Concussion Management Plan The University of Alabama Athletic Department The following policies and procedures have been instituted by The University of Alabama Athletic Department in an effort to identify, diagnose, manage and return athletes safely to competition following a concussion. Pre-Season Education: • • • • Concussion educational information based on the NCAA concussion fact sheets will be included in The University of Alabama Athletic Department StudentAthlete Handbook. Each student-athlete will receive a copy of the handbook at the beginning of the academic year and will provide a signed acknowledgement that they have received it and understand that they are responsible for the material in the handbook. Each athlete will sign a statement in which they accept responsibility for reporting their injuries (including concussions) and illnesses to the University of Alabama Sports Medicine staff. At the beginning of each academic year, the athletics compliance office meets with all student-athletes for each sport sponsored by the institution. As part of this compliance meeting, the concussion protocol is reviewed. Also during this meeting, each student-athlete signs an acknowledgement stating that they have received the information and are aware that they are responsible for reporting injuries (including concussions) and illnesses to the sports medicine staff. Said acknowledgement is signed in one of two ways, either electronically through UA’s use of online compliance software, or via a hard copy version signed in-person. All coaches, team physicians and athletic trainers will receive the NCAA concussion fact sheet during the mandatory annual medical meeting which includes CPR training, concussion education and EAP training. Each individual will be required to sign that they have attended the medical meeting and received the concussion education information. The meeting will occur on an annual basis during the first two weeks of fall semester. All administrators responsible for oversight of a sport will receive the NCAA concussion fact sheet during their initial meeting with the compliance staff. They will each be required to provide signed acknowledgment of having received and read the concussion material. Pre-Participation: • • • A history of any previous concussion will be conducted at pre-season physicals for all student athletes. Any previous concussion will be documented and the medical records will be obtained for review by the team physician for that sport. Any student athlete that is thought to have previously sustained a significant head injury or a history of multiple head injuries will undergo a full neurological assessment by the team physician. • • A baseline balance score using the Balance Error Scoring System (BESS) and a baseline Sideline Concussion Assessment Tool will be performed on all athletes. The test results will be maintained in the athlete’s medical records and used as a baseline for future injury management. Clearance for participation or need for further consultation, evaluation or testing will be at the discretion of the team physician. The team physician also has the discretion to order a new baseline concussion assessment six months or beyond for any varsity student-athlete with a documented concussion, especially those with complicated for multiple concussion history. Recognition and Diagnosis of Concussion and Post-Concussion Management: • • • • • • • Any student athlete at the University of Alabama who exhibits signs or symptoms consistent with a concussion as deemed by the medical staff, with or without a witnessed injury, will be removed from activity (practice or game) immediately and undergo a thorough evaluation by a member of the University of Alabama Sports Medicine team. This may include certified athletic trainers or team physicians; athletic training students are not responsible or allowed to evaluate athletes with signs and symptoms of a concussion nor are they allowed to participate in any decision making regarding return to competition. Once a student athlete has been diagnosed with any form of concussion or mild traumatic brain injury, he/she will NOT be allowed to return to any activity or competition for the remainder of that day. The evaluation of a concussion by a member of The University of Alabama Sports Medicine team will include a symptom assessment, a physical and neurological examination, a cognitive assessment, a balance examination and a clinical assessment for cervical spine trauma, a skull fracture and intracranial bleed. The emergency action plan should be activated for any of the following: o Glasgow Coma Scale < 13 o Prolonged loss of consciousness o Focal neurological deficit suggesting intracranial trauma o Repetitive emesis o Persistently diminished/worsening mental status or other neurological signs/symptoms. o Spine injury Following initial injury, the athlete will continually be evaluated and monitored by the certified athletic trainer and team physician if present. If there is any worsening of the student athlete’s symptoms, the team physician will be notified immediately (if not already present for evaluation) and the athlete will be transported to a medical facility that can manage and treat severe closed head injuries. While in Tuscaloosa, the referral facility of choice will be DCH Regional Medical Center. When managing head injuries away from Tuscaloosa, the referral site will be at the discretion of the host-team’s medical staff. Oral and/or written instructions will be given to the student-athlete who suffers a concussion and another responsible adult, which may include a parent or roommate. • Student-athletes who have a prolonged recovery from a concussion will be evaluated again by the team physician in order to consider best management options and additional diagnosis, including but not limited to: o Post-concussion syndrome o Sleep dysfunction o Migraine or other headache disorders o Mood disorders such as anxiety or depression o Ocular or vestibular dysfunction Return to Play: • • • Student-athletes who sustain a concussion will undergo follow-up cognitive and balance testing and should have limited physical and cognitive activity until all tests have returned to baseline. Once concussion symptoms have resolved and cognitive/balance tests have returned to baseline, the student-athlete must undergo a supervised stepwise progression management plan by a health care provider with expertise in concussion that specifies: o Light aerobic exercise without resistance training o Sport-specific exercise and activity without head impact o Non-contact practice with progressive resistance training o Unrestricted training o Return to competition A student-athlete that has been diagnosed as having a concussion will not be allowed to return to activity until they are cleared by a team physician. The team physician will be the only one to determine return to play and will have full and complete authority to make that decision. Return to Learn: When athletes at The University of Alabama sustain a concussion from any cause, it is important to realize that their ability to learn and subsequently their academic progress may be hampered. For this reason, it is imperative that proper steps be taken in order to notify the Academic Department and arrange for proper management of athletes that have sustained concussion. At present, when an athlete sustains a concussion from any cause, they are held out of all physical activity until their symptoms resolve. They are evaluated by the athletic training staff daily and then cleared only by the team physician when they are ready to resume participation in their sport and training. During this time of physical rest, it is important for the athlete to have some degree of cognitive rest in order to allow for enhanced recovery of symptoms. While it would be impossible to completely remove the athlete from all of their academic responsibilities, some adjustments in demand and academic requirements should be made. Other forms of mental stimulation such as TV watching, loud noises, non-academic computer use, video games and texting should be limited or eliminated during this recover time allowing as much academic work as possible. The following guidelines should be used in regards to managing the cognitive rest needed for the athlete to recover taking into account that each athlete and each concussion are different so it would be impossible to set out strict recommendations. The management of the return to learn program will be in full compliance with the ADAAA. • • • • • • When an athlete sustains a concussion, they should be removed from all academic responsibilities for the remainder of that day. If the student-athlete cannot tolerate light cognitive activity, they should remain at their residence to rest. Once light cognitive activity is tolerated, the athlete may return to the classroom as tolerated. If at any point the student-athlete experiences return of symptoms or scores on clinical measures decline, the team physician should be notified and the student-athletes cognitive activity should be reassessed. The extent of academic adjustments needed should be decided by a multidisciplinary team that may include but not be limited to the team physician, athletic trainer, academic representative, academic counselor, course instructors, coach, college administrator, Office of Disability representative, and psychologists and/or neuropsychologists. The level of involvement by each member of this multi-disciplinary team should be made on a case-by-case basis. Modification of class schedule and academic accommodations may be necessary for up to two weeks and will be coordinated by Jon Dever, Associate Athletic Director for Student Services. Prompt re-evaluation by a team physician and members of the multi-disciplinary team, if appropriate, will be done on any student athlete whose symptoms last longer than two weeks or who has worsening of concussive symptoms with academic challenges. Most concussive symptoms typically resolve within two weeks, however, there are occasions when symptom can persist for weeks to months. When an athlete has persistent symptoms, adjustments in curriculum and testing may prove more challenging. It is important to verify that the athlete is truly having continuation of concussive symptoms as often there are other conditions that may present with the same symptomatology such as post-concussive syndrome, attention deficit disorder, sleep dysfunction, migraines and other headache disorders, anxiety and or depression, and simply assuming these symptoms are the result of the concussion and just waiting them out may prove counter-productive. When an athlete has not recovered in an anticipated time frame, the student athlete may need a change in their schedule and academic requirements. Special arrangements may be required for extended absences, tests, term papers or other projects. In these situations, the athlete may need the assistance of special support services provided by the University of Alabama. An athlete presenting with prolonged symptoms must be re-evaluated to check for other co-morbid conditions and then a detailed long-term academic plan must be instituted. Special resources available to the student athlete such as the Office of Disability Services, the ADAAA office, or specific Learning Specialists may need to be involved in the continuing management of the athlete with prolonged symptoms. As treatment continues and the athlete recovers, then a gradual return to normal academic function may ensue. Every effort will be made by the University of Alabama Athletic Department and the Academic Department to ensure that an athlete that has sustained a concussion will be treated in such a manner as to ensure his safe return to sport and maintain their academic progress. Reducing Head Trauma Exposure Management Plan: Efforts will be made to reduce exposure to head trauma. Examples of methods to minimize head trauma exposure include but are not limited to: • Adherence to Inter-Association Consensus: Year Round Football Practice Contact Guidelines • Adherence to Inter-Association Consensus: Independent Medical Care Guidelines • Reducing gratuitous contact during practice • Taking a “safety first” approach to sport • Taking the head out of contact • Coaching and student-athlete education regarding safe play and proper technique. UNIVERSITY OF ARIZONA SPORTS MEDICINE Mild Traumatic Brain Injury (MTBI) / Concussion Guidelines The University of Arizona Sports Medicine Department recognizes that concussion/mild traumatic brain injuries (MTBI) pose a significant risk for all student-athletes. These injuries should be taken seriously by all people involved including but not limited to student-athletes, their families, medical staff, coaches, and academic staff. The University of Arizona (UA) management plan for concussions includes: Education, acute injury management for suspected concussion, and treatment of concussion and return-to-learn and play decisions. Education: All student-athletes, coaches, athletic administrators and medical staff will have education/training appropriate to their position. NCAA concussion fact sheets will be available for each to review. All coaches will receive education on concussion during their annual “Emergency Medicine Training” (see appendix for objectives of training) The Associate Director of Athletics of C.A.T.S. Medical Services will review this policy with athletic administrators and medical staff on an annual basis. Medical staff will receive annual training on concussion symptoms/management, emergency action plans for our venues, and common/serious medical conditions. Each party will sign an acknowledgement of having received and understood the concussion material. Student-athletes must complete a pre-participation physical before participation in any organized athletic activity for the UA. Elements of that process related to concussion include (but are not limited to): • Receiving education and educational materials about concussions (including but not limited to NCAA Concussion Education Fact Sheet) • Receive education on the importance of safety first approach, proper technique and taking the head out of contact for applicable sports. • A review of their history of concussions and head injuries including symptom evaluation • Confirmation of the SA's responsibility to report injuries and illnesses (including signs and symptoms of concussions) including their signature accepting that responsibility • Baseline computerized neuropsychological testing (including baseline symptom score) using the ImPACT program • Balance evaluation (Utilizing BioDex, BESS or other applicable assessment) • Team physician clearance and/or the need for additional consultation or testing Acute injury management for suspected concussion: At the time of the injury or at any point after a mechanism that could cause a concussion, a student-athlete and/or coaches are required to report if any of the following symptoms are present. Physical symptoms: Headaches, nausea/vomiting, fatigue, visual problems, balance problems, sensitivity to light, sensitivity to noise, numbness/tingling, dizziness Cognitive symptoms: Loss of consciousness, feeling mentally foggy, problems concentrating, problems remembering, feeling more slowed down Emotional symptoms: Irritability, sadness, feeling more emotional, nervousness Sleep symptoms: Drowsiness, sleeping more than usual, sleeping less than usual, trouble falling asleep A student-athlete is to be held out of all activity until they are evaluated by a UA Team Physician or athletic trainer (medical staff). The physician or athletic trainer shall operate within their scope of professional practice, during evaluation and treatment of a concussion. The medical staff member will perform an appropriate evaluation to determine if a MTBI/concussion is present. If a MTBI/concussion is present the student-athlete is withheld from practice, competition and work outs and will be assessed whether it is necessary to refrain from going to class, meetings and travel for the remainder of that day. The medical provider's return-to-play decision is final and may not be challenged. The initial evaluation will include a symptom assessment, physical and neurologic exam (including cognitive assessment) and balance exam. Other injuries including cervical spine trauma, skull fracture and intracranial bleed will be ruled out. Any student-athlete will be emergently transported by EMS for further medical care should any of the following be present: • • • • • • Glasgow Coma Scale < 13 Prolonged loss of consciousness A focal neurological deficit suggesting intracranial trauma Repetitive emesis Persistently diminished/worsening mental status or other neurological signs/symptoms Spine injury Following the initial evaluation, determination of the severity of the injury, need for emergent or urgent transportation, medical evaluation or treatment, frequency and duration of serial evaluations will be made. The student-athlete will then have to be cleared by the Team Physician or their designee prior to returning to active participation in workouts, practice or competition. Medical staff responsibilities at the time of diagnosis: 1. Student-athlete education: Injured student-athlete will be given verbal review of concussion symptoms, factors that make symptoms worse, activity restrictions and warning signs for more serious symptoms or signs that would require emergent treatment and advice to call 911 should those symptoms/signs be observed. The student-athlete will be given the post-concussion education sheet. (See appendix) 2. Notification and education of person staying with injured student-athlete. Injured studentathletes should be discouraged from staying alone following a head injury. Post-concussion education sheet will be shared with contact person. 3. Notification of the Team Physician or their designee if they are not present at the event, and documentation of the injury, evaluation, and plan for the student-athlete in their medical record. These responsibilities must be documented by a member of the medical staff. Treatment of concussion and return-to-play decisions The concussed patient will be evaluated by a team physician or designee at intervals while symptomatic and prior to return to any sports participation including exercise, weight training, individual workouts, practice or competition. Evaluation may include but not limited to physical examination, review of symptoms at rest/exertion, balance assessment, visual field assessment as well as review of results of neuropsychological testing (ImPACT program, with comparison to their baseline results). The team physician and/or other members of the multi-disciplinary team will take special consideration during the re-evaluation of the patient who is experiencing changing or concussion symptoms that persist for more than two weeks. Initially, the concussed student-athlete will have limited physical and cognitive activity until symptoms improve. An individualized patient-specific progression back into sport will be established. This progression will include the following steps without worsening or provoking new symptoms: • • • • • Light aerobic exercise without resistance training Sport-specific exercise and activity without head impact Non-contact practice with progressive resistance training Unrestricted training Return to competition A final exertion exercise stress test, vestibular/ocular stress test along with neuropsychological exam will be implemented at the discretion of the team physician or designee. The exertion exercise stress test along with progression will be patient-specific and sport specific. Each step of the progression and testing will be documented along with the patient’s reaction to the activity. Additional testing, evaluation and neuropsychologist consultation will be at the discretion of the Team Physician or designee. The team physician, psychologist and athletic trainer during the full recovery process will assess for signs and symptoms other problems including but not limited to: • • • • • • Post-concussion syndrome Sleep dysfunction Migraine or other headache disorders Mood disorders such as anxiety and depression Ocular or vestibular dysfunction Illicit drug use Return-to-learn In the event a student-athlete is diagnosed with a concussion, academic accommodations will be made if necessary. The team academic advisor will be notified of the student-athlete’s concussion (if the patient allows the release of this protected medical information) and possible limitations in the classroom. The medical team and academic team will have the responsibility of helping the student-athlete navigate the return-to-learn process. The student-athlete and/or the academic advisor will be provided with documentation explaining the student-athlete’s injury that can be disseminated to student’s instructors and other academic professionals as needed. The student-athlete who suffers a concussion will be evaluated for the need to be excused from tutors, study table and classroom work the day of the injury. An individualized plan will be created for the student-athlete that may includes staying at home if light cognitive activity cannot be tolerated as well as a gradual return to classroom participation and studying as tolerated. An assessment will be made to determine the most optimal environment to limit exacerbation of symptoms. That may or may not be the patients “home”. Modification of academic commitments including class and tutoring schedules will be made as directed by the medical staff with the assistance of the academic advisor or designee. Reevaluation by the medical staff will occur if concussion symptoms worsen with academic challenges. In the event of a more complex case or prolonged return-to-learn, a multi-disciplinary team will be identified to assist the student-athlete. This team may include, but is not limited to, a team physician, athletic trainer, psychologist, neuropsychologist consultant, neurologist, faculty athletic representative, academic counselor, course instructors, college administrators, office of disability services representatives, SALT Center and coaches. Additional campus resources will be recruited for the complex case if modification of academic commitments is unsuccessful. These resources will be compliant with the Americans with Disabilities Act Amendment Act (ADAAA) and will include learning specialists, the campus office of disability services, SALT Center, Dean of Students, Campus Health Service Administration and the ADAAA office. Reducing Exposure to Head Trauma To attempt to reduce concussions in Football the