accident. The problems he encountered inspired his school principal to implement a concussion team model and return-to-learn strategies in his building. The principal orchestrated the design and implementation of a policy that was later adopted by the school board. This included a concussion team training for the district administrators, school nurses, school psychologists, school counselors, and athletic trainer.
Following are several reputable concussion training resources that are available online:
1. Brain101 (http://brain101.orcasinc.com):
This site is a user friendly, visually appealing, and straightforward resource to guide the planning, training, and implementation of a school-wide concussion management system and team. The site includes resources specific to coaches, educators, parents, and teen athletes. The site includes brief informative/training videos, which are accompanied by questions regarding how to handle concussion-related management in the school. The site also includes practical resources to assist in implementing a concussion management plan schoolwide, including a signs and symptoms of concussion handout, staff notification letter, return-to-activities guide, concussion management team’s roles and responsibilities, and more.
2. BrainSTEPS (www.brainsteps.net; Brain Injury Association of Pennsylvania, Inc., the Pennsylvania Department of Education, & the Pennsylvania Department of Health, 2007):
BrainSTEPS is a brain injury school re-entry consulting program; STEPS stands for Strategies Teaching Educators, Parents, and Students. Although this is a Pennsylvania-based program, many of the resources on the site can be applied anywhere. Further, it is an outstanding example of positive collaboration—in this case among the Department of Health, Department of Education, and Brain Injury Association—for addressing issues associated with youth concussions. This site includes information on concussion signs and symptoms, concussion teams in schools, and the implementation of return to school procedures.
BrainSTEPS.net offers a variety of webinars, including Concussions in the Classroom—Return to Learning, IEPs and Effective Program Planning for Students with Traumatic Brain Injury, Intervention for Adolescents With Acquired Brain Injury, and Strategies for Executive Skills Development in Students With TBI. The webinars are accompanied by classroom resources for teachers and concussion team members.
3. Centers for Disease Control and Prevention—Heads Up to Schools (www.cdc.gov/headsup/schools/index.html; CDC, 2015):
This site provides resources on concussion signs and symptoms, promoting awareness, and tips for parents on how to provide care to students who have sustained concussion. The CDC provides fact sheets about concussion that are directed toward parents, school professionals, and coaches, most of which are downloadable in both English and Spanish. The site also provides information about how to return students to the classroom after sustaining a concussion, and provides PDFs with tips for teachers to assist in returning students to the classroom.
The Heads Up program also includes concussion awareness flyers that can be customized, downloaded, and posted in schools. These flyers are simple, visually appealing, and include information about common symptoms and the importance of reporting concussion symptoms to a school professional.
Detailed information regarding helmet safety can also be found on the CDC’s Heads Up to Schools site. Fact sheets on appropriate helmet fit, usage, and coverage are available for many different types of sports (helmets for skateboarding, ice hockey, football, bike riding, etc.). Three brief online concussion training courses are also available on this site; one for clinicians, one for youth sports coaches, and one for high school sports coaches.
4. The Center on Brain Injury Research and Training (http://cbirt.org; University of Oregon, n.d.):
The Center on Brain Injury Research and Training provides a number of presentations on brain injury research, many of which involve how to support students who have sustained a traumatic brain injury, how to involve parents in concussion care, and research-based interventions for students who have sustained concussions. The site also includes resources for families, educators, and service providers based on best practice recommendations for working with students with concussion.
5. Colorado Kids Brain Injury Resource Network (http://cokidswithbraininjury.com; Brain Injury Networking Team, 2015):
Cokidswithbraininjury.com provides information geared toward educators and professionals, as well as information for parents on how to support students who have sustained concussion. The site includes detailed yet simple resources and tools that can simply be printed and used in schools; examples include: Brain Check Survey, Comprehensive Health Assessment, and Brain Injury Observation Form. The site also includes helpful resources such as “Key Terms” for concussion in schools. Much of this site is specific to Colorado-based resources and law, however, the site also includes national law updates and national resources such as the CDC, and Brain Injury Association of America.