UA will follow the Football Practice guidelines set for the PAC 12 Conference. For all other sports the UA will follow all practice guidelines set forth by NCAA and PAC 12 Conference. All coaches will be encouraged to put an emphasis on proper technique, taking the head out of contact and a safety first approach. When appropriate the medical staff will partake in medical record review of injuries to assess how and when they occurred and will use this information to educate coaches, student athletes and administrations on ways to prevent injuries including but not limited to concussions. The medical staff will also partake in Quality Assurance/Quality Improvement programs as they relate to injury prevention. Independent Medical Care The UA will ensure that the medical staff has autonomy of medical care. The medical staff will have unchallengeable authority to determine medical management and return-to-play decisions of studentathletes. The medical staff will have unchallengeable authority to stop any activity they deem unsafe. To ensure proper medical care is delivered to the student athletes the UA Team Physicians are not employees of the Athletics Department. The athletics department has a University Memo of Understanding with Campus Health Services (CHS) to provide Team Physicians to the Athletics Department. The team physicians are full time CHS employees who report to and are evaluated by the Medical Director of the CHS. The athletic trainers (AT) report thru the Athletics Department ultimately to the Athletics Director. The AT staff by Arizona state licensure law must work under direction of a physician. A yearly evaluation of medical care (see appendix) delivered to ensure appropriate medical care was delivered will be accomplished by a team physician before the physician will sign the Arizona State required AT/Physician written agreement (see appendix) NOTE: This is a guideline for the management of MTBI/concussion, based on the medical knowledge and experience of our staff, available guidelines, best practice documents, consensus statements and recommendations of the NCAA. All injuries, including MTBI/concussion, are unique to the events surrounding the injury and to the person sustaining the injury. Each case will be managed with awareness of this uniqueness and with the goal of ensuring the student-athlete's health and wellness. Adopted August 24, 2010 Reviewed and Updated May 7, 2015 Randy P. Cohen ATC, DPT-Associate AD for Medical Services Donald E. Porter MD- Head Team Physician Greg Byrne- Athletic Director Above names will be designated as an electronic signature MD Sports Medicine 5/7/15 PHYSICIANS EVALUATION Name Employee Number Hire Date From Rating Period to The athletic trainer communicates pertinent medical information to physician on new injuries in a timely manner Far Exceeds Requirements Exceeds Requirements Meet Requirements Meets some of the Requirements Does Not Meet Requirements The athletic trainer communicates pertinent medical information to physician in a timely manner on existing patients Far Exceeds Requirements Exceeds Requirements Meet Requirements Meets some of the Requirements Does Not Meet Requirements The athletic trainer refers the appropriate patients to the team physician and in a timely manner Far Exceeds Requirements Exceeds Requirements Meet Requirements Meets some of the Requirements Does Not Meet Requirements The athletic trainer refers the appropriate patients to outside specialists and notifies the team physician in a timely manner when appropriate Far Exceeds Requirements Exceeds Requirements Meet Requirements Meets some of the Requirements Does Not Meet Requirements Meets some of the Requirements Does Not Meet Requirements The athletic trainer provides proper treatment and rehabilitation Far Exceeds Requirements Exceeds Requirements Meet Requirements The athletic trainer follows all instructions and guidelines set forth by supervising physician Far Exceeds Requirements Exceeds Requirements Meet Requirements Meets some of the Requirements Does Not Meet Requirements Comments ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Physician Name________________________________________________ Date_______________________ 7 – Athletic Trainer The University of Arizona Athletic Department Coaches Emergency Training CPR/AED Objective: Acquire and maintain (review yearly with Medical Staff) certification according to American Red Cross or American Heart Association guidelines. Emergency Action Plan (EAP) Objectives: Understand role in Emergency Action Plan. Working knowledge of specific venue(s) used. Knowledge of location of EAP’s at each venue used. Knowledge of location of AED’s in the Athletics Department. Sickle Cell Objectives: Learn and understand in general how Sickle Cell Trait can interact with exercise. Understand the importance of gradual implementation of activity. Understand need for extra rest/recovery time. Understand the importance for Student-Athlete to take care of oneself. Understanding the need of limiting activity if S-A is ill. Rhabdomyolosis Objectives: Understand the general physiological process. Understand risk factors and need for gradual increase in activities after rest period. Knowledge of signs and symptoms of this condition. Understand how to prevent this condition from occurring. Asthmatic Athletes Objective: Understand general physiological process of asthma. Know which athletes are asthmatic and use medication. Understand risk factors that could exacerbate the condition. Concussion Objectives: Know signs and symptoms of concussion. Importance of reporting signs and symptoms. Importance of holding S-A out of practice and competition. Understanding progression of return to participation following clearance by Medical Staff. Know ways to minimize risk of concussion for specific sport Lightning Objectives: Working knowledge of lightning protocol. Importance of determining a safe shelter and location of safe shelter sites at your particular athletic venue. Understanding of the Flash-to-Bang method for measuring lightning distance. Nutritional Supplements Objectives: Know University Policy on nutritional supplements. Coach Signature: ________________________ Printed Name:____________________ Date: _____________ Instructor Signature: _____________________ Printed Name:____________________ Date: _____________ Rev. May 2015 Sports Medicine You have been diagnosed with a concussion and need to have someone (friend, roommate or family member) with you overnight. You do not need to wake up every hour overnight. A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Typical symptoms include headache, vision changes, nausea, memory/concentration problems, dizziness, mood and sleep problems among others. Your symptoms can get better or worse while you recover depending on what you’re doing and how long it has been since your injury. They are typically worst 24-48 hours after the injury. You should rest as much as possible, try to eat normal meals, and drink plenty of fluids. Medication: You can use Tylenol for headache. Do not take aspirin, Advil (Motrin, iprin, ibuprofen), Aleve (Naprosyn, naproxen) or any other new medication without direct instructions from a physician. WATCH FOR ANY OF THE FOLLOWING PROBLEMS Worsening headache Vomiting Decreased level of consciousness Dilated pupils Increased confusion Stumbling/loss of balance Weakness in one arm/leg Blurred vision Increased irritability Increased dizziness If any of these problems develop call 911 and go to the emergency room. Notify your athletic trainer of changes in your condition. Athletic Trainer_______________________________ Phone Number_________________ Avoid the following activities until instructed by the medical staff as they will make your symptoms worse: • Loud music • Physical exertion (exercise, biking, lifting anything heavy, sex) • Driving or operating a motor vehicle • Reading • Alcohol use • Computer work • Prolonged television watching • Video games • Texting You are not cleared to return to ANY physical exertion or sports, including weight lifting, running, practice or competition until you are medically cleared by a team physician. Report back to the athletic training room on ____________________ at __________am/pm Update Feb 11 2011 Arizona State University Mild Traumatic Brain Injury (MTBI)/Concussion Program Arizona State University Expanded Concussion Protocols Arizona State University Athletics has maintained a strong commitment to the health and wellness of its student-athletes with a robust concussion protocol. While the preceding “current” MTBI Concussion policy clearly communicated ASU’s commitment to student-athlete well-being, in the last 24 months Sun Devil Athletics has taken certain measures and steps to advance to the forefront of college athletics relative to concussion prevention, detection, and research. This advancement includes: • • • The incorporation of a modified NFL SNAP (Sideline Neurologic Assessment Program) for football home and away games and soccer home competitions; Consultation from the Barrow Neurological Center and NFL lead neurologist on concussion protocols and; Partnership with the Riddell corporation, the TGEN group (Translational Genomics Research Institute), Barrow Neurological Center in groundbreaking concussion research. We welcome this opportunity to outline and in some cases enhance our concussion protocols. Pre-Season Education: Arizona State University has updated its pre-season education on concussions to include all of the following: o o o o o o All student athletes Coaches Team Physicians Athletic Training Staff and graduate assistants Strength and conditioning coaches Athletic Directors overseeing Division I sports teams The previous educational practices of brief lectures and video training with football have now been upgraded to not only to include an online education module, but also a learning assessment segment for ALL STUDENT-ATHLETES. This module/assessment is to be placed on the institution’s secure Blackboard to allow for tracking and proof of completion of this preseason education component. Education includes explanation of what constitutes a concussion, the medical need to be protected by being pulled from harm’s way until resolved and the process of knowing what to expect through the return to learn and return to play regimens. Additionally, NCAA generated and/or other applicable materials (i.e., fact sheets), will be distributed to the aforementioned parties. Pre-participation Assessment: Arizona State University has utilized the neurocognitive ImPACT test since its inception for its baseline concussion assessment. To upgrade the baseline ImPACT testing now all student-athletes will have a baseline ImPACT assessment. The high risk sports will have a repeat baseline ImPACT performed every two years, regardless of sustaining a head injury or not. High risk sports will include, at the minimum, baseball, basketball, diving, football, gymnastics, ice hockey, lacrosse, pole vaulting, soccer, softball, water polo, and wrestling. The pre-participation exam includes a brain/concussion injury history along with reviewing the symptom score on the individual’s ImPACT test. Balance evaluation had been trialed utilizing both the Sway and King Devick, but it has since been decided to utilize the modified BESS evaluation that accompanies the SCAT – 3 exam. This includes the Double Leg Stance, Single Leg Stance, and the Tandem Stance. In addition, all high risk sports will receive a baseline SCAT – 3 exam. The team physician will have final determination of pre-participation medical clearance. Recognition and Diagnosis of Concussion: All team physicians and athletic trainers (including graduate assistant athletic trainers) receive annual education and training regarding concussion recognition and diagnosis. Outlined below is the specific protocol for recognition and diagnosis of concussion with the football studentathletes. This is our most advanced model, however a similar protocol is present for all other sports as well: Arizona State University’s Football Sidelines Concussion Best Practices (employed during both practices and competitions). ● Team Physicians and team athletic trainers are trained observers ● Team Physician with brief view/observation of team unit each time off the field ● Any suspected head injury should be brought to designated Team Physician with helmet removed Modified/Brief MTBI Assessment for Sideline: o Do you remember the hit? o Did you black out or lose consciousness? o Do you have a headache, neck pain, or pain/tingling down extremities? o Do you have blurred or double vision, or sensitive to light? o Do feel dizzy or lightheaded, feel like in a fog? o Do you remember the play, your responsibility, the score, the half, our win/loss record, today’s date? Exam: Cervical/Head exam, EOM exam, minimum of at least one closed eye balance test Suspected head injuries are pulled from competition and may be escorted to the locker room where physician performs a full SCAT 3 exam. Cleared athletes should be on team physician’s radar screen for a minimum of 15 minutes of live time. All disqualified athletes, suspected of sustaining a head injury, are removed from competition and not permitted to return to activities until further evaluation is performed in coherence with this protocol. FOOTBALL (Home and Away) ONLY AND HOME SOCCER GAMES Arizona State University has instituted the S.N.A.P. program in 2014 that mimics the NFL program for added observers during football games and women’s soccer (See Addendum I). The S.N.A.P. (Sideline Neurologic Assessment Program) is led by a local neurologist who happens to be the NFL’s lead neurologist for this program on the NFL’s Head, Neck and Spine committee. The certified athletic trainer in the booth is the same one that the NFL uses to cover the Arizona Cardinals. There are two neurologists on the field and all are in communication with each other and a designated team physician on the sidelines. Any impact that generates concern for a potential head injury is communicated to the team physician who immediately evaluates that athlete when able to remove that athlete from play. Concerns are also shared with the head football trainer who immediately notifies that athlete’s position coach to aid in the removal of said athlete. A pilot program for women’s soccer had one neurologist present at all home games to assist in identifying and evaluating any potential head injuries. All other sports at Arizona State University are evaluated by appropriate personnel (ATC, MD) and protocols are followed as listed in this document. Post-Concussion Management: Any severe neurological occurrence initiates the Emergency Action Plan (EAP) Severe neurological conditions include but are not limited to: Glasgow <13, Focal Neurologic deficits, Persistent and worsening mental status and/or other neurologic symptoms, and spine injury of any type. The EAP consists of the EMT unit on the sidelines, team physicians, athletic trainers and neurologists from the SNAP (in the case of football – home and away – and soccer – home). The designated team physician is the director of all activities once the EAP is initiated. He/she directs the team in appropriate neurologic assessment and coordination of previously assigned duties of each team member. EMT units are always updated on every game day as to the EAP and transport of all neurologic conditions to Barrow’s Neurologic Hospital. Diagnosed Concussions: All athletes diagnosed with a concussion are given all warnings and precautions both verbally and written. A roommate, parent, coach, or teammate is also assigned and given the same instructions and are asked to provide overnight availability and observance of the athlete’s first night of diagnosis. Athlete is removed from all activities and put on “Brain Rest” for a minimum of 24 hours and a letter excusing athlete from course work is given to that athlete’s academic advisor to aid in the communication of athlete’s injury to his/hers’ professors. Diagnosis of concussion is also reported to academic support staff. The athlete then reports daily to the medical staff and completes a symptom score each day. Any new or concerning changes in the athlete’s symptoms are then evaluated by a team physician that day. Prolonged symptoms or new conditions that could fall under “Post-Concussion Syndrome” are then evaluated by the team physician and addressed/treated or referred to our designated neurology concussion expert at Barrow’s Neurologic for further evaluation and treatment regimen. Those conditions are as follows and not limited to: Sleep dysfunction, emotional lability including anxiety and depression, headaches or migraines and ocular and vestibular dysfunction. Return to Play: All return to play decisions are directed by a team physician. Athletes are followed by their daily concussion symptom scores and then determined by the team physician for the timing to begin the stepwise progression for return to play. All return to play should also be in coherence with our “return to learn” protocols. Once an athlete is at or close to their baseline level of cognition, a graduated stepwise return to play can be initiated providing no worsening or return of symptoms arise at any stage. Our stepwise approach follows several steps that can at times be combined but not to be abbreviated and cover a minimum of 4-6 day time period. Final clearance is decided by the team physician combined with athletes return to baseline balance and ImPACT evaluations. Graduated return to play protocol Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage 1. No activity Symptom limited physical and cognitive rest Recovery 2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity <70% maximum permitted heart rate No resistance training Increase HR 3. Sport-specific exercise Skating drills in ice hockey, running drills in Add movement soccer. No head impact activities 4. Non-contact training drills Progression to more complex training drills, Exercise, coordination and e.g., passing drills in football and ice hockey cognitive load May start progressive resistance training 5. Full-contact practice Restore confidence and assess Following medical clearance participate in functional skills by coaching normal training activities staff 6. Return to play Normal game play Adapted from Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Return-to-Learn: Return-to-learn (RTL) is a parallel concept to return to play in that it is an individualized, stepwise program for successful reintegration into the classroom. As concussion and mild traumatic brain injury are covered under the Americans with Disabilities Act Amendments Act (ADAAA), our program, in working with the campus disability office, is compliant with ADAAA law. As student athletes return to school after a concussion, it is important to observe for the following: increased problems with attention or concentration, increased problems remembering or learning new information, longer time needed to complete tasks or assignments, difficulty organizing tasks or shifting between tasks, inappropriate or impulsive behavior during class, greater irritability, less ability to cope with stress, more emotionality, fatigue, difficulties in a stimulating environment including physical symptoms such as headache, nausea, or dizziness. Successful RTL is dependent on several variables, including identification of co-morbid conditions that can delay recovery. It is also important to note that each student athlete will recover at a different rate. After diagnosis of a concussion, a multidisciplinary team consisting of the team physician, athletic trainer, and team academic support staff will guide RTL, with all members communicating about updates. This team will be supported by a counseling center representative, faculty athletic representative, and individual teacher(s) as needed. While a student athlete is symptomatic, they will continue to be seen at regular intervals by the team physician. 1. Immediate cognitive rest at home, with no return to cognitive work on same day of diagnosis. Cognitive rest includes resting in a cool, dark room, away from bright lights and loud noises. It also entails the avoidance of potential stressors such as class, reading, computer work, writing papers and also including leisure activities such as driving, playing video games, watching television and texting. *Due to the energy crisis that occurs after a concussion, providing both physical and cognitive rest allows the brain to heal more quickly. When the student athlete is asymptomatic at rest, they may progress to the next phase. 2. Trial 10-30 minutes of light cognitive activity. This may be reading or a math challenge. If the student athlete is unable to tolerate this, they should stay home or in the residence hall. To move to the next stage the student athlete needs to be able to sustain concentration for 30 minutes without symptom exacerbation and the symptoms need to disappear with cognitive rest breaks. 3. Return to partial day of school. Return to the classroom should include no more than 30-45 minutes of cognitive activity at one time, followed by at least 15 minutes of rest. Student athletes may attend 1-3 classes per day with interspersed rest breaks. There should be minimal expectations for productivity with no tests or homework. As student athlete status continues to improve, being able to tolerate 4-5 hours of activity with breaks and no increase in symptoms, they may move to the next stage. 4. Full day with maximum support. Student athletes would attend most classes, with 2-3 rest breaks throughout the day of 20-30 minutes. No tests or quizzes. Minimal homework of less than 60 minutes and minimal to moderate expectations for productivity. To move to the next stage they should be able to tolerate increased demands with only 1-2 breaks needed. 5. Full day with moderate support. Student athletes would attend all classes with 1-2 rest breaks throughout the day of 20-30 minutes. May begin quizzes. Moderate homework up to 60-90 minutes and moderate expectations for productivity. At this time a schedule can be established for make-up work. 6. Full day with minimal support. Student athletes would attend all classes with 0-1 rest breaks throughout the day of 20-30 minutes. They may begin modified tests with breaks and extra time. Homework of 90 minutes and maximum expectations for productivity. 7. Full day with no support needed. Student athletes attend their full class schedule with no rest breaks. There are maximum expectations for productivity and begin to address make-up work. Most student athletes with concussion recover in 2 weeks and will not require a significant program. However, for those athletes who have delayed recovery, the team physician, the team learning specialist, the ASU Disability Resource Center and the faculty representative (if necessary) will help facilitate academic adjustment, accommodation, and modification including an individualized education plan. Reducing Exposure to Head Trauma: Reducing exposures to head trauma is mostly an education issue. Along with the coach’s education module is an education section depicting numerous examples of ways to reduce an athlete’s exposure to differing forms of head trauma in different sport venues. Another aspect to reducing exposure to head trauma is the review of all concussions as they inevitably occur and critique the mechanism of injury to decide if there was any possible preventative measures that may have been employed prior to the head injury. ADDENDUM I Sideline Neurological Assessment Program (S.N.A.P.) Introduction and Summary: Traumatic brain injury (TBI) affects over 1.5 million Americans annually. TBI is the leading cause of death and disability in youth populations and is considered the “signature” injury of the Iraq and Afghanistan wars. TBI, even its mildest form (concussion), can result in disabling symptoms such as persistent headaches, sleep disturbance, personality changes, and cognitive deficits. Although the long-term consequences of repeated brain injury continue to be explored, current data suggest a significant association with neurodegenerative diseases such as dementia, Parkinson’s disease, and amyotrophic lateral sclerosis (Lou Gehrig’s disease). Athletic activity is among the highest risk factors for concussion in a young and otherwise healthy population. Recent media publications highlight the potential dangers to professional athletes, especially in football. The greatest risk of permanent neurological injury and rarely death presents when an athlete is returned to the field prematurely and suffers a second or third concussion. Those risks are more substantial in the collegiate athlete. Mandates at the professional level place neurotrauma specialists on the field to provide coverage and sideline consultation. Anticipating adoption of professional football mandates, early programmatic development provides an opportunity to influence design and implementation at the NCAA level. Creating a model concussion program in partnership with Arizona State University will enhance its leadership position in collegiate sports. For both home and away games in 2014, the Sideline Neurological Assessment Program (S.N.A.P.) will: • • • • • Identify potential concussive injuries on the field Communicate with the team medical staff via radio Provide sideline neurological assessments for athletes with suspected concussion and other neurological injuries Create an emergency action plan for catastrophic neurological injury Be a model program for the NCAA Roles and Responsibilities: Sideline spotter The S.N.A.P. spotter is to identify potential neurological injury from the sidelines. Two spotters are placed on the home sideline, one at either of the field. Utilizing a dedicated radio channel, S.N.A.P. spotters communicate with the head team physician and/or head ATc regarding collisions of an extreme nature or clinical signs concerning for concussion. At the head team physician's discretion, athletes with suspected concussion will then be evaluated by the sideline neurotrauma specialist. The S.N.A.P. spotter may be a neurotrauma specialist (neurologist or neurosurgeon), athletic trainer, assistant team physician, or resident/trainee in any of those disciplines. At least one of the two S.N.A.P. spotters must be a neurotrauma specialist that also serves as the sideline consultant. In the event that the one of the spotters is a trainee/resident, the second spotter must be a must be a board certified/board eligible neurotrauma consultant that is either a neurologist or neurosurgeon. With the exception of sideline consultant, it is critically important that the S.N.A.P. spotter's role be exclusive to the spotter and not be combined with any other responsibilities or duties. Sideline neurotrauma consultant In the event of a potential concussion, the S.N.A.P. neurotrauma specialist will perform a brief neurological assessment and render an opinion to the head team physician. A more detailed evaluation may be performed in the clinic room. In order to ensure continued coverage during the clinic room assessment, the second spotter will remain on the field. After assessing an athlete with suspected concussion, the S.N.A.P. neurologist will make a diagnosis and advise the head team physician on fitness for return to play. Ultimate decisions for participation are at the discretion of the head team physician. Event reporting Within 8 hours of game completion, the S.N.A.P. neurologist consulting on any neurologic injury will provide a detailed report to the head team physician. Details include; athlete demographics, time of event, diagnosis, mechanism of injury, action taken, and follow up and/or treatment recommendations. Emergency action plan for catastrophic neurological injury Catastrophic neurological injury is a rare, but devastating occurrence and an emergency action plan for these scenarios is critical to minimizing permanent neurological sequelae. Elements of the emergency action plan include identification of sideline emergency medical staff for airway management and a designated tertiary center specialized in neurological injury. Visiting team coverageThe Sideline Neurological Assessment Program will not be extended to visiting teams. However, visiting teams will be made aware of the presence of neurotrauma specialists on the field, in the event of catastrophic neurological injury. Requirements: S.N.A.P. neurologists (2) Radios with dedicated channel (3) One for the S.N.A.P. neurology consultant One for the S.N.A.P. Spotter One for the ASU head team physician or designee Closing thoughts: Mild traumatic brain injury/concussion and its sequelae threaten the future of all contact sports, especially football. Proactive efforts are required to ensure the health of student athletes and the future of NCAA football. The Sideline Neurological Assessment Program (S.N.A.P.) is an innovative effort that will be a model system of care for the entire NCAA and establish Arizona State University as a leader in the promotion of initiatives to protect the health and safety of its student athletes. CONCUSSION MANAGEMENT PLAN The following policy and procedures addressing neurocognitive baseline testing, identification, evaluation, treatment, education, return-to-play and return-to-learn guidelines for concussion management have been developed in accordance with the NCAA and the University of Arkansas’ commitment to providing quality healthcare to each of our student-athletes. By employing these protocols, the University of Arkansas Athletics Department will meet the following objectives:  Equitable access to healthcare will be provided for all Razorback student-athletes. The University of Arkansas ensures that student-athletes have appropriate healthcare, including equitable access to athletic healthcare providers for each varsity sport.  All athletics healthcare providers will understand and follow emergency action plans to provide a safe environment for our student-athletes. The University of Arkansas maintains an annually updated emergency action plan for each athletic venue. All athletic healthcare providers will review the plan annually.  Appropriate medical personnel will oversee healthcare for student-athletes and will determine time lines for return-to-play and return-to-learn. The Sports Medicine team is clearly empowered to have the unchallengeable authority to determine management and return-to-play and return-to-learn of any ill or injured student-athlete.  Clear assignment of responsibilities will ensure proper execution of medical protocols. The Sports Medicine Team has clearly defined roles related to concussion management.  The Sports Medicine Team will practice within the standards of the 2012 Zurich Consensus Guidelines regarding concussion management and return to play.  Selected staff members will read, understand and follow required educational materials and protocols related to concussions and will actively participate in these protocols. All members of the coaching, strength and conditioning, and athletic training staffs will receive educational materials (e.g., the NCAA Concussion Fact Sheet) to assist in identifying the signs and symptoms of concussion. Team physicians, sport administrators and the director of athletics also will receive these materials and all will acknowledge in writing that they have read and understood the materials. Coaches will be given the concussion management plan, their role within the plan will be identified and they will be required to sign an acknowledgement of their receipt and understanding of concussion education and protocols.  All student-athletes will read and understand required educational materials related to concussions and will actively participate in these protocols. Further, they will sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the medical staff, including signs and symptoms of concussions. Student-athletes will be given take-home educational materials (e.g., the NCAA Concussion Fact Sheet) and will acknowledge in writing that they have read and understand the materials.  Baseline testing will be appropriately employed and documented as part of the required protocol for all student-athletes. All student-athletes are required to complete baseline testing prior to their first practice and the same assessment tools will be used post-injury at appropriate time intervals. These tests will include--but are not limited to--balance testing, paper-based (SCAT 3) and computerized (IMPACT) neuropsychological screening, brain injury and concussion history, cognitive assessment and symptom evaluation. Team physicians will determine pre-participation clearance and/or the need for additional consultation or testing.  Appropriate care and professional medical judgement will be employed to provide optimal care to student-athletes who may have suffered concussions. Student-athletes will be removed from practice or competition when they show signs, symptoms or behaviors consistent with a concussion. The student-athletes also will be evaluated by a healthcare provider with experience in the evaluation and management of concussions. Student-athletes will be monitored for deterioration and given written instructions on management of concussions. Final authority on return-to-play and return-to-learn will reside with Dr. Ramon Ylanan.  Appropriate recovery time will be taken for each student-athlete diagnosed with a concussion. Student-athletes diagnosed with concussions will be withheld from competition, practice and classroom activies for the remainder of the day, at a minimum. Student athletes will be evaluated by a team physician and will follow a medically supervised process for return-to-learn and return-to-play. Once asymptomatic, at or above baseline on neurocognitive baseline tests, after completion of an exertional protocol and after returning-to-learn without reoccurence of symptoms, student-athletes will be allowed to full return-to-play.  Appropriate written records must be maintained. The Sports Medicine Team will be responsible for documentation of the incident, evaluation, continued management and clearance of any and all student-athletes with concussions.  Student-athlete safety is paramount. As a result, emphasis will be placed on following current sport rules. Purposeful or flagrant head or neck contact in any sport will not be tolerated and current rules of play will be strictly enforced. The department will take a “safety first” approach to sports, including adherence to contact guidelines, gratuitous contact and maintaining educational initiatives as safe play and proper technique protocols are identified in response to future concussion research. CONCUSSION MANAGEMENT TEAM A multi-disciplinary team will be responsible for employing the protocols outlined in this document are assigned respective roles in mild traumatic brain injury/concussion management. All individuals who will serve these roles will participate in education and review sessions at least once per year.  Primary Care / Sports Medicine Physician (Dr. Ramon Ylanan) will have final clearance on all concussions. He will supervise stepwise progression and he will serve as the final authority on a student-athlete’s return-to-learn and return-to-play.  Primary Care Doctors (Assigned by Team) will diagnose mild traumatic brain injuries and will defer to and communicate with Dr. Ylanan regarding final clearance.  Orthopedic Medicine Doctors (Assigned by Team) will diagnose mild traumatic brain injuries and will defer to Dr. Ylanan for final clearance.  Nurse Practitioner (Kelly Lueders) will recognize mild traumatic brain injuries, will refer student-athletes to their respective team physicians they show symptoms of concussion, and will defer to Dr. Ylanan for final clearance.  Athletic Training Staff (Assigned by Team) will recognize and treat mild traumatic brain injuries, will refer student-athletes to a team physician if they show symptoms of concussion, and will defer to Dr. Ylanan for final clearance.  Neuropsychologist (Dr. Sarah Downing) will consult as a specialist in IMPACT interpretation and concussion rehabilitation.  Neurosurgeon (Dr. J.B. Blankenship) will consult as a specialist in brain, spinal cord and peripheral nerves injuries will be involved with complicated mild traumatic brain injuries.  Academic Counselor/Learning Specialist (Assigned by Team) will help navigate return-to-learn activities with student-athletes and will coordinate compliance activities with campus disability services, ensuring ADAAA compliance.  Director of Clinical and Sport Psychology (Dr. Michael Johnson) will help navigate return-tolearn activites and congnitive management.  Faculty Athletics Representative (Dr. Sharon Hunt) will help navigate complex return-to-learn cases, as needed. EDUCATION Participation in sport may result in injury or illness, including concussions. A concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). All student-athletes will read and understand required educational materials related to concussions and will actively participate in these protocols. Further, they will sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the medical staff, including signs and symptoms of concussions (Appendix A). Student-athletes will be given take-home educational materials (e.g., the NCAA Concussion Fact Sheet) and will acknowledge in writing that they have read and understand the materials. Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Imbalance Dizziness Nervousness Nausea Sensitivity to light Sensitivity to noise Numbness/tingling Headache Drowsiness Sadness Fatigue Difficulty remembering Difficulty concentrating Loss of consciousness Signs and symptoms must be reported to the University of Arkansas Sports Medicine staff immediately upon onset, before the continuation of any activity. The final decision for return to learn and return to play rests with Dr. Ramon Ylanan and is unchallengeable. Dr. Ylanan will supervise stepwise progression through the recovery plan. Selected staff members will read, understand and follow required educational materials and protocols related to concussions and will actively participate in these protocols. All members of the coaching, strength and conditioning, and athletic training staffs will receive educational materials (e.g., the NCAA Concussion Fact Sheet) to assist in identifying the signs and symptoms of concussion. Coaches will be given the concussion management plan, their role within the plan will be identified and they will be required to sign an acknowledgement of their receipt and understanding of concussion education and protocols (Appendix B). Team physicians (Appendix C), athletic trainers (Appendix D) sport administrators (Appendix F) and the director of athletics (Appendix E) also will receive these materials and all will acknowledge in writing that they have read and understood them (Appendix E). PRE-PARTICIPATION ASSESSMENT Baseline testing will be appropriately employed and documented as part of the required protocol for all student-athletes on an annual basis. All student-athletes are required to complete baseline testing prior to their first practice and the same assessment tools will be used post-injury at appropriate time intervals. These tests include--but are not limited to--balance testing, paper-based (SCAT 3) and computerized neuropsychological screening (IMPACT), brain injury and concussion history, cognitive assessment and symptom evaluation. Team physicians will determine pre-participation clearance and/or need for additional consultation or testing. If a student-athlete presents a complicated or multiple-concussion history, additional baseline testing may be conducted mid-year or at another appropriate interval as determined by the team physician. Utilazation of the SCAT 3 tool will evaluate potential signs of concussion, including brain injury and concussion history, symptom evaluation, cognitive assessment, and balance evaluation (BESS). Further, utilization of IMPACT will evaluate potential brain injury and concussion history, symptom evaluation and cognitive assessment. RECOGNITION AND DIAGNOSIS OF CONCUSSION If a student-athlete has signs, symptoms or behaviors consistent with a concussion, the student-athlete will be removed from competition and evaluated by an athletic trainer or team physician with concussion experience. Initial assessment’s will include assessment of cervical spine trauma, skull fracture and/or intracranial bleeding. Utilization of the SCAT 3 sideline assessment tool will evaluate potential signs of concussion, including brain injury and concussion history, symptom evaluation, cognitive assessment and balance evaluation (BESS). Please refer to Appendix G for specific guidelines for head injury evaluation. Once a concussion is suspected or diagnosed, the student-athlete will be further evaluated by Dr. Ramon Ylanan, who is experienced and trained in the management of concussions. In consultation with Dr. Ylanan, the athletic training staff and primary care physicians will work together to order additional testing (e.g. imaging, neuropsychiatric testing and referrals) as needed and outline a plan for return-to-learn and return-to-play. Dr. Ylanan will supervise stepwise progression to recovery. The final decision for return-to-learn and return-to-play rests with Dr. Ylanan and is unchallengeable. In certain cases, such as extensive travel, Dr. Ramon Ylanan will be available by phone to assist the athletic training staff with decisions regarding the need for urgent evaluations. If a student-athlete is diagnosed with a concussion, the student-athlete will be removed from participation and shall not return to activity on that day. The University of Arkansas will have a physician with experience in the management of concussion either on-site or on-call for all home athletic events. At all times, a physician with experience in the management of concussions will be available for phone consultation. Student-athletes diagnosed with a concussion will be given written instructions on management of concussions and monitored for deterioration overnight. This is optimally done by roommates, significant others, family, guardians or anyone expected to be staying with student-athlete overnight. POST-CONCUSSION MANAGEMENT The Emergency Action Plan will be activated if the following are present during the initial evaluation of a student-athlete with a suspected head or neck injury: cervical spine injury/trauma, skull fracture, Glasgow Coma Scale < 13, prolonged LOC > 1 minute, focal neurological deficit suggesting intracranial trauma, repetitive emesis, persistently diminished/worsening mental status or other neurological signs/symptoms. Evaluation by the athletic trainer and team physician will determine whether or not the student-athlete is safe to go home or should be taken to the hospital. Serial evaluation and monitoring for deterioration following injury will be conducted. Student-athletes diagnosed with a concussion will be given written instructions on management of concussions and monitored for deterioration overnight. Optimally, this will be done by roommates, significant others, family, guardians or anyone expected to be staying with student-athlete overnight. Student-athletes will receive the document outlined in Appendix H before they are released from the site of the assessment. Student-athletes with prolonged symptoms may require additional diagnosis and best management options. These student-athletes may need additional referral for vestibular therapy, post-concussion syndrome, mood disorders, sleep deprivation, migraines or nutritional disorders. In such instances, team physicians will conduct follow-up evaluations to consider additional treatment and management options. RETURN-TO-PLAY FOLLOWING A CONCUSSION The timetable for a return-to-play and return-to-learn will be individualized and dependent on numerous factors. For a student-athlete to return-to-play, he or she must at a minimum, meet the following progressive standards:    The student-athlete must have full resolution of symptoms. The student-athlete must be at or above his or her previous baseline testing. The student-athlete has undergone an appropriate step-by-step return to activity plan and has tolerated a graded exertional protocol without symptoms returning, including the following:  Light aerobic exercise without resistance training  Sport-specific exercise and activity without head impact  Non-contact practice with progressive resistance training  Unrestricted training  Return-to-competition Finally, clearance for return-to-play resides solely with Dr. Ramon Ylanan, who will supervise the stepwise progression through the plan. As with all conditions, no one clinical factor can be used to either diagnose concussions or determine when return to activities is safe after concussion. Symptoms, clinical evaluation, diagnostic studies and testing such as neuropsychological tests all will be weighed in the decision. RETURN-TO-LEARN FOLLOWING A CONCUSSION Concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). 80-90% of concussions resolve spontaneously within 7-10 days, follow a sequential course towards resolution, however, some concussions take a protracted course towards resolution. Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Imbalance Dizziness Nervousness Nausea Sensitivity to light Sensitivity to noise Numbness/tingling Headache Drowsiness Sadness Fatigue Difficulty remembering Difficulty concentrating Loss of consciousness After suffering a concussion, there is a brain energy crisis. Due to this crisis, cognitive rest is necessary to enhance the recovery process. A student-athlete’s academic schedule may need some modification in the first one to two weeks following a concussion. In such cases, the athletic trainer and academic counselor often will be able to handle academic modifications through recovery. An individualized plan will be documented that may include remaining at home until light cognitive activity can be tolerated, along with gradual return to the classroom. More complex cases of prolonged return-to-learn will be managed by a multi-disciplinary concussion management team. If cases are prolonged, campus resources will be identified by the learning specialist and accommodations will be made in compliance with ADAAA through the Office of Disabilities Services as needed. The academic services staff will communicate with faculty to make them aware of injuries and the related symptoms that student-athletes may experience. Student-athletes will refrain from all classroom activity the same day as a concussion. Possible modification to classroom activity to allow cognitive rest, providing adequate time for recovery, while allowing the student-athlete to participate in some classroom activity, also may be necessary. When the student-athlete resumes class, faculty will be aware that their academic performance may suffer during the recovery process and that student-athletes should progress to the classroom and studying activities as tolerated. Please refer to Appendix I for a sample return-to-learn letter. Final authority to return-to-learn will reside with Dr. Ramon Ylanan, who will continue re-evaluation of the studentathlete until symptoms resolve. If symptoms are persistent after a 14-day period, further modifications will be recommended by the multidisciplinary team. STEPS TO REDUCE EXPOSURE TO HEAD INJURIES The University of Arkansas Department of Athletics will continue to emphasize ways to minimize head trauma exposure and will expand its efforts as additional research is conducted to identify best practices for prevention and treatment of concussions. Following are examples of current efforts:  Adherence to the Inter-Association Consensus: Year-Round Practice Contact Guideline  Preseason: For days in which two practices are scheduled, live contact will only be allowed in one practice. A maximum of four live contact practices will occur in a given week, and a maximum of 12 total will occur in preseason. Further, only three practices (scrimmages) will include live contact for greater than 50 percent of the practice schedule.  Inseason: Inseason is defined as the period between six days prior to the first regular-season game and the final regular-season game (or conference championship game, for participating institutions). There will be no more than two live contact practices per week during this period.  Spring Practice: Of the 15 allowable sessions that may occur during the spring practice season, up to eight practices will involve live contact with only three of the live contact practices to include greater than 50 percent live contact (e.g. scrimmages). Live contact practices will be limited to two in a given week and will not occur on consecutive days. Definitions -Live contact practice: Any practice that involves live tackling to the ground and/or full speed blocking. Live-contact practice may occur in full-pad or half-pad (also known as “shell,” in which a player wears shoulder pads and shorts, with or without thigh pads). Live contact does not include: (1) “thud sessions,” or (2) drills that involve “wrapping up;” in these scenarios players are not taken to the ground and contact is not aggressive in nature. Live contact practices are to be conducted in a manner consistent with existing rules that prohibit targeting to the head or neck area with the helmet, forearm, elbow, or shoulder, or the initiation of contact with the helmet. -Full pad practice: Full-pad practice may or may not involve live contact. Full-pad practices that do not involve live contact are intended to provide preparation for a game that is played in a full uniform, with an emphasis on technique and conditioning versus impact.  Education of football student-athletes on proper tackling techniques and practicing good sportsmanship See Appendix J.  Continued emphasis of student-athlete safety as a priority, including an annual meeting of the sports medicine staff and the Athletic Director, during which the unchallengeable authority of the team physicians will be clearly articulated. During this meeting, the Athletic Director and staff will discuss the culture and environment of surrounding student-athlete care and support for their well-being.  Provide educational materials to student-athletes, coaches, athletic trainers and athletic administration to certify that they have carefully read, fully understand, and aware of the signs/symptoms of concussions. APPENDIX A Name ________________________________________ Date________________________ A concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Sensitivity to light Sadness Imbalance Sensitivity to noise Fatigue Dizziness Numbness/tingling Difficulty remembering Nervousness Headache Difficulty concentrating Nausea Drowsiness Loss of consciousness Signs and symptoms must be reported to the University of Arkansas Sports Medicine staff immediately upon onset, before the continuation of any activity. Return to any activity will be determined by the University of Arkansas Sports Medicine staff after proper evaluation. This is to certify that I have carefully read, fully understand, and that I am aware of the signs/ symptoms of concussions. I have received education on the signs/symptoms associated with concussions. I acknowledge that all signs and symptoms of concussions must be reported to the University of Arkansas Sports Medicine staff immediately upon onset. Student-Athlete’s Signature Date Parent or Guardian’s Signature Date APPENDIX B Name ________________________________________ Date________________________ A concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Sensitivity to light Sadness Imbalance Sensitivity to noise Fatigue Dizziness Numbness/tingling Difficulty remembering Nervousness Headache Difficulty concentrating Nausea Drowsiness Loss of consciousness Signs and symptoms must be reported to the University of Arkansas Sports Medicine staff immediately upon onset, before the continuation of any activity. Return to any activity will be determined by the University of Arkansas Sports Medicine staff after proper evaluation. This is to certify that I have carefully read, fully understand, and that I am aware of the signs/ symptoms of concussions. I have received the NCAA concussion fact sheet education material on the signs/symptoms associated with concussions. I acknowledge that all signs and symptoms of concussions must be reported to the University of Arkansas Sports Medicine staff immediately upon onset. Coach’s Signature Date APPENDIX C Name ________________________________________ Date________________________ A concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Sensitivity to light Sadness Imbalance Sensitivity to noise Fatigue Dizziness Numbness/tingling Difficulty remembering Nervousness Headache Difficulty concentrating Nausea Drowsiness Loss of consciousness Signs and symptoms must be reported to the University of Arkansas Sports Medicine staff immediately upon onset, before the continuation of any activity. Return to any activity will be determined by the University of Arkansas Sports Medicine staff after proper evaluation. This is to certify that I have carefully read, fully understand, and that I am aware of the signs/ symptoms of concussions. I have received the NCAA concussion fact sheet education material on the signs/symptoms associated with concussions. I acknowledge that all signs and symptoms of concussions must be reported to the University of Arkansas Sports Medicine staff immediately upon onset. Team Physician’s Signature Date APPENDIX D Name ________________________________________ Date________________________ A concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Sensitivity to light Sadness Imbalance Sensitivity to noise Fatigue Dizziness Numbness/tingling Difficulty remembering Nervousness Headache Difficulty concentrating Nausea Drowsiness Loss of consciousness Signs and symptoms must be reported to the University of Arkansas Sports Medicine staff immediately upon onset, before the continuation of any activity. Return to any activity will be determined by the University of Arkansas Sports Medicine staff after proper evaluation. This is to certify that I have carefully read, fully understand, and that I am aware of the signs/ symptoms of concussions. I have received the NCAA concussion fact sheet education material on the signs/symptoms associated with concussions. I acknowledge that all signs and symptoms of concussions must be reported to the University of Arkansas Sports Medicine staff immediately upon onset. ATC’S Signature Date APPENDIX E Name ________________________________________ Date________________________ A concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Sensitivity to light Sadness Imbalance Sensitivity to noise Fatigue Dizziness Numbness/tingling Difficulty remembering Nervousness Headache Difficulty concentrating Nausea Drowsiness Loss of consciousness Signs and symptoms must be reported to the University of Arkansas Sports Medicine staff immediately upon onset, before the continuation of any activity. Return to any activity will be determined by the University of Arkansas Sports Medicine staff after proper evaluation. This is to certify that I have carefully read, fully understand, and that I am aware of the signs/ symptoms of concussions. I have received the NCAA concussion fact sheet education material on the signs/symptoms associated with concussions. I acknowledge that all signs and symptoms of concussions must be reported to the University of Arkansas Sports Medicine staff immediately upon onset. Director of Athletics Signature Date APPENDIX F Name ________________________________________ Date________________________ A concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Sensitivity to light Sadness Imbalance Sensitivity to noise Fatigue Dizziness Numbness/tingling Difficulty remembering Nervousness Headache Difficulty concentrating Nausea Drowsiness Loss of consciousness Signs and symptoms must be reported to the University of Arkansas Sports Medicine staff immediately upon onset, before the continuation of any activity. Return to any activity will be determined by the University of Arkansas Sports Medicine staff after proper evaluation. This is to certify that I have carefully read, fully understand, and that I am aware of the signs/ symptoms of concussions. I have received the NCAA concussion fact sheet education material on the signs/symptoms associated with concussions. I acknowledge that all signs and symptoms of concussions must be reported to the University of Arkansas Sports Medicine staff immediately upon onset. Administrator Signature Date APPENDIX G HEAD INJURY EVALUATION GUIDELINES If a suspected head injury occurs, the student-athlete will be removed from competition and evaluated by a healthcare provider. The initial evaluation should rule out cervical spine injury/trauma, skull fracture, prolonged LOC > 1 minute, intercranial trauma, neurological deficit, repetitive emesis, persistently diminished/worsening mental status and/or other neurological signs/symptoms. If a student-athlete has a suspected concussion, he or she will be evaluated using the SCAT 3 sideline assessment. If a student-athlete is diagnosed with a concussion, the student-athlete will be removed from participation and shall not return to activity on that day. The University of Arkansas will have a physician with experience in the management of concussion either on-site or on-call for all home athletic events. At all times, a physician with experience in the management of concussions will be available for phone consultation. Student-athletes diagnosed with a concussion will be given written instructions on management of concussions and will be monitored for deterioration overnight. Optimally, this will be done by roommates, significant others, family, guardians or anyone staying overnight with the student-athlete. Once a concussion is suspected or diagnosed, the student-athlete will be evaluated by Dr. Ramon Ylanan who is experienced and trained in the management of concussions. Dr. Ylanan, the athletic training staff and primary care physicans will work together to order additional testing (imaging, neuropsychiatric testing and referrals) as needed and outline a plan for return-to-learn and -play. The final decision for return-to-learn and -play rests with Dr. Ramon Ylanan and is unchallengeable. In certain cases, such as extensive travel, Dr. Ramon Ylanan will be available by phone to assist the athletic training staff with decisions regarding the need for urgent evaluations. The timetable for return-to-play and return-to-learn will be individualized and dependent on numerous factors. For a student-athlete to return to play, the following minimum standards must be met:  The student-athlete must have full resolution of symptoms.  The student-athlete must be at or above their previous baseline testing.  The student-athlete has undergone an appropriate step-by-step return-to-activity plan and has tolerated a graded exertional protocol without symptoms returning.  Clearance for return-to-play resides solely with the team physician. As with all conditions, no one clinical factor can be used to either diagnose concussions or determine when return to activities is safe after concussion. Symptoms, clinical evaluation, diagnostic studies and testing such as neuropsychological tests all must be weighed in the decision. Clinical judgment will make the final determination. Those student-athletes with prolonged symptoms may require additional diagnosis and best management options. These student-athletes may need additional referral for vestibular therapy, learnind disorders, mental health disorders, sleep deprivation and nutrional disorders. APPENDIX H CONCUSSION INFORMATION FOR THE UNIVERSITY OF ARKANSAS STUDENT ATHLETE What is a concussion? A concussion is an injury to the brain caused by a blow to your head, neck, face or body which transmits force to the brain. This injury causes the brain not to function normally for a period of time. Concussions may be referred to as mild traumatic brain injuries and get better with time. However, occasionally there can be a more significant problem, and it is important that the symptoms from a concussion be monitored. When you suffer this injury, you may have problems with concentration and memory, notice an inability to focus, feel fatigued, have a headache or feel nauseated. Bright lights and loud noises may bother you. You may feel irritable or have other symptoms. What should I watch for? After evaluation by your athletic trainer and team physician, it may be determined you are safe to go home. Otherwise, you may be taken to the hospital. If you are sent home, you should not be left alone. A responsible adult should accompany you. Symptoms from your concussion may persist when you are sent home but should not worsen, nor should new symptoms develop. You and your chaperone should watch for such things as: 1. 2. 3. 4. 5. 6. 7. Increasing headache Increasing nausea or vomiting Increasing confusion Unusual sleepiness or difficulty being awakened Trouble using your arms or legs Garbled speech Convulsions or seizures If you notice any of these problems or have any other problem that appears worse as compared to how you felt at the time you left the stadium or practice, immediately call the athletic trainer or physician. In an emergency, call 911 or have someone transport you to the hospital immediately. Is it okay to go to sleep? Concussions, many times make players feel drowsy or tired. As long as you are not getting worse, it is all right for you to sleep. We recommend a responsible adult be at home with you in case any problems arise. May I take something for pain? Do not take any medication unless your athletic trainer or team physician has instructed you to do so. Normally, we do not advise anything stronger than Tylenol. Avoid the use of Aspirin, Motrin, Aleve, Ibuprofen or any other anti-inflammatory medication that you may have been taking. We also ask that you not consume alcohol and avoid caffeine and any other stimulants. If you are taking any supplements, we highly suggest that you discontinue the use of them as well. The athletic trainer and team physician will determine when you can restart medications and supplements. May I eat after the game? It is fine to eat if you are hungry. Remember, some players do have a sense or nausea and fatigue, and often find that their appetite is suppressed immediately after a concussion. Do not force yourself to eat. Do I need a CT scan or MRI examination? If the team physicians have determined that you are able to go home after the game, these types of diagnostic tests are not necessary. If you are sent to the hospital with a more serious injury, a CT scan or MRI examination is likely. If your symptoms linger for several days after a concussion, CT scan or MRI examination may be considered by your athletic trainer or team physician. How long will I be observed? You are to report to the athletic training room the morning after your concussion. You will be assessed by the athletic trainer and team physicians. You will take a neurocognitive test and your symptoms will be monitored. Return-to-play decisions vary by individuals, and will be based on physical exam and a return to baseline on the neurocognitive test. Athletic Trainer: _____________________________________ Contact Number: ______________________________________ Team Physician: _____________________________________ Contact Number: ______________________________________ You are to report to the athletic training room on: Day: ___________________________Time:_______________________ APPENDIX I RETURN-TO-LEARN FOLLOWING A CONCUSSION Concussion or Mild Traumatic Brain Injury (MTBI) or comotio cerebri is defined as a complex pathophysiologic process affecting the brain’s function. It is induced by traumatic biomechanical forces after impact to the head, face, neck or body that leads to a functional, not structural, disturbance which may or may not involve LOC (Loss of Conciousness). 80-90% of concussions resolve spontaneously within 7-10 days, follow a sequential course towards resolution, however, some concussions take a protracted course towards resolution. Student-athletes are responsible for reporting their injuries and illnesses to the medical staff; including signs and symptoms of concussions (MTBI’s). Signs and symptoms include, but are not limited to: Vomiting Sensitivity to light Sadness Imbalance Sensitivity to noise Fatigue Dizziness Numbness/tingling Difficulty remembering Nervousness Headache Difficulty concentrating Nausea Drowsiness Loss of consciousness After suffering a concussion, there is a brain energy crisis. Due to this crisis, cognitive rest is necessary to enhance the recovery process. A student-athlete’s academic schedule may take some modification in the first one to two weeks following a concussion. Please work with the student-athlete’s Athletic Trainer, Academic Counselor and Learning Specialist when navigating return-to-learn activities. A multidisciplinary team will navigate more complex cases as of prolonged return-to-learn. If cases are prolonged, campus resources will be identified by the learning specialist and accommodations will be made in compliance with ADAAA through the Office of Disabilities Services as needed. The Sports Medicine staff and Student-Athlete Development staff wants to make you aware of this injury and the related symptoms that the student-athlete may experience. __________________________ sustained a concussion on ____/____/_____. Student-athletes should refrain from all classroom activity the same day as a concussion. Possible modification to classroom activity to allow cognitive rest, providing adequate time for recovery, while allowing the student-athlete to participate in some classroom activity may also be necessary. When the studentathlete resumes class, please be aware that their academic performance may suffer during the recovery process. The student-athlete should progress to the classroom and studying activities as tolerated. Final authority to return to learn will reside with Dr. Ramon Ylanan, Primary Care Sports Medicine Physician, who will continue re-evaluation of the student-athlete until symptoms resolve. Any consideration you may provide academically during this time would be greatly appreciated. If you have any questions or concerns, please do not hesitate to contact the Student Athlete Development staff or Sports Medicine staff. Thank you for your time and consideration during this process. Matt Summers, M.Ed., ATC Director of Athletic Training 479-575-2586 mtsumm05@uark.edu Football Only Name_________________________________________ Date __________________________________ Do not use your helmet to butt, ram, or spear an opposing player. This is in violation of the football rules and such use can result in severe head or neck injuries, paralysis or death to you and possible injury to your opponent. Contact in football may result in CONCUSSION-BRAIN INJURY which no helmet can prevent. Symptoms include: loss of consciousness or memory, dizziness, headache, nausea or confusion. If you have symptoms, immediately stop playing and report them to your coach, athletic trainer or parents. Do not return to a game or practice until all symptoms are gone and you have received MEDICAL CLEARANCE. Ignoring this warning may lead to another and more serious or fatal brain injury. This is to certify that I have carefully read and that I fully understand the warning labels(s) attached inside and/or outside the football helmet issued to me by the University of Arkansas Athletic Department. _____________________________________________ _________________________________ Student-Athlete’s Signature Date _____________________________________________ _________________________________ Parent or Guardian’s Signature (Parent signature is required if student-athlete is under 18 years of age) Date University of Arkansas Athletics Department Certificate of Compliance for NCAA Constitution 3.2.4.17 and 3.2.4.17.1 Pursuant to NCAA Constitution 3.2.4.17 and 3.2.4.17.1 this document shall serve as the University of Arkansas’ certificate of compliance for our institution’s concussion management plan for our Razorback student-athletes. The attached plan includes, but is not limited to, the following: (a) An annual process that ensures student-athletes are educated about the signs and symptoms of concussion. Student-athletes must acknowledge that they have received information about the signs and symptoms of concussion and that they have a responsibility to report concussion-related injuries and illnesses to a medical staff member; (b) A process that ensures a student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from athletics activities (e.g., competition, practice, conditioning sessions) and evaluated by a medical staff member (e.g., sports medicine staff, team physician) with experience in the evaluation and management of concussions; (c) A policy that precludes a student-athlete diagnosed with a concussion from returning to athletics activity (e.g., competition, practice, conditioning sessions) for at least the remainder of that calendar day; and (d) A policy that requires medical clearance for a student-athlete diagnosed with a concussion to return to the athletics activity (e.g., competition, practice, conditioning sessions) as determined by a physician (e.g., team physician) or the physician's designee. The University of Arkansas will submit its Concussion Safety Protocol to the Concussion Safety Protocol Committee prior to May 1st of each year. The attached protocol includes: a) Policies and procedures that meet the requirements of Constitution 3.2.4.17. b) Procedures for pre-participation baseline testing of each student athlete; c) Procedures for reducing exposure to head injuries; d) Procedures for education about concussion, including a policy that addresses return-to-learn; e) Procedures to ensure that proper and appropriate concussion management, consistent with best known practices and the Inter-Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines, is made available to any student-athlete who has suffered a concussion; and f) Procedures requiring that the process of identifying, removing from game or practice, and assessing a student-athlete for a possible concussion are reviewed annually. _________________________________ Athletics Director Printed Name ___________________________________ Athletics Director Signature ___________________ Date Auburn University Concussion Management Protocol (Revised June 3, 2015) Purpose: To provide guidelines for the prevention and treatment of concussions in collegiate athletics at Auburn University. Medical Overview Auburn University’s healthcare model includes equitable and equal access to the same healthcare providers/care for each sport. Auburn University’s healthcare providers are empowered with unchallengeable autonomous authority to determine medical management and return-to-play decisions of student-athletes. Auburn University’s concussion management plan is team physician directed. The team physician or another designated physician who has expertise in the management of sports-related concussions will have the final authority to determine management and return-to-play of any concussed studentathlete. Any member of the healthcare team, i.e., physicians, certified athletic trainer, nurse practitioner, physician assistant or graduate assistant athletic trainer may identify a student-athlete with concussive type symptoms. The student-athlete will be removed from play and referred to the team physician or his designated substitute for evaluation. The team physician or his designated substitute will then determine appropriate management and return-to-play protocols. Auburn University will ensure coaches have acknowledged they understand the concussion management plan, their role within the plan and that they received education about concussions. Auburn University’s athletic healthcare providers will practice within the scope of their professional practice as outlined by the State of Alabama. This includes physicians, certified athletic trainers, physician assistants, clinical/sports psychologists, and referral physicians or neuropsychologist. Although sports currently have rules in place, athletics staff, student-athletes and officials should continue to emphasize and educate that purposeful or flagrant head or neck contact in any sport should not be permitted. Student-athletes, coaches and athletics staff shall maintain a ‘safety first’ approach to sport and continue to monitor and evaluate safe play and maintain coaching and studentathlete education regarding safe play and proper technique. 1 Page Pre-Season Education All student-athletes, coaches, team physicians, athletic trainers and athletics administrators will be presented with educational materials (NCAA Video/Fact Sheets-attachments 2/3) on concussions before each competitive season. Each party will provide a signature of acknowledgement that they have received, read and understand the concussion material provided by the institution (attachment 4 for student-athletes). Auburn University shall require student-athletes to sign a statement in which the student-athlete accepts the responsibility for reporting any head trauma/head injury (concussion) and illness to the institutional medical staff, including signs and symptoms of concussions (attachment 4). Pre-Participation Assessment Auburn University will record a baseline concussion history and assessment for each incoming varsity student-athlete (first-years and transfers) prior to their first practice. The team physician will determine pre-participation clearance and/or the need for additional consultation or testing. In addition, student-athletes in any sport who have a significant concussion history will also obtain a baseline concussion assessment prior to the first practice. These student-athletes may require additional testing at the discretion of the team physician if a student-athlete has a documented concussion, complications with concussions or multiple concussion history. The same baseline assessment tools will be used post injury at the appropriate time intervals. The baseline assessment tools will consist of: 1. The use of a symptom check-list and standardized cognitive assessment test (SCAT3/4) and balance error scoring system (BESS). 2. The student-athletes will undergo a computer-based concussion assessment test called ImPACT testing. 3. Auburn University shall require student-athletes and their parents/legal guardian to complete and sign a concussion history form. Recognition and Diagnosis of Concussion Auburn University will have on file and annually update an EAP (emergency action plan) for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress (asthma), and sickle cell trait collapses. 2 Page When an Auburn University student-athlete shows any signs, symptoms, or behaviors consistent with concussion, the student-athlete shall be removed from practice or competition and be evaluated by any member of the athletics’ healthcare team with experience in the evaluation and management of concussions. The initial concussion assessment will include but not limited to: symptom assessment, physical and neurological exam, cognitive assessment and balance exam. Tools used for assessment will include: symptom checklist, SCAT3/4, ImPACT and BESS. Clinical evaluation for cervical spine trauma, skull fracture and intracranial bleed shall also be performed. A student-athlete diagnosed with a concussion shall be withheld from practice or competition and not return to activity for the remainder of that day and will be withheld until cleared by the team physician. Student-athletes that sustain a concussion outside of their sport will be managed in the same manner as those sustained during sport activity. Post-Concussion Management The student-athlete will receive serial monitoring for deterioration. Student-athletes will be provided with written instructions upon discharge: preferably with a roommate and/or a parent or guardian (attachment 6). Student-athletes that show signs of increased deterioration that includes but is not limited to: Glasgow Coma Scale <13, prolonged loss of consciousness, focal neurological deficit suggesting intracranial trauma, repetitive emesis, persistently diminished/worsening mental status or other neurological sign/symptoms or spine injury shall activate the Emergency Action Plan that includes transportation for further medical care. The student-athlete will be held from physical activity and evaluated by the team physician as outlined within the concussion management plan. Re-assessment by the medical staff will occur daily and symptoms monitored until completely asymptomatic and a return-to-play is possible (attachments 7/8). Communication with the student-athletes academic advisor will be necessary. Once asymptomatic and the neurological exam are within normal limits, return-to-play will follow a medically supervised stepwise project (attachment 1). Student-athletes who have had continued evaluation by the team physician and experience prolonged recoveries following a concussion may require additional diagnosis and further modes of treatment/care. Additional diagnosis may include but are not limited to: post-concussion syndrome, sleep dysfunction, migraines, mood disorders and ocular or vestibular dysfunction. Auburn University Sports Medicine will document the incident, evaluation, continued management and clearance of the student-athlete with a concussion. At minimum, the Sports Concussion Assessment Tool 3 (SCAT3) will be utilized for concussion documentation. 3 Page Return to Play Final authority for return-to-play shall reside with the team physician. The student-athlete will follow a medically supervised stepwise return-to-play protocol. This will consist of repeat evaluation, symptom checklist, balance exam and ImPACT exam at a minimum as directed by the team physician. Scores will be compared to both baseline and normative values. If these test results return to acceptable clinical ranges, the student-athlete will complete a series of progression exertional testing as outlined by the flow chart (attachment 1). Re-evaluation is again conducted by the team physician for a return-to-play decision. In the event that symptoms return in any part of this return-to-play plan, the student-athlete will remain held from physical activity and be re-evaluated by the team physician. Return-to-Learn Academic advisors and professors will be notified of the student-athlete’s concussion, with permission for release of information from the student-athlete. The student-athlete will be excused from class the day of the initial concussion. Appropriate academic accommodations (in compliance with the ADAAA) will be sought to help the student-athlete strike an optimum balance between rest and continued academic progress during recovery for a minimum of 2 weeks (attachment 5). Lead by the team physician, the certified athletic trainer, academic counselor and professors will coordinate appropriate academic accommodations while the student-athlete is recovering from the concussion. The team physician is to be notified if concussion symptoms worsen with academic challenges. The team physician will coordinate care with other necessary personnel (ex: Learning Specialists or the Office of Accessibility) with student-athletes experiencing more complex cases of greater than 2 weeks with return-to-learn issues. 4 Page Stepwise Exertional Testing Protocol Following Concussion (attachment 1) Team Physician re-evaluation: symptom check-list, physical and neurological exam, cognitive assessment and balance exam. ImPACT exam. Exertional Testing Protocol DAY 1: 15 mins. On stationary bike. Exertional intensity <70% max predicted heart rate. IF NO CHANGE OR INCREASE IN SYMPTOMS, MOVE TO NEXT DAY Symptom Check-list—IF NO CHANGE OR INCREASE IN SYMPTOMS: DAY 2: 15 mins. On stationary bike or treadmill. Exertional intensity <90% max predicted HR. Strength training with Medical Staff (i.e.: push-ups, sit-ups, body wt. squats, machines) IF NO CHANGE OR INCREASE IN SYMPTOMS, MOVE TO NEXT DAY Symptom Check-list—IF NO CHANGE OR INCREASE IN SYMPTOMS: DAY 3: Advanced cardio/strength training/sport specific drills with Strength/Medical Staff. IF NO CHANGE OR INCREASE IN SYMPTOMS: Non-contact practice with team and coaches. Continued symptom monitoring. IF NO CHANGE OR INCREASE IN SYMPTOMS, MOVE TO NEXT DAY Symptom Check-list—IF NO CHANGE OR INCREASE IN SYMPTOMS: DAY 4: Re-evaluation by Team Physician and determination for final return-to-play. FULL CONTACT PRACTICE as determined by the Team Physician. 5 Page Continued monitoring by Medical Staff. CONCUSSION A FACT SHEET FOFI STUDENT-ATHLETES WHAT IS A WHAT ARE THE OF A A concussion is a brain injury that: [5 53'153?1 133' *1 mm" to the Wild 0" deY- 1r'ou can?t see a concussion. but you might notice some of the me mum? It'll-h AMI-her Phi? hitting a hard surface 5115b right away. Other can show up hours or days after the injury. as the ground. ice or ?oor. or being hit by a piece of equipment Concussion include: such as a hat. lacrosse stick or ?eld hockey ball. . Amnma? . lCan change the way your brain normally works. Confusion. . Can range from mild to severe. . Headache_ . Presents itselfditferently for each athlete. Lass chnanusne? - Can occur during practice or competition in ANY sport. . Balance problems or dizziness. . Can happen even if you do not lose consciousness. Double or vision . Sensitivity to light or noise. HOW CAN I PREVENT A . Nausea (feeling that you might vomit}. Basic steps you can take to protect yourself from concussion: . Feeling sluggish. foggy or groggy. a Do not initiate contact with your head or helmet. You can still get a Feeling unusually irritable. a concussion if you are wearing a helmet. - Concentration or memory problems [forgetting game plays. facts. I: Avoid striking an opponent in the head. Undercutting, flying meeting times}. elbows. stepping on a head. checking an unprotected opponent. . Slowed reaction time. 2111:: ?1mm?; headda" cause 3f th 1 Exercise or activities that involve a lot of concentration. such as 1? 0w at was Epmmenl 95 or an r" 950 studying. working on the computer. or playing video games may cause . B?Dod SP0 ?mnsh 1P at all time-5' {such as headache or tiredness} to reappear or . Practice and perfect the skills of the sport WHAT SHOULD I DO iF I THINK i HAVE A Don?t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also. tell your athletic trainer and coach if one of your teammates might have a ooncussion. Sports have injury timeouts and player nibstitutions so that you can get checked out. Report it. Do not return to participation In a game, practice or other activity with The sooner you get checked out. the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer. or health care professional can tell you Ifyou have had a concussion and when you are cleared to return to play. it concussion can aliect your ability to perform everyday activities. your reaction time. balance. sleep and classroom performance. Take time to recover. if you have had a concussion. your brain needs time to heal. While your brain is still healing. you are much more likely to have a repeat concussion. in rare cases. repeat concussions can cause permanent brain damage. and even death. Severe brain injury can change your whole life. BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. For more information and resources. visit and wwviLC[tilgovrf Concussion. Reference to any commercial entity orproo?itrtor sen-ice on this page should not be construed as on endorsement the Govemmrri' of?rr remain! or r'rsprodm's (Attachment 2) 6 Page CONCUSSION A FAST SHEH FDR COACHES THE FACTS IS A IAchoncussionseresa'ious. - Cmn??im? can occur without loss ofconsciousne? or other trenm?tte?t-othehasd. Concessions sm shoresult imhim'ng - blowsto?sebolir ssweu esto?ueheed. withessho?mrorbeinghitbys [derangement smiles shot. I Concessions can occurjn my sport. hotness sti?e! ?eld hurleth I Recognition endprop-er response to concussions when this}.r ?rst L?fm?? A POSSIBLE oomoussmn Thur? 1mm?. [magma Haiku-Ms Miami genes 1A5 concusions represent 5 to 13 percent ofeJJ reported injuries mowmmt ofthe heed; depende on the sport. 1.1me in the student-athlete?s behavior. thinking or physirel signs and BIG HS AND Signs Observed By Coaching Staff Reported By sm-nmlete I er slmned. I Headache or in head. I?euseanreurrlti'u. I Forgets pins. I Bum protleme or shalom. Ils maefgamemmeoremonent I Dm?eorbuw'?sbn. I Moves I Senetmh light. I Answersmes?me slim. I Sellst?uly to news. I Loses consumes {em tl'lefl?. I Feeling sun-aim. haz?oggy or m. Ion-mum. IDeesnet?feel right" 7 Page PH EVEN-I1 AND PH EFAHATIUN its a coach, )nuplav a kev role in preventing concussions and remonding to them propeti}.r when they occur. Here are some stepsvou cantalre to ensure the bat outcome for vonr student-athlet?: - Educate student-a??etes and coacl'ting sta?'ahout concussion. Explain your concenis about concumion andvour expectations of ale play to student-athletes. athleticsst?'and assistant coaches. create an environment that supports reporting. access to proper evaluation and conservative return-to-plav. Review and practice your action plan for your facility. Know when vou will have sideline medical care and when you will not, both at home and awav Emphasiae that protective equipment should ?t properly, be wellmaintainedi and be worn consistentlv and correctlv. Reviewthe Concussion Fact Sheet for Studnit-Atltletes with your team to help them recognire the signs ofa concussion Review with your athletics staif Sports Medicine Handbook guideline: lConcussion or Mild Traumatic Brain Injury in die Athlete. Insist that ?eryr cornes ?rst. Teach student-athletes safe-play techniquea and encourage them to follow the rules of plav. Encourage student-athletes to practice good sportsmanship at alltintes. Encourage student-athletes to immediatelyr report of concussion - Prevent long-term problems. A repeat concuaion that occurs before the brain recovers from the previous one (hours, days or weeksl can slow recover}.r or increase the likelihood ofhaving long-tenrt problems In rare cases, repeat concussions can result in brain permanent brain damage and even death. IF 1Halal THINK STUD HA5 IF Ft CDNC USSIDN l5 SUSPECTED: SUSTAI A Gauguss'g?: 1. Rem the smdent-alhlete from play. Lookfor tlte signs and THE m1th Pk? mm? and adequate of concusion ifvotir student-athlete has experienced a 5 3153331 can mm& in blow to the head. Do not allot?.r tlte student-athlete to just ?shake it fm. mm of." Each individual athlete will respond to concussions di?erenthr. An Egg-.133? ?ha mmim mh?n?mcmm?l 2. Ens-re that Ihe student-athlete ls evdualeacl righl away by Wham?: the Immediateh?referthe student- den-?ith hash}; m?mm ppm-t. athlete to the appropriate athletics medical ata?, such as a certi?ed In? am} Him? in that m_mu athletic trainer, tearn phvsician or health care professional mm charm? eapetiencedin concussion evaluation andmanagema'it. 3. Allow Ihe student-athlele to telutn to play only-width permission from ahedth cane profession? with experience ll evalualing Ear concussion. Allow athletics medical staif to rel}.r ontheir clinical skills and protocolsin evaluatingtheathleteto etiablish the appropriate time to rerum to plav. A return-to?plav progrenion dtould occur in an individualized step-wise ?shion with gradual amnion andrislt ofoontact. 4. Develop a game plan. Student-athletes should not retunt to play urttil all have resolved, both rat and during exertion. Manv times, that means they will be out for the remainder ofthat dav. Infact, as concussion management continues to evolve witlt new science, the careisbecomiagmore conservative and return-to-plav time frames are gettinglonger. Coaches should have a game plan that acootints for this change. MISS GAME THAN SEASON. WHEN IN DBUBT, SIT THEM For more information and resources, visit and Eghence t'tI EIme won't-local his page :thoIIH not be construed an: an endowment I?I'Gomt qft'tte mama Neptune-I1: ormt'cot. (Attachment 3) 8 Page Auburn University Student-Athlete Concussion Statement I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion fact sheet, I am aware of the following information: _______ A concussion is a brain injury, which I am responsible for reporting to my team physician Initial or athletic trainer. ________ A concussion can affect my ability to perform everyday activities, and affect reaction Initial time, balance, sleep, and classroom performance. ________ You cannot see a concussion, but you might notice some of the symptoms right away. Initial Other symptoms can show up hours or days after the injury. _______ If I suspect a teammate has a concussion, I am responsible for reporting the injury to my Initial team physician or athletic trainer. _______ I will not return to play in a game or practice if I have received a blow to the head or body Initial that results in concussion-related symptoms. _______ Following a concussion, the brain needs time to heal. You are much more likely to have a Initial repeat concussion if you return to play before your symptoms resolve. _______ In rare cases, repeat concussions can cause permanent brain damage, and even death. Initial _______________________________________ Signature of Student-Athlete ________________ Date _______________________________________ Printed Name of Student-Athlete (Attachment 4) 9 Page Michael Mil, Aubu rn University Sparta Medicine 3495 Dnnahue Dr Suite Hill? Auburn,ALJ?tieii Date: an 'i'i'Eti 5 -F-t RF: [Patient Name) Tn Whom It May Cnneem: CDNCUSSIDN REQUEST Auburn Alhletirs. 3115' 5. Donahue Dr. Twit" {Patient Name} was seen by me teday fer pest-epneussinn (Patient Name} should have the following temporary aeademie aeenmmedatinns in plane until they Baa-cues. have reached the peintnfi?ull sees-very ?'nm this injury. a. Partial schnel attendance as allowed by including days DH: 35 needed as well as early departure, depending nn their level of I). nl'quines and tests the time being until {Patient Name} feels well enough to take them and has been able tn adequater prepare e. Extended deadlines fer elass assignments as needed Lu aydid mental m'eresertien and flare up. d. {Patient Name} site uld not be asked to till-DE mere than ene eaaminatinn a day, may require additional time to telte eaaminatiens, and hnmewnrk assignments. a. {Patient Name] should net participate in any physical activity heyend light walking. {Patient Name] shuuld nut be participating in physical eduuatinn. spans activities. heavy lifting, physical exertinit. nr any aetiyity with signi?cant risk of fall ing or head tmuma. f. {Patient Name] shnuld avoid unnecessary mental activity, especially rcFrein Frern yidee gamesr tesi messagin g] e-mail, and any nther physical er engnilive inlelleetual activities that may prey-eke post- enneussinn 3. (Patient Heine) she itld aeeid any nth-er stimulus nr aeliyity that ea uses any tn return at wnrsen. Respectfully, Michael D. Gnudlett, M.D., '1'ean1 Physician Auburn University (Attachment 5) 10 Page Michael D. Gendleit, [#111, than}. it.an rn University Sparta Medicine 5 3-1-9 5 lJn-nehue Dr Elli?! #30" MEDICINE Euncuseiun Heme ll??lgiin n3 Date: 41"] THEME Ill}. El: Eni'n'e-rsirp Athletes. 335' 5-. [lenuhue Elrbelieve that [Patient Name} 5uata1neti a ceneneeien en To make met-m 355-1111 {Patient Name} please feliew the fellbwing important reenmrnendatiena below. -- please remind them in repert it} the athletic training reblrnielinie an at fer a fellow 1111- evaluatien. Please re?aiew the reiluwiug list, if any ef'thent develda?i prinr t0 Ihe iiJllu'i-r up with the athletic trainer. contact your physician er eentaet EMS: Any decrease in the ievei efeenaeinuanaas Any increase in the severity An increase in the number of 55-111 plume Any Weeklies-a er nuntbneaa in the arms er legs Any dif?culty with. facial expressions. ?fth?: lane~ hearing, vision, and balance Abnormal repatriatinn, pntne, bleed pressure Neclt pain Seizure t'ncne of the anew liat Deena, please fa]an the balance a You may use acetamlnephen (Tylenol) fer a headacheether medication unleae instructed in by a physician Use icepaelta on head and neck f'er eem fort Eat a light diet it is bit ta- return ta sch-114:1] it is Dl-t it} ge in sleep and get a full nights rest, there is lit) need in wake up every hour Db not take part in any errenueue activity unlil eleared by ynln' athletic trainer and physician 1' Dn- net drink nlenhbl {1r eatidrint: Spicy feeds er beverages Illi?l?. Please direct: any queatiena er ceneerns be Dr. Guedlett immediately. Michael D. Gendlett, Team Physician Auburn University Cell Pbbne: 3341-7511-1293 (Attachment 6) 11 Page Auburn University Sp?rls Medicine Dr. Michal?! Gmdfeme: Spurl: Cu ncussinn Dale: fair-in Yasmin Fmioua Cnncussim?s}: 2 3+ Migraine Headach?'? L955 0f funscinusness Date or Prim Cuntzus?un: :?LDDJ'Luaming Disability? I Seizure .r urn 'r-mr 5 D: Eula-:5: gyr?lt?m Duratl?n- Hr-i Sui?. rm. 3. HI EH15 hub-urn. .IlnL Mil-$9 Histan ?fl?mcnt nan-m Assess mcnl: l. Cumuulm Day 3 Date. Await-5w Status: Ciinician Smut: 1 Carnation Dag; 4! Date: Atrin'w Sralua CLinician signature: 3. Cum-emu? Day I'r' Date: Acti's?in' 513.1115: Clinician. Signature: :L?h'ltf Slams 1. Run L'ntu $53.1er I. Lig i1: Aercbi: {Cudiorasauiar Challenge Claw] mm? 53mm,? 3- 5pm Speci?c Exaaises {it Urdtredi Physician} 4 Nutrian Day '3 Date. Artinry Status: 5. Camussiun Dar Date: Nnn?tmtact Tumblg {Resistance Taming Gt} 1. Full Comm Tainan; Activity Status: Sign-mm: 6. Return To Camp-5mm (Attachment 7) 12 Page SPORTS EDICEHE kill ?Mhu-n L'niu'nr'iirr Ali'ulnr-rt b. Dmuhw E'dr. Suir: i-u-hurn M. 3-5" Cummsian Elm; NAME: HATE: SPURT: CDNCUSSI 1N Eval. Dale DI'Las'l Headache fl SVM PTCIMS Headache in -N -I3-alanuc I ?Blurt;-r uisiun wjaiun .ll - 't -Fch "dazed" {unfunjm?u down like "in a -D:w:iness - or [11w emmianul vDi I uaual usual Jess. tanoise -Nu rnhness ur ?re jam normal? -A :13 uthcr a. 'l'?'TelL .531" PTUM SCORE: Rate Eran} a scale aft} mm: to a severe FIE HESS TEST EEUHE: TUTAL SC h'l'H LETE SIG I H: E: m1 E: (Attachment 8) 13 Page Baylor University Concussion Management Plan Education The Concussion Management Plan will be included in the Student-Athlete Handbook and reviewed with each sport program. Every student?athlete must sign a form acknowledging that he/she has read the Plan and has had the opportunity to ask questions about it before they are allowed to practice. Concussion recognition and treatment is a team process where many members of the athletic department are involved. The following athletic department members will annually be taught the signs and of a concussion by using the NCAA Concussion Fact Sheets, Reading the Baylor University Concussion Management Plan and the signing of the Concussion Acknowledgement Form: student?athletes, coaches, team physicians, athletic trainers and athletic administrators. What is a Concussion? A concussion is de?ned as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face or neck or a blow elsewhere on the body with an "impulsive" force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. 3. Concussion may result in neuropathologicai changes but the acute clinical largely reflect a functional disturbance rather than a structural injury. 4. Concussion results in a graded set of clinical that may or may not involve loss of consciousness. Resolution of the clinical and cognitive typically follows a sequential course. in a small percentage of cases, however, post-concussive may be prolonged. 5. Concussion will show no abnormality on standard structural neuroimaging studies. Signs and of a Concussion: Concussions may cause abnormalities in clinical physical signs, behavior, balance, cognitive, and/or sleep. Signs and include, but are not limited to: Headache Inability to focus Loss of consciousness Delayed verbal or motor responses Visual disturbances Ringing in ears Confusion or disorientation irritability Amnesia Emotional Iability Dizziness or balance problems Fatigue or feeling slowed down Siurred or incoherent speech Excessive drowsiness Vacant stare or dazed Sleep disturbances Baylor University 04/ 15 Personnel: A certified andlor licensed athletic trainer with training in the diagnosis, treatment and management of concussions shall be present for all practices and competitions of high risk sports and on call for all other sports or events. PPElBaseline Testing: Baseline assessment for each student?athlete will be obtained prior to the first date of practice in all sports. The testing will include impact, SCAT3, concussion history and physical examination. The team physician will determine pre-participation clearance and/or the need for additional consultation or testing. The same baseline assessment tools will be used post?injury at appropriate time intervals. The athletic trainer will administer the baseline assessment, as well as the subsequent tests. and the results shall be evaluated by a team physician. If a student-athlete has suffered a documented concussion they are required to establish a new baseline test. Such test must be conducted at least six (6) months following their latest concussion and the results from this later test shall be established as their new baseline. Evaluation: Any student-athlete exhibiting signs and of a concussion will be immediately removed from play and evaluated by a team physician or athletic trainer with concussion experience. Any student? athlete diagnosed with a concussion shall not return to activity for the remainder of that day. The student? athlete shall be serially monitored for deterioration and will be provided with written instructions if discharged home after suffering a concussion. The student-athlete will be given Impact and SCAT3 tests for baseline and follow?up. Emergency Plan: Any student-athlete with severe progressive or worsening signs and and/or signs of of an associated injury will be transported immediately. Student?athletes suspected cervical Spine trauma, skull fracture. and/or intracranial bleeding shall be stabilized and transported to emergency facilities. Any student?athlete with the following signs: Glasgow Coma Scale <13, Prolonged loss of consciousness. Focal neurological deficit suggesting intracranial trauma, repetitive emesis, persistently diminished/worsening mental status or other neurological or spine injury will activate the Emergency Plan and be transported for further medicat care. Baylor niversity 04/15 Referral to a Physician: Student?athletes who experience a concussion associated with loss of consciousness, worsening signs or sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression, ocular or vestibular dysfunction and/or post?concussive signs or lasting greater than 24 hours will be referred to a team physician for additional evaluation. Return to Play: Student-athletes suffering a concussion must be cleared by a team physician or medically qualified designee with concussion experience before returning to activity and play. Student?athletes suffering a concussion must be free at rest, for a minimum of 24 hours, before starting any exertional activity. Student?athletes must progress through each step listed below without his/her condition becoming worse before he/she wiil be allowed to return to activity and play. if during the course of the progressive steps any signs or reoccur. the student?athlete must return to the previous step until the signs or no ionger occur. Step 1: Light aerobic exercise without resistance training Step 2: Sport-specific exercise and activity without head impact Step 3: Non?contact practice with progressive resistance training Step 4: Unrestricted training Step 5: Return?to?competition The student-athlete must return to baseline with Impact and SCAT3 tests before he/she will be allowed to return to play. Multiple Concussions: Any student-athlete suffering two or more concussions within the same calendar year shall not be eligible to return to activity until evaluated and cleared by a team physician. Follow-up Evaluation: Following the initial evaluation and the student-athlete leaving the a responsibie adult will be placed in charge of the student-athlete and instructed on the signs and of a concussion. They wiil be given the Home Instruction for Concussions Form and emergency contact information as additional resources. The student-athlete will be re?evaluated the day after the concussion. Baylor University 04/ 15 Return to Learn: The return to learn will be coordinated by the sport specific athletic trainer. The student-athlete will not be allowed to return to any classroom activity on the same day as a concussion. For more severe cases a multi?disciplinary team will be formed to coordinate treatment and rehabilitation. The team will be formed on a case by case basis including the team physician and athletic trainer with the following positions added as deemed necessary: academic counselor, course instructor(s), Of?ce of Access and Learning Accommodation, and/or coaches. Student?athletes with of a concussion will be given an individualized plan to coordinate the return to academics. Accommodations for student?athlete suffering concussion include, but are not limited to the following: 1) Remain at home/dorm if the student athlete cannot tolerate light cognitive activity. 2) Gradual return to classroom/study as tolerated. 3) Re?evaluation by team physician if concussion worsen with academic challenges. 4) Modification of schedule/academic accommodations for up to 2 weeks, as indicated, with help from the identified point-person. 5) Re?evaluation by team physician and members of the multi-disciplinary team, as appropriate, for student athlete with greater than 2 weeks. The Office of Access and Learning Accommodations will be consulted when the student athlete has medical issues that require accommodations in the classroom as deemed necessary by the athletic trainer and/or team physician and will be used to coordinate such accommodations with faculty and staff. The Of?ce of Access and Learning Accommodations will engage campus resources for cases that cannot be managed through schedule modificationiacademic accommodations and will make sure that all federal and state regulations are followed for accommodations including but not limited to regulations. Reducing Exposure to Head Trauma: Baylor University is committed to making sure that student?athletes are able to participate in their sport in a safe manor. This wiil be accomplished by the following methods: 1) Provide safe areas for practice and competition 2) Proper Protective Equipment 3) Proper Coaching Techniques 4) Provide the ability of Sport administrators or medical staff to deem an activity unsafe. Baylor University 04/15 Home Instructions for Concussion I believe that sustained a concussion on . To make sure that he/she recovers, please read the following important recommendations below. Additionally, please remind them to report to the athletic training room on at for a follow up evaluation. Please review the following list of If any of these develop prior to the scheduled follow up visit with the athletic trainer. please contact the athletic trainer at the cell number below, a physician or the local EMS: Any decrease in the level of consciousness Any increase in the severity of Any increase in the number of Any weakness or numbness in the arms or legs Any difficulty with facial expressions, numbness of the face, hearing, vision, balance Neck Pain Seizure Vomiting If none of the listed above occur, please follow the instructions below: 0 You may use acetaminophen (Tylenol) for a headache but do not use any other medication unless instructed to do so Use icepacks on head and neck for comfort Eat a light diet and nothing that might upset your stomach Do not drink alcohol or eat/drink spicy foods or beverages Do not return to classroom activities on the day of the concussion Emergency Contact information: Athletic Trainer: Phone: Make sure the athletic trainer has your cell phone and knows how to contact you overnight if needed. Baylor University 04/15 BAYLOR ATHLETIC DEPARTMENT Concussion Acknowledgement Form A concussion or mild traumatic brain injury can cause a variety of physical, cognitive, and emotional Concussions range in significance from minor to major, but they all share one common factor they temporarily interfere with the way your brain works. If you or any of your team members have any of the listed below following a blow to the head or suspected concussion, please contact the athletic trainer or team physician and advise them of the situation. Headache Nausea Balance Problems Dizziness Diplopia Double Vision Confusion PhotOphobia Light Sensitivity Dif?culty Sleeping Misophonia Noise Sensitivity Blurred Vision Feeling Sluggish or Groggy Memory Problems Difficulty Concentrating Should you have any questions or require further information, please do not hesitate to contact an athletic trainer or team physician or look at one of the links below. NCAA Web Site on Concussions: NCAA Concussion Fact Sheet for Student Athletes: NCAA Concussion Fact Sheet for Coaches: Center for Disease Control Web Site on Concussion: By signing below I have read and understood this form and have no further questions. Name: (Print) Baylor ID: Signature: Date: Baylor University 04/ 15 Boston College Sports Medicine Guidelines for Care of the Concussed Student-Athlete This document is for use by Boston College Sports Medicine Clinicians when treating StudentAthletes (S-A’s) who have suffered a concussion or are suspected of having suffered a concussion. The term ‘Mild Traumatic Brain Injury’ (mTBI) is not interchangeable with the term concussion, and will not be used in this document. Policy Guidelines Boston College maintains concussion care guidelines based on the most current research and consensus statements from noted experts around the world. This policy is reviewed yearly to insure that we are following the most current standard of care and that the policy reflects new requirements dictated by both the National Collegiate Athletic Association (NCAA) and the City of Boston’s Ordinance for College Athlete Head Injury. There is no wording within the NCAA or Boston legislation that allows for ‘interpretation’ by the clinician in regards to initial care of the S-A with a suspected head injury; this policy must be followed to ensure the safety of the SA and to ensure that Boston College is compliant with NCAA and Boston regulations. A concussion is considered a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. This can be caused by a direct blow or impulsive forces transmitted to the head and typically results in a rapid onset of neurological impairments and clinical symptoms. A concussion is a functional injury, not a structural injury and may or may not include loss of consciousness (LOC). A concussion is not identifiable on standard imaging (CT, MRI). At no time will any Sports Medicine clinician assign a ‘grade’ to the concussive injury suffered by a S-A. Although there are a multitude of grading scales that have been created to assist in the diagnosis and management of concussion, these will not be employed by Boston College. Attempting to ‘slot’ an S-A’s injury into one of these scales for the purpose of creating a care plan and a projected timeline places unnecessary restrictions and expectations on the clinician and is not the standard of care. Per requirements, any athlete who is deemed to have suffered a concussion, or is suspected of suffering a concussion after experiencing trauma shall be removed from all physical activity for the remainder of that calendar day. Boston College requires evaluation of the athlete, as soon as possible, by a Sports Medicine Clinician. If it is determined that the athlete has suffered a concussion, that athlete will be held from further activity and will be guided and monitored through the protocols outlined in this document. Return to play clearance will be determined by a team physician and will be documented in writing and provided to the Assistant Athletic Director for Sports Medicine. The City of Boston Ordinance requires that, specifically for the sports of Football, Ice Hockey and Men’s Lacrosse, a “Neurotrauma Consultant” be in attendance at any competition held within the City of Boston. By Ordinance definition, the Neurotrauma Consultant can be a neurologist or a “primary care CAQ sports medicine certified physician that has documented competence and experience in the treatment of acute head injuries”. This physician will evaluate any suspected head injury suffered by either a home or visiting athlete and make recommendations for further care. If visiting teams have medical staff in attendance, they will make the final decision regarding the athletes playing status. Pre-Season Education Student-athletes in each sport will be presented with NCAA concussion fact sheets and educational material on concussions via “Jump Forward” from the compliance office and from pre-season compliance meetings prior to practice or competition. Student-athletes will review the material with the understanding that they accept responsibility for reporting all of their injuries and illnesses to the medical staff, including signs and symptoms of concussions. Each student-athlete will initial and sign an acknowledgement of receipt, reading and understanding of concussion education. Coaches, Sport Administrators, and the Athletics Director will be educated about concussions and the Concussion Safety Protocol as follows: Concussion education will be provided to coaches, Sport Oversight Administrators and the Athletics Director at the beginning of the academic year during an appropriate staff or compliance meeting. Coaches should understand their responsibility for helping to identify student-athletes exhibiting potential signs, symptoms or behaviors consistent with a concussion and getting them evaluated by the Athletic Trainer and/or Team Physician. Coaches will also be educated about strategies that reduce a studentathlete’s exposure to head trauma. Coaches, Sports Administrators, and the Athletics Director will sign an acknowledgement of receipt, reading and understanding of concussion education. Team Physicians and Athletic Trainers will be provided concussion education material annually and will sign acknowledgement of receipt, reading and understanding of such material. Initial and Baseline Assessment All incoming freshmen and all new S-A’s will undergo a Sport Pre-Participation Physical through University Health Services. During this physical, the examining physician shall review the S-A’s prior medical history including any history of brain injury or concussion as well as any current symptoms. Those S-A’s reporting prior head injury will be asked to provide a thorough history of their previous concussive incidents including dates incurred, length of symptoms, and time missed from athletics and academics. Each S-A will be administered a baseline Standard Assessment of Concussion. A balance screening shall also be administered by the examining physician or athletic training staff. Those S-A’s who are participating in contact and collision sports will also undergo computerized neurocognitive testing prior to participation. The Boston College sports that are classified as contact and collision are listed below. The results of these tests will be recorded in the S-A’s medical chart. The examining physician will make a determination for the need of any type of specialized follow-up consultation related to preexisting conditions and/or prior history of head injury. The sports which will be required to undergo computerized neurocognitive baseline testing include: Baseball M & W Basketball Diving Field Hockey Football M & W Ice Hockey W Lacrosse Pole Vaulting M & W Soccer M & W Skiing Softball Evaluation/Diagnosis Signs and Symptoms of Concussion Below is a list of signs and symptoms that may be used by the clinician to assist in the initial evaluation of the head injured S-A. This list is extensive but not all-inclusive and should serve only to provide ‘triggers’ that may be used for identifying the S-A with a concussion. A similar, but more specific list will be utilized for follow-up with the concussed S-A. Understand that symptoms may vary over time and serial monitoring will occur regularly to further assess neurocognitive status. Re-evaluation is recommended daily in the initial post injury phase due to the variable sequelae that may ensue. Physical Headache Fatigue Dizziness Photophobia Sensitivity to noise Nausea Balance problems LOC Vision difficulty Cognitive Difficulty remembering Difficulty concentrating Feeling slowed down Feeling in a fog Slowed reaction times Altered attention Amnesia Emotional Behavioral changes Irritability Sadness Feeling emotional Nervousness Anxiety Sleep Sleep more than usual Sleep less than usual Drowsiness Trouble falling asleep Acute/Emergency Evaluation and Care (Sideline/Bench – immediately post injury) At any time that a concussion is suspected, the S-A shall be removed from further participation and undergo an initial concussion evaluation. If the S-A is conscious and alert and without evidence of other limiting injuries (i.e. c-spine injury), they will be removed to the sideline/bench/athletic training room for evaluation. At that time the clinician will, at a minimum, perform the following exam: -The injury history, date/time, and history of previous concussion will be determined and recorded including any loss of consciousness -An initial injury verbal symptom checklist will be utilized to record any symptoms reported by the S-A. -A basic neurologic exam will take place assessing cranial nerves -The SAC will be administered -Upper and lower extremity coordination will be assessed. -Pupils shall be examined for size, shape and reaction to light. If the athlete is symptomatic and the clinician determines that the athlete is concussed, serial monitoring will occur until symptoms stabilize or improve. Depending on sport, timing, and location, the helmet may be taken away from the injured player. Once symptoms stabilize, the player will continue to be monitored at regular intervals but shall not return to practice, play, or perform any other type of physical activity that day. Findings of this initial assessment and serial monitoring will be recorded on a Sideline Head Injury Evaluation Card (see attachments) or on a similar smart phone application which can later be printed for the S-A’s medical record. The Emergency Action Plan shall be initiated and the S-A should be removed from the venue utilizing c-spine precautions as needed and transported to the closest emergency department if any of the following are present: -Prolonged Loss of Consciousness (LOC) -Focal neurologic defect as found with intracranial injury -Repeated or worsening emesis -Significant alteration or deterioration in mental status -Glasgow Coma Scale score of less than 13 Sub-Acute Evaluation (Controlled/Quiet Environment – ideally within 1-2 hours of injury) After the initial acute evaluation, the clinician shall perform a more in-depth evaluation of the head injured athlete in a more stable environment such as the Athletic Training Room, locker room or clinic. The Assessment of Concussion form shall be utilized for this evaluation (see attachments). This form includes a graded symptom checklist that should be completed by the SA with assistance of the clinician as needed. Depending on the time elapsed since the SAC was initially administered in the acute evaluation, another SAC may be required. Additional neurological exams will take place to evaluate the status of the S-A. If the clinician is a physician, the form should be completed in its entirety, if the clinician is an athletic trainer, the form shall be completed as fully as possible with the understanding that some of the assessments will not be carried out. If the athlete reports to be symptom free and the remainder of the exam is normal, the clinician may choose to engage the athlete in exertional maneuvers and then reassess symptoms. Also at this time, a care plan will be discussed. If this sub-acute exam was not completed by a team physician, a follow-up physician exam will be required as soon as possible (and within 48 hours). Depending on signs and symptoms from this sub-acute exam, the clinician may opt to require the S-A to be observed at a health care facility. (On-Campus Health Services, Local Hospital) If the S-A is allowed to return to their room, specific timing and location of the next follow-up exam will be discussed with the S-A. Further, the S-A and another responsible adult will be provided with the Concussion Home Instruction Sheet (see attachments) and will be provided with contact information and instructions in the event that the S-A’s condition worsens. The clinician should review the home instructions with the S-A, with emphasis given to cautions regarding medication (no NSAIDs) and activity levels, both physical and cognitive (see below). Sub-Acute Care and “Return-to-Learn” Along with the follow-up exam already mentioned above, the S-A will be instructed in appropriate behaviors in order to maximize healing conditions for concussion. This will include continued physical rest and also cognitive rest. The athlete will be instructed to limit reading, ‘screen time’ (texting, video game play, computer work) and any other cognitive activity that requires focus/concentration. Learning Resources for Student Athletes (LRSA) will be alerted to the extent of the injury in order to assist with the cognitive rest recommendations. The athlete will be required to discuss a “Return to Learn” plan with both Team Physicians and their LRSA Learning Specialist Advisor who will serve as the ‘point person’ for handling needed academic accommodations. If needed the athlete may initially be housed in a low-sensory environment at University Health Services if cognitive activity increases symptoms. The goal of LRSA and team physicians will be to assist the S-A to minimize cognitive stress while making an attempt to stay current academically. The LRSA Advisor shall make recommendations regarding the resumption of class work and class attendance in a gradual fashion for a period of up to two weeks. In their ongoing monitoring of the concussed S-A, the team physicians, in conjunction with the LRSA Advisor, will make recommendations for continued or increased assistance from University staff as well as off-campus resources to assist with any prolonged Return-to-Learn issues that might continue beyond the initial two week period post-injury. However, increased assistance may be sought out at any time during the monitoring of the S-A’s recovery as determined by team physicians or the LRSA Advisor. All recommendations suggested by oncampus and/or off-campus clinicians shall adhere to the ADA Amendments Act of 2008. Oncampus resources include Disability Services Office, The Connors Learning Center, University Counseling Services and Office of the Academic Deans. Off-campus resources would initially include the Concussion Neuropsychology Group at Children’s Hospital with referral to other expert clinicians as needed. Follow-Up Evaluation & Care The concussed S-A shall be re-evaluated within (or close to) 24 hours post injury. At this time, the Concussion Follow-Up Assessment Form and Self-Report Symptom Scale document will be utilized for the exam (see attachments). All clinicians should note that on this form the selfreport symptom scale is NOT graded on severity of symptoms but rather on duration of symptoms. This must be explained carefully to the S-A and a time frame for symptom report must be selected and noted on the form. Because the scale is different than that employed during the sub-acute exam, the total symptom score should not be compared between these two exams. When utilizing this follow-up form, the clinician should take into account the timing of the administration of the self-report in regards to the length of time that the S-A has been awake and whether or not the S-A is utilizing any medication that may mitigate symptoms. The form should be completed with care being taken to note any changes in the S-A’s condition as well as documentation of the next time and location for serial follow-up evaluation. Daily monitoring of the concussed S-A shall continue and the Concussion Follow-Up Assessment Form and Self-Report Symptom Scale shall again be employed during these evaluations. ImPACT neurocognitive testing will be carried out on physician recommendation only after the acute and sub-acute symptoms have resolved and the athlete has completed at least the initial two steps of the Return to Play Protocol. The athlete should not undergo ImPACT testing during the initial post-injury phase. Comparison of the ImPACT scores will be made with baseline scores if available or with normative data. The neurocognitive testing results will assist the overall evaluation of the S-A but will not serve as the only measure of progress nor as the only indicator for return to play clearance. The team physicians shall continue daily monitoring until such as time as the S-A has successfully completed all evaluations, testing values have returned to levels at or near baseline and the S-A has successfully completed the Return-to-Play progression outlined below. If the SA is experiencing a prolonged recovery and has not been cleared to return to play and/or is still experiencing cognition issues related to Return-To-Learn, team physicians shall convene to discuss additional differential diagnoses as well as other evaluative and care options. As described previously, off-campus resources would initially include the Concussion Neuropsychology Group at Children’s Hospital with referral to other expert clinicians as needed. Return to Play Considerations The Return to Play (RTP) protocol following a concussion follows a stepwise progression and is not initiated until approximately 24 hours after the S-A is asymptomatic and other neurological evaluations are considered back to normal. A physician must approve the commencement of the RTP progression. The progression outlined below is to be carried out in a step-wise fashion with constant monitoring both before and after activity by a sports medicine clinician. The Concussion Follow-Up Assessment Form and Self-Report Symptom Scale will be used again after each step. If recurrence of symptoms is noted and/or a change in the neurological exam occurs, the athlete will again be held from activity for approximately 24 hours and re-evaluated. If the symptoms have resolved, the athlete will drop back to the previous step and be allowed to resume the progression. Integration of two steps within a 24 hour period is permissible only with physician approval. Step 1 – Light aerobic exercise to increase heart rate (walking, stationary bike, elliptical, etc.) Step 2 – Sport specific cardio activity (ex: skating, running) Step 3 – Progressive resistance exercise Step 4 - Non-contact practice Step 5 – Return to full contact play with clearance by physician *While self-evident when following all of the guidelines outlined in this document, it should be noted that at no time will a Student-Athlete be allowed to return to play if they still require academic adaptations or accommodations related to their concussion. Special Considerations The sports medicine clinician may consider obtaining a neurological consult or an adjustment of the RTP progression in certain situations. Find below a list of some of those situations that may warrant a change in the normal protocol.      Structural Head Injury Multiple Concussions Extensive duration of symptoms at any point post injury Significant amnesia or LOC greater than 1 minute Co-morbidities such as a past history medical history of migraine, depression, ADHD, sleep disorder, and/or other mental health issues Summary It is important to note that concussion evaluation and management must be handled on a case-bycase basis. There is no ‘typical’ clinical course for the resolution of the injury itself and the post concussive management. In following the mission of Boston College Sports Medicine, we will protect and promote the safety, health and well being of every student athlete and will provide and coordinate the care of our athletes while working with our coaches as they prepare for athletic competition. Post concussive care will focus on limiting the potential catastrophic and long term risks involved with concussive injuries. The evaluation, care and return to play decisions will be based on current best medical practices and the clinical judgments made by Boston College clinicians specifically for each injured individual. Reviewed/Revised June 2015 Cal Sports Medicine Concussion Management Plan 4/23/15 PRE-INJURY MANAGEMENT - - - All incoming student athletes undergo a pre-participation physical exam (PPE) that includes a thorough history and physical exam. A yearly interval history is taken in subsequent years of participation. If there is a history of concussion or head injury, further questioning includes details surrounding previous injuries (mechanism, symptoms, duration, work up), and evaluation for modifiers (prior concussion history, learning disabilities requiring stimulant medications, psychiatric history, migraines, seizure history). If a student athlete has significant history of prior concussion(s) or head injury, or significant other modifiers, a Cal Team Physician may request additional consultation with neuropsychology or other specialists. Student athletes will undergo baseline neuropsychological (NP) testing and symptom evaluation using the computerized Immediate Post-Concussion Assessment and Cognitive Testing program (ImPACT), Standardized Assessment of Concussion (SAC), and a baseline balance assessment. Cal team physician will determine initial pre-participation clearance status. ACUTE INJURY/SIDELINE MANAGEMENT - - - - In the event of a suspected head injury, immediate concern should be given to rule out cervical spine trauma, skull fracture, and intracranial injury. Evaluation follows standard ABCDE first aid principles. If a student athlete exhibits any signs, symptoms or behaviors consistent with a concussion, the student athlete shall be removed from practice or competition and not allowed to return to play until they are evaluated by a Cal sports medicine healthcare provider with experience in the evaluation and management of concussion. If no certified athletic trainer (ATC) or team physician is available, and the student athlete has minimal symptoms, contact the ATC / team physician to determine a plan for evaluation of the student athlete. If unable to contact the Cal sports medicine staff, contact UHS Urgent Care at 510-642-5005. Symptomatic student athletes should not transport themselves. For away contests when an ATC is not available, the host institutions medical staff should be utilized. If an ATC is on site and the student athlete is stable medically, the SAC, symptom and balance assessment along with physical examination should be used for the evaluation of the injured student athlete. If an ATC is on site and the assessment is concussion, the student athlete cannot return to play or practice the same calendar day. If the student athlete is evaluated by the team physician and/or other clinician and the diagnosis is concussion, the student athlete cannot return to play or practice the same calendar day. If a student athlete is diagnosed with concussion, or suspicion of concussion exists, the student athlete will receive serial monitoring for changes or deterioration. A student athlete with suspected spine/skull/intracranial injury, worsening symptoms, especially worsening headache, repetitive vomiting, increased confusion, garbled speech, lethargy or extreme sleepiness, trouble using their arms or legs, convulsions or seizure activity, should be transported emergently by paramedic to the emergency room. Objective findings such as Glasgow Coma Scale <13, focal neurological deficit, or loss of consciousness longer than 1 minute also requires emergent transport. POST-ACUTE INJURY MANAGEMENT - - - Physician evaluation of all concussed student athletes with timing dependent on ATC assessment & clinical judgment. The ATC should contact the team physician to discuss follow up. The team physician will: o Determine additional testing / consultation as indicated o Educate student athlete regarding importance of reporting all / any symptoms o Determine if any modifications to school or other demands necessary (e.g. refer to Disabled Students Program (DSP), communicate with professors, parents, others) Follow up / ongoing management o Daily follow up of symptoms using symptom checklist o Post-injury neuropsychological (NP) testing (e.g. ImPACT), SAC testing, and balance testing as determined by team physician. o Follow up with ATC/team physician once ready to progress activities as well as to return to full play (If not seen in follow up by team physician, must be discussed) Strict cognitive and physical rest. Student athletes with concussion and a responsible party will be provided with oral and/or written instructions upon discharge. RETURN-TO-LEARN MANAGEMENT - - - Individualized decision; made by the team physician. Consultation from other specialists will be obtained in more complex cases. Possible consultants include, but is not limited to, neuropsychologist, counseling and psychological services staff, disabled students program staff, academic counselors, learning specialists, faculty athletic representative, and academic faculty/staff. A letter verifying a concussion/head injury may be provided by a physician to assist academic faculty/staff with providing accommodations. The following statement is included in this correspondence: “Major exams may not be representative of academic ability in the immediate postconcussive period. We recommend no finals/major exams or projects for 7 days following the diagnosis of concussion.” General guideline of graduated progression in cognitive/academic activity: o No classroom activity on same day of concussion o Remain at home and rest if experiencing significant symptoms with cognitive stimulation (like computer use or reading) lasting <30 minutes o Once able to tolerate 30 minutes of cognitive activity, it is ok to resume modified class attendance (modified class attendance options include attending the first 30 minutes of classes, breaks between classes, half-days, etc) o Upon return to class, load can be increased as tolerated. If exacerbation of symptoms, return back to previous level of cognitive activity where there were no symptoms and attempt to progress again after 24 hours - Physician re-evaluation will take place if symptoms worsen with academic challenges or if full return to academics has not been achieved within 2 weeks. Student athletes will not return to full contact/play until full return to academics has been achieved. All accommodations and services will comply with Americans with Disabilities Act Amendments Act (ADAAA). RETURN-TO-PLAY MANAGEMENT - - - Individualized decision; made by the team physician. Consultation from the athletic trainer, student athlete, neuropsychological / balance testing, and additional outside consultation as appropriate. Time student athlete held out of activity, rate of progression, all individualized, with decision made by team physician. Modifiers to consider: o Age o Prior history of concussion (#, specifics of injury(s), severity of injuries, recency) o Learning disabilities (e.g. ADHD) o Migraine History o Seizure history o Other (e.g. emotional readiness, anxiety, depression, parental concern) Student athlete must by symptom free in regards to concussion (without medications) prior to returning to cardiovascular exertion (exception may be in the case of possible post concussive syndrome). A student athlete with signs / symptoms of concussion at rest or exertion should not continue to play. Gradual progression in activity; step-wise with gradual increments in physical exertion and risk of contact: o Cardiovascular challenge (15 – 20 minutes) o Unlimited cardiovascular activity, sport-specific exercise without head impact o Non-contact training drills, progressive resistance training o Full-contact practice / unrestricted training o Return to game play Rate of progression and final clearance is determined by the team physician o No return to contact until NP and balance testing considered acceptable o If NP testing interpreted as abnormal, repeat NP testing as appropriate, with at least 48 hours between repeat testing, or as determined by team physician. CLEARANCE AND FINAL FOLLOW UP - Final authority for return-to-play shall reside with Cal team physician or team physician designee. Additional consultation and/or testing may be indicated and will be determined by the team physician. Student athlete education regarding importance of reporting all symptoms as well as increased risk for concussion, and delay in recovery, with subsequent injury. New baseline evaluation will take place 6 months post injury, or as determined by team physician. ADMINISTRATIVE MANAGEMENT/EDUCATION - ATC’s on site/available for all at risk practices and games, physician on site/available for at risk home events. Host institution’s medical staff utilized for away contests where no Cal sports medicine staff are available. - - - - Emergency action plan on file for each athletics venue to respond to student athlete catastrophic injuries and illnesses, including concussion plan for all high risk sports. Healthcare plan on file that assures equitable access to healthcare providers for all student athletes. The University will adhere to independent medical care guidelines. Cal sports medicine healthcare providers have the unchallengeable authority to determine management and return-to-play of any ill or injured student athlete. A countable coach should not serve as the primary supervisor for a Cal sports medicine healthcare provider nor should they have sole hiring or firing authority over that provider. All athletic programs will adhere to any NCAA or conference contact guidelines. All coaches and equipment staff are in line with best practice in terms of proper athletic technique and protective equipment. All student athletes must annually read and sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. All student athletes, coaches, team physicians, athletic trainers, and the directors of athletics are provided with written educational material (at minimum the NCAA concussion fact sheet) on concussion annually, including signs and symptoms of concussion, and neuropsychological testing (ImPACT). Each party will provide a signed acknowledgement of having read and understood the concussion material. Coaches must acknowledge understanding of concussion educational materials and the written management plan. Documentation will be kept regarding baseline evaluation, initial injury evaluation, continued management, and clearance of the student athlete with concussion. ROLE OF ATHLETICS HEALTHCARE PROVIDERS *In general, all athletics healthcare providers and consultants will practice within the standards established for their professional practice. 1) Cal Team Physicians: a. Authority to screen, evaluate, and treat concussion in accordance with written concussion management plan b. Authority to diagnose concussion c. Authority to make any and all management/return-to-play decisions using best practice clinical decision making and in accordance with written concussion management plan d. Only healthcare provider able to give final medical clearance for return-to-play e. Authority to provide and approve any and all educational materials to student athletes, caregivers, and coaches f. Authority to designate other healthcare providers to make same decisions as above when deemed necessary (e.g. during away competition) g. Authority to interpret ImPACT, modified BESS, and SAC testing 2) Cal Certified Athletic Trainers: a. Authority to screen, evaluate, and treat concussion in accordance with written concussion management plan b. Authority to make the assessment of concussion c. Does not have authority to make return-to-play decisions unless directed by Cal team physician (or team physician designee) d. Authority to provide any and all educational materials to student athletes, caregivers, and coaches e. Authority to perform and interpret modified BESS and SAC testing 3) Physicians, Physician Assistants, and Nurse Practitioners at Cal Student Health Center a. Authority to screen, evaluate, and treat concussion in accordance with best practice clinical decision making b. Authority to diagnose concussion c. Does not have authority to make return-to-play decisions unless directed by Cal team physician (or team physician designee) d. Authority to provide any and all educational materials to student athletes, caregivers, and coaches e. Will contact Cal team physician and/or Cal certified athletic trainer in cases of diagnosed or suspected concussion to arrange follow up care f. Does not have authority to interpret neuropsychological testing 4) Consultants a. Neurology, neuropsychology, or any other consultant deemed appropriate by Cal team physicians may participate in the care of concussed student athletes in conjunction with Cal team physicians b. Consultant recommendations (including return-to-play) will be used as part of the decision making process, but may not be the sole basis of final concussion management decisions c. Neuropsychology will be consulted to interpret ImPACT tests as deemed necessary by Cal team physicians SPORTS MEDICIE CON CUSSI ON MANAGEMENT PROTOCOL CONTENTS CONCUSSION MANAGEMENT GUIDELINES Guidelines INDEPENDENT MEDICAL CARE GUIDELINES Appendix A FOOTBALL PRACTICE GUIDELINES Appendix B CONCUSSION: A FACT SHEET FOR STUDENT-ATHLETES Appendix C STUDENT-ATHLETE CONCUSSION STATEMENT ACKNOWLEDGEMENT Appendix D BASELINE ASSESSMENT SYMPTOM SCALE Appendix E CONCUSSION: A FACT SHEET FOR COACHES Appendix F ATHLETIC STAFF CONCUSSION STATEMENT ACKNOWLEDGEMENT Appendix G CONCUSSION HEAD INJURY INFORMATION TAKE-HOME INSTRUCTIONS Appendix H CONCUSSION ASSESSMENT SYMPTOM SCALE Appendix I CONCUSSION AWARENESS LETTER Appendix J EMERGENCY ACTION PLANS Appendix K BASEBALL Doug Kingsmore Baseball Stadium Venue Basketball Littlejohn Coliseum Venue Diving Fike Recreation Center McCue Natatorium Venue Diving Accident Policy Football Jervey Meadows Football Practice Fields & Indoor Practice Facility Death Valley Memorial Stadium Venue Golf Larry B. Penley Jr. Golf Facility Venue Clemson Golf Practice Facility Venue Walker Golf Course Practice Facility Rowing East Beach Rowing Venue Soccer Jervey Meadows Men and Women’s Soccer Practice Fields Riggs Soccer Stadium Venue Tennis Hoke Sloan Indoor Tennis Center Venue Hoke Sloan Outdoor Tennis Venue Track The Indoor Track Venue Rock Norman Track Complex Venue Volleyball Jervey Volleyball Venue CONCUSSION SAFETY PROTOCOL CHECKLIST Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Appendix L CONCUSSION MANAGEMENT GUIDELINES I. INTRODUCTION The NCAA Executive Committee has developed a consistent, association-wide approach to Concussion Management. It is the responsibility of all student-athletes to report injuries and illnesses to their Athletic Trainer. This includes, but is not limited to, signs and symptoms related to concussions. The Clemson University Sports Medicine Department recognizes and acknowledges that concussions or traumatic brain injuries (TBI) need immediate attention. A concussion is defined as a generally short-lived impairment of neurological function brought on by a direct or indirect traumatic force applied to the head or body. Symptoms are usually rapid in onset, but of short duration and generally resolve spontaneously. It is usually a functional disturbance and not a structural one. Loss of consciousness may or may not be involved. Exact recovery periods from these types of head injuries are uncertain and will often vary. Clemson University Sports Medicine adheres to the NCAA Concussion Policy and Legislation. In addition, Clemson University Sports Medicine abides by the Independent Medical Care Guidelines (APPENDIX A) and Football Practice Guidelines (APPENDIX B) as addressed by the Safety in College Football Summit. All members of the Clemson University Sports Medicine staff will practice within the scope of their established professional practice. All of the concussion management progression lies exclusively with the Clemson University Sports Medicine Staff, and The Team Physician will make the final determination of return-to-play once asymptomatic and postexertion assessments are within normal limits. The entire concussion management process of the student-athlete from the baseline assessment, initial postinjury evaluation, and eventual return to full athletic and academic participation, including any diagnostic testing, shall be documented within their medical file. II. BASELINE ASSESSMENT / EDUCATION Prior to any athletic activity, every student-athlete will be required to sign a Student-Athlete Concussion Statement Acknowledgement (APPENDIX D) annually stating they receive, have read, and understand the information provided by the NCAA document Concussion: A Fact Sheet for Student-Athletes (APPENDIX C). This document on concussions includes the definition of a concussion, how to prevent concussion, the symptoms of a concussion, and how to report any concerns for themselves, or a teammate regarding a concussion. Before any athletic participation, every student-athlete will undergo baseline testing. Baseline testing includes a medical history, a Baseline Assessment Symptom Scale with a Balance Error Scoring System (BESS) (APPENDIX E), and a computerized neuropsychological test. All Clemson University Coaches, Strength and Conditioning Staff, Athletic Trainers, Team Physicians, Vickery Hall Academic Staff, and the Director of Athletics will be required to sign an Athletic Staff Concussion Statement Acknowledgment (APPENDIX G) annually stating that they receive, have read, and understand the information provided by the NCAA document Concussion: A Fact Sheet for Coaches (APPENDIX F). This document includes facts and the definition of a concussion, signs and symptoms to be aware of, how to prevent concussions, and what to do if they suspect a concussion has occurred in a student-athlete. In an attempt to educate student-athlete’s playing football, the Clemson University Football coaches go over drills to teach proper form prior to contact during fall and spring practice. These sessions are videoed and kept on file. III. CONCUSSION The Clemson University Sports Medicine team will determine whether or not a concussion has occurred, realizing that each concussion and each student-athlete are different and individual treatment plans are necessary. Page 1 of 3 Signs and Symptoms of a Possible Concussion (including but not limited to): • • • • • • • Headache Nausea Balance Problems Dizziness Diplopia - Double Vision Confusion Photophobia – Light Sensitivity • • • • • • Difficulty Sleeping Misophonia – Noise Sensitivity Blurred Vision Feeling Sluggish or Groggy Memory Problems Difficulty Concentrating When a student-athlete exhibits signs, symptoms, or behavior consistent with a possible concussion, they shall be removed from practice or competition and evaluated by the Certified Athletic Trainer and/or the Team Physician. The student-athlete will be evaluated and monitored for a minimum of 15 minutes to determine their status as it relates to being concussed. Once a student-athlete has been diagnosed with having a concussion, they shall be removed from physical activity for the remainder of that day, and not allowed to participate in academic activities. The student-athlete, or their parent, guardian, or roommate, will be provided instructions on further care and the Concussion Head Injury Information Take-Home Instructions (APPENDIX H) upon discharge. The student-athlete will be monitored multiple times daily for progression of symptoms from rest, physical exertion, and mental exertion by the Clemson University Sports Medicine staff. The student-athlete will see a Team Physician every morning and at other times throughout the day as deemed necessary, to determine their status as it pertains to their concussion symptoms, their athletic participation status, and their academic participation status. The Clemson University Sports Medicine Staff will use a Concussion Assessment Symptom Scale (APPENDIX I) and a Balance Error Scoring System (BESS) daily, along with other examinations deemed necessary during the evaluation of the concussed student-athlete until the symptoms have subsided and/or have been resolved. A computerized neuropsychological test will also be performed, however, computer neuropsychological tests should not be used as a standalone measure to diagnose the presence or absence of a concussion. All of these evaluations will be compared to the baseline values of the student-athlete and will aid in the Return-to-Play and Return-to-Learn progression. In the case of a prolonged recovery, the team physician will determine the need for further diagnostic imaging, testing, or outside consultation on a case-by-case basis. With permission for release of information from the student-athlete, the Vickery Hall Academic Advisors and their Professors will be notified and updated on the condition of the student-athlete after they suffer from a concussion. IV. EMERGENCY ACTION Clemson University Sports Medicine personnel will execute the Clemson University Sports Medicine Emergency Action Plan (APPENDIX K) for further medical care and/or transportation as deemed necessary. This may include injury to the neck and/or spine, headtrauma, and/or severe concussion signs and/or symptoms. The following items may be used to determine the status of the student-athlete as it pertains to transportation to a medical facility and/or initiating the Emergency Action Plan: 1. A Glasgow Coma Scale that diminishes below a 13 2. Prolonged loss of consciousness as it relates to the concussion 3. A neurological exam deficit that may suggest intracranial trauma 4. Repetitive/Uncontrolled vomiting (Emesis) 5. A persistent decline of the student-athlete's mental status and/or neurological signs/symptoms 6. Significant spinal related trauma/injury V. RETURN-TO-PLAY The Athletic Trainer and the Team Physician will monitor the progression of the student-athlete and their return to athletic and academic activities. The Clemson University Sports Medicine Staff will use the Concussion Assessment Symptom Scale and a Balance Error Scoring System (BESS) daily, along with other examinations deemed necessary during the evaluation of the concussed student-athlete, to determine how quickly the Return-to-Play and progression is performed. The following stages are to be followed in the progression of athletic activity: The athlete must be asymptomatic before progressing to the next stage, as follows: Stage 1: At rest and daily living activities for ~24 hours. Stage 2: Weight lifting and conditioning Stage 3: Non-contact drill work Stage 4: Contact drill work Stage 5: Full contact practice and drill work Stage 6: Full participation with the release of the Team Physician. Page 2 of 3 VI. RETURN-TO-LEARN The Clemson University Team Physicians, Sports Medicine Staff Athletic Trainers, and the Athletic Academic Success Center (a.k.a. Vickery Hall staff) will work together to determine the Return-to-Learn status of a post-concussed studentathlete. The Vickery Hall staff will be the point persons when dealing with a student-athletes’ professors and any accommodations that may be needed in their return to the classroom and activities that are associated with their full academic return. he Clemson University Team Physicians, Sports Medicine Staff Athletic Trainers, and Vickery Hall staff will work together to determine the daily status of the student-athlete. When a student-athlete has been diagnosed with a concussion, they will be held from practice, competition, and class activities that same day. The Vickery Hall staff will be notified on the status of the student-athlete. On subsequent days that follow a concussion, the student-athlete will be seen by the Team Physician each morning before classes begin. At that time, the decision will be made by the Clemson University Team Physician if the studentathletes’ symptoms have progressed to allow them to attempt to go to class, study hall, and tutoring sessions that day. The Vickery Hall staff will be alerted of the decision from the Clemson University Team Physician about the studentathlete’s progression for that day. The Vickery Hall staff will, in turn, convey the status of the student-athlete to their professors. The Clemson University Team Physician will initiate the Concussion Awareness Letter (APPENDIX J) so this can be delivered to the Vickery Hall staff, and then to the student-athletes’ professors. Regardless of returning to class that day or not, the student-athlete will be seen by the Clemson University Team Physician and Sports Medicine staff at the appointed time that afternoon. If the student-athlete is allowed to return to class, they will be evaluated that afternoon in orderTto complete an updated symptom checklist. This will aid in determining how their day of learning progressed. The student-athlete will be required to complete a Concussion Assessment Symptom Scale each day post-concussion until they are symptom-free. This process will continue until the student-athlete has returned to full classroom activity. Vickery Hall staff will play an important role in the day-to-day progression of the student-athlete in return to full classroom, study hall, and tutoring activities. They will also be the point persons in dealing with accommodations that the student-athlete may need while returning to full classroom activities. If there is a need to involve the Clemson University Disability Services Center to aid in compliance with the Americans with Disabilities Act Amendments Act (ADAAA), the Vickery Hall staff will handle this process. In any concussion case when a student-athlete needs counseling, the Sports Medicine staff will aid in referring him/her to the Athletic Department’s Licensed Counselor, located at Redfern Student Health Center on campus. PROLONGED / MULTIPLE CONCUSSION MANAGEMENT TEAM In the event of a more complex case of symptomatic Return-to-Learn with a student-athlete, or in the event of multiple concussions, the following Concussion Management Team may need to meet and develop a personalized plan for the student-athlete. The Team Physician will enact and lead this team as he sees fit for prolonged recovery from a concussion. This team may or may not be enacted after 2 weeks. This will be determined by the Team Physician and the Vickery Hall Academic Counselor on an individual basis. This team will be responsible for assisting the student-athlete in engaging campus resources for those cases that cannot be managed through schedule modification. If necessary, the plan may involve having the student-athlete take a medical withdrawal from the University for the semester in which they are enrolled while recovering from their concussion. TEAM MEMBERS: • • • • • Clemson Team Physicians Director of Sports Medicine / Head Athletic Trainer Full-time Athletic Trainer with respective sport Clemson University Athletic Department Licensed Counselor Vickery Hall Staff Member(s) that are directly involved with the student-athlete This policy is intended to guide patient care. Medical conditions and specific medical situations are often complex and require health care providers to make independent judgments. These policies may be modified by practitioners to achieve maximal patient outcomes. Page 3 of 3 INDEPENDENT MEDICAL CARE GUIDELINES Independent Medical Care for College Student-Athletes Guidelines Purpose: The Safety in College Football Summit resulted in inter-association consensus guidelines for three paramount safety issues in collegiate athletics: 1. Independent medical care in the collegiate setting; 2. Concussion diagnosis and management; and 3. Football practice contact. This document addresses independent medical care for college student-athletes in all sports. Background: Diagnosis, management, and return to play determinations for the college student-athlete are the responsibility of the institution’s athletic trainer (working under the supervision of a physician) and the team physician. Even though some have cited a potential tension between health and safety in athletics,1,2 collegiate athletics endeavor to conduct programs in a manner designed to address the physical well-being of college student-athletes (i.e., to balance health and performance).3,4 In the interest of the health and welfare of collegiate student-athletes, a student-athlete’s health care providers must have clear authority for student-athlete care. The foundational approach for independent medical care is to assume an “athlete-centered care” approach, which is similar to the more general “patient-centered care,” which refers to the delivery of health care services that are focused only on the individual patient’s needs and concerns.5 The following 10 guiding principles, listed in the Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges,5 are paraphrased below to provide an example of policies that can be adopted that help to assure independent, objective medical care for college student-athletes: 1. The physical and psychosocial welfare of the individual student-athlete should always be the highest priority of the athletic trainer and the team physician. 2. Any program that delivers athletic training services to student-athletes should always have a designated medical director. 3. Sports medicine physicians and athletic trainers should always practice in a manner that integrates the best current research evidence within the preferences and values of each student-athlete. 4. The clinical responsibilities of an athletic trainer should always be performed in a manner that is consistent with the written or verbal instructions of a physician or standing orders and clinical management protocols that have been approved by a program’s designated medical director. 5. Decisions that affect the current or future health status of a student-athlete who has an injury or illness should only be made by a properly credentialed health professional (e.g., a physician or an athletic trainer who has a physician’s authorization to make the decision). 6. In every case that a physician has granted an athletic trainer the discretion to make decisions relating to an individual studentathlete’s injury management or sports participation status, all aspects of the care process and changes in the student-athlete’s disposition should be thoroughly documented. 7. Coaches must not be allowed to impose demands that are inconsistent with guidelines and recommendations established by sports medicine and athletic training professional organizations. 8. An athletic trainer’s role delineation and employment status should be determined through a formal administrative role for a physician who provides medical direction. 9. An athletic trainer’s professional qualifications and performance evaluations must not be primarily judged by administrative personnel who lack health care expertise, particularly in the context of hiring, promotion, and termination decisions. 10. Member institutions should adopt an administrative structure for delivery of integrated sports medicine and athletic training services to minimize the potential for any conflicts of interest that could adversely affect the health and well-being of studentathletes. Page 1 of 2 APPENDIX A Team physician authority becomes the linchpin for independent medical care of student-athletes. Six preeminent sports physicians associations agree with respect to “… athletic trainers and other members of the athletic care network report to the team physician on medical issues.”6 Consensus aside, a medical-legal authority is a matter of law in 48 states that require athletic trainers to report to a physician in their medical practice. The NCAA Sports Medicine Handbook’s Guideline 1B opens with a charge to athletics and institutional leadership to “create an administrative system where athletics health care professionals – team physicians and athletic trainers – are able to make medical decisions with only the best interests of student-athletes at the forefront.”7 Multiple models exist for collegiate sports medicine. Athletic health care professionals commonly work for the athletics department, student health services, private medical practice, or a combination thereof. Irrespective of model, the answer for the college student-athlete is established independence for appointed athletics health care providers.8 Guidelines: Institutional medical line of authority should be established independently of a coach, and in the sole interest of student-athlete health and welfare. Medical line of authority should be transparent and evident in athletics departments, and organizational structure should establish collaborative interactions with the medical director and primary athletics health care providers (defined as all institutional team physicians and athletic trainers) so that the safety, excellence and wellness of student-athletes are evident in all aspects of athletics and are studentathlete centered. Institutions should, at a minimum, designate a licensed physician (M.D. or D.O.) to serve as medical director, and that medical director should oversee the medical tasks of all primary athletics health care providers. Institutions should consider a board certified physician, if available. The medical director may also serve as team physician. All athletic trainers should be directed and supervised for medical tasks by a team physician and/or the medical director. The medical director and primary athletics health care providers should be empowered with unchallengeable autonomous authority to determine medical management and return-to-play decisions of student-athletes. References: 1. Matheson GO. Maintaining professionalism in the athletic environment. Phys Sportsmed. 2001 Feb;29(2) 2. Wolverton B. (2013, September 2) Coach makes the call. The Chronicle of Higher Education. [Available online] http://chronicle.com/article/Trainers-Butt-Heads-With/141333/ 3. NCAA Bylaw 3.2.4.17 (Div. I and Div. II; 3.2.4.16 (Div. III). 4. National Collegiate Athletic Association. (2013). 2013-14 NCAA Division I Manual. Indianapolis, IN: NCAA. 