6. Get Schooled on Concussions (www.getschooledonconcussions.com; McAvoy & Eagan Brown, 2015):
Get Schooled on Concussions is a website that focuses on “return-to-learn”recommendations, “written by educators for educators.” The main objective of this site is to provide teachers, administrators, school nurses, school mental health counselors, and parents with one-page fact sheets on concussion recovery in the classroom. This site provides educators and school professionals with to-the-point fact sheets on important aspects of, returning to academics such as: What to Do About Work Output, When to Write a Section 504 Plan, What to Do About Tests, and Academic and Symptom Monitoring. This site also provides archived return-to-learn trainings, as well as information on upcoming trainings.
7. Nationwide Children’s Hospital Concussion Clinic (www.nationwidechildrens.org/concussions; Nationwide Children’s Hospital, n.d.):
Nationwide Children’s Hospital provides medical and management services for children and their families who have sustained many kinds of illnesses, injuries, or disabilities. This site directs the reader to their concussion clinic and concussion resources page. This site provides resources on a variety of topics including, but not limited to, easy-to-use tools for parents, coaches, educators, school administrators, and athletes; a guide to the concussion management team (including roles, responsibilities, etc.); information regarding baseline neurocognitive testing; current articles on concussion; and so on. The site also includes a page on frequently asked questions regarding Ohio’s concussion law.
8. University Interscholastic League/National Federation of State High School Associations—Concussion Oversight Team (www.uiltexas.org/health/concussions; University Interscholastic League, n.d.):
This site provides information regarding the suggested acknowledgment, supervision, and management/treatment of concussion in schools, as suggested by the National Federation of State High School Associations (NFHS) and Texas law. The site also includes a link to a free course titled Concussion in Sports—What You Need to Know, which is supported by NFHS and CDC, that focuses on providing resources to help educate coaches, officials, parents, and students on concussion awareness, recognition, and proper management. Though many of the resources on this site are specific to the law and protocol of Texas schools, the site includes return-to-play resources, a concussion management protocol, and suggested guidelines for concussion management that can be applicable to any school system.
PARENTS
This book has described how parents are key members of the school-based concussion team. They know their child better than anyone and they can notice small behavioral changes more readily than others might, particularly a physician who may only see the child for annual well-child visits. Parents might notice changes in sleeping and eating, reactions to minor stressors, and overall demeanor. Therefore, school personnel should always ask parents, “What have you noticed?” when monitoring a student’s progress through concussion recovery.
While parents should not be expected to diagnose concussions, they do need to know when to take their child to a doctor for evaluation for a suspected concussion. The sooner a child receives proper treatment, the better the likelihood for a positive outcome. Therefore, it is crucial that parents be involved in district-level training and prevention initiatives.
Parents can be taught some of the simple assessment techniques that were described in Chapter 4. They can ask simple questions to check their child’s short-term memory, such as “What was the score of the game?” “What school were you playing against?” and “What do you remember about what happened?”
It is important that parents realize that many doctors have not received adequate training in diagnosing concussions. One colleague’s local hospital is notorious for sending students home from the emergency department declaring that because the child’s CT scan was clear, they didn’t have a concussion (see Chapter 1 myths). Because concussion training is relatively new to the medical field, most doctors currently in practice received little or no education about it during their training. Instead, they are receiving information about concussion through professional readings and continuing education seminars (if at all). Thus, it’s important that when selecting a doctor, parents not only consider the doctor they have used for years, but that they ask about the doctor’s training in concussions. In many cases, parents are well advised to seek out a concussion specialist to care for their child.
Parents will usually be their child’s strongest advocates, eager to find out what their son or daughter needs and how they can facilitate the recovery process. However, in some situations, parents may not understand the serious repercussions that can come with too much activity while a concussion is still healing. If their child is an athlete, parents may want them to get back into the game, to hold onto their status as the star on the soccer team, or to maintain their trajectory toward a football scholarship. This can be a difficult dynamic for school staff members to navigate. In all cases, it can be helpful to have the release of information (ROI) signed to allow conversation between a physician and the concussion team leader. In this type of case, the physician—as long as he or she is well educated about concussions and the recovery process—can often give additional support and guidance.
Parents can be a tremendous help to their children throughout the recovery process, as well as in terms of helping prevent concussions in the first place. Again, most parents are active partners in the recovery process. However, if the student and/or the family are non-compliant members of the concussion team and refuse to follow recommendations, it is important that the CTL documents situations and correspondence. The CTL should also document the school’s efforts. Having clear communication and a supportive relationship can help ensure compliance.
Ben
When Ben sustained his concussion playing football, his father was upset that he was not allowed to resume practice and play. The following year, Ben’s father continued to present some difficulties to the school team.
“This is ridiculous,” Mr. Davidson grumbled. “I played football for 10 years and got my share of dings, but I turned out fine.”
“You have trouble remembering things from time to time,” Mrs. Davidson murmured.
“Who doesn’t!” Mr. Davidson snapped. “The truth is, the boy just needs to toughen up—and football is the way he’s gonna do it!”
“It sounds like football was a really important part of your life when you were in school,” the school psychologist said. “I was the same way with ice hockey. What is it about football that you like the most for Ben?”
“I want him to be part of a team,” Mr. Davidson said evenly, “To work hard, to compete, and to be a man.”
“Ben doesn’t seem as enthusiastic about football, but he is very excited about the possibility of joining the running club instead,” added his school counselor, Ms. Ernst. “He’d get a lot of things out of it that you’re looking for in football—teamwork, competition, strength development—and it would be good conditioning for football or another sport he chooses down the road.”
NEXT STEPS
Some readers of this book may be learning much of this information for the first time. Others may be reading it as part of a required course or for professional development with a school team. Given that readers are coming at this text from a variety of angles, keep in mind the following general recommendations for next steps:
Establish a concussion team at your school: Review the key personnel recommended for participation in a concussion team in Chapter 3. Talk with your school or district administration to gain support for implementation of a team model.
Designate a CTL: A school-based concussion team is only as strong as its leader. The professional who serves in this role will vary from school to school. Maybe this person is you. Regardless, keep in mind that if the designated CTL changes jobs or moves to a different school, a new person needs to be appointed and existing cases (including those being followed from previous years) need to be transitioned.
Educate your community: Help provide information to all students, parents, athletic staff, and educators about how concussions can affect learning, behavior, and health. An online resource for this is Brain 101: The Concussion Playbook (http://brain101.orcasinc.com), which teaches students what to look for and encourages them to tell an adult if they think they have a concussion. There is an excellent 15-minute video on this site—encourage sharing of this video with students.
Define your concussion protocol: Ensure that there is a written protocol or manual for your school and that all concussion team members understand their responsibilities.
A FINAL NOTE
Physical rest and cognitive rest are both essential for concussion recovery. With appropriate response and treatment, more than 80% of students with concussions recover within 3 weeks (Collins, Lovell, Iverson, Ide, & Maroon, 2006). However, if concussive injuries are not managed appropriately, recovery time can be prolonged and academic difficulties can persist. Thus, it is essential to have a school-based concussion management plan in place while a child heals. Such a plan includes appropriate environmental and academic adjustments, a mechanism for progress monitoring, and communication among school personnel, medical personnel, and families.
As much as some of us would like to, we cannot wrap kids in bubble wrap to send them out into the world. Engaging in physical play, playing sports, and learning to drive a car are all ways youth can sustain concussions, but they’re also important parts of both child development and our culture. Climbing on monkey bars can help develop a child’s coordination, playing on the baseball team can help develop sportsmanship, and driving a car can help develop a sense of independence. At the same time, with any of these activities comes risk of injury, and with injury comes the responsibility for an appropriate, coordinated response.
NEW PATHS
Some concussions can derail a student athlete’s projected path. This book concludes with Julia’s story, and the new path that she forged in the aftermath of her postconcussion syndrome.
Julia
Julia had always been a high-achieving student academically as well as athletically, but after her last concussion, her grades began to slip. Julia had a complex constellation of symptoms, including headaches, fatigue, poor memory, nervousness, and irritability. With help from her school-based concussion team, her teachers, and her parents, Julia received appropriate adjustments at school that facilitated her recovery.
Julia had dreams of a soccer scholarship to a big state university. However, after her last concussion, it was apparent that an athletic career was not in her future. Julia felt lost and angry and confused. Not only had her academic performance suffered as a result of her concussion, but she lost much of her sense of belonging and social circle, which had all centered on her soccer and basketball team.
“Sometimes I feel like I’ve moved to a new school,” she told her mother. “I feel like I have to make friends all over again.”
“Your friends still care about you so much,” said her mother, who proceeded to name specific friends and the things they had done to stay connected to Julia during her recovery.
“I know,” Julia sighed, “but it’s just not the same. I mean, when I’m around them, and they’re talking about something that happened at practice or on the bus on the way to a game, I feel so left out. It’s like they have these inside jokes that I’ll never be part of again.”
Julia’s mother encouraged her to stay connected to her old friends and teammates, but also to explore new social groups and areas of interest.
“It’s a great opportunity,” she said, “to learn how to do something new…something you’ve always wanted to do but haven’t had time for.”
Julia’s summers had always been dominated by sports camps and conditioning. During the summer after her junior year, she and her mother took a 2-week trip to California and spent a great deal of time reading and relaxing at their local swimming pool.
“It was this great opportunity to spend time together before Julia’s senior year, and before she launches into the rest of her life,” Julia’s mother told the Mrs. Beck, the school counselor. “And she’s started taking guitar lessons—she seems to have a real gift for it.”
“That’s very positive,” nodded Mrs. Beck.
“I’m not saying everything is rosy and perfect,” said Julia’s mom. “She still seems down from time to time, but her schoolwork has improved and she’s looking at more colleges over the break. She can see opportunities there, too—although she’ll need more student loans without the possibility of a scholarship, but she’s not just limited to schools with strong soccer programs anymore.”
Julia continued to pursue her love of guitar during the rest of high school and even recorded some songs that received thousands of hits on YouTube. She remained close with several of her former teammates and also made new friends who were involved with her school’s music program, including her new boyfriend, Danny. When a freshman at her school sustained a similar injury and was sidelined from play for the rest of the soccer season, Mrs. Beck connected the two young ladies over lunch so Julia could share her story—and her strategies—with someone else.
REFERENCES
Brain Injury Association of Pennsylvania Inc., the Pennsylvania Department of Education, & the Pennsylvania Department of Health. (2007). BrainSTEPS. Retrieved from http://www.brainsteps.net
Brain Injury Networking Team. (2015). Colorado kids brain injury resource network. Retrieved from http://cokidswithbraininjury.com
Cantu, R., & Hyman, M. (2012). Concussion and our kids: America’s leading expert on how to protect young athletes and keep sports safe. New York, NY: Houghton Mifflin Harcourt Publishing Company.
Centers for Disease Control and Prevention. (2015). Center for disease control and prevention: CDC 24/7: Saving lives, protecting people. Retrieved from http://www.cdc.gov/headsup/index.html
Collins, M., Lovell, M. R., Iverson, G. L., Ide, T., & Maroon, J. (2006). Examining concussion rates and return to play in high school football players wearing newer helmet technology: A three year prospective cohort study. Neurosurgery, 58(2), 275–286. doi:10.1227/01.NEU.0000200441.92742.46
Manganello, J. A. (2008). Health literacy and adolescents: A framework and agenda for future research. Health Education Research, 23(5), 840–847. doi:10.1093/her/cym069
McAvoy, K., & Eagan Brown, B. (2015). Get schooled on concussions: Return to learn (RTL). Retrieved from http://www.getschooledonconcussions.com
National Federation of State High School Associations Sports Medicine Advisory Committee (2013). Soft or padded headgear in non-helmeted sports position statement. Retrieved from https://www.nfhs.org/media/1015199/2013-nfhs-smac-postion-statement-on-soft-headgear-1.pdf
Nationwide Children’s Hospital. (n.d.). Nationwide children’s: When your child needs a hospital, everything matters. Retrieved from http://www.nationwidechildrens.org/concussions
Pryor, R. R., Casa, D. J., Vandermark, L. W., Stearns, R. L., Attanasio, S. M., Fontaine, G. J., & Wafer, A. M. (2015). Athletic training services in public secondary schools: A benchmark study. Journal of Athletic Training, 50(2), 156–162. doi:10.4085/1062-5060-50.2.03
University Interscholastic League. (n.d.). Health and safety: Concussions and concussion management protocol requirements and information. Retrieved from http://www.uiltexas.org/health/concussions
University of Oregon. (n.d.). The center on brain injury research & training. Retrieved from http://cbirt.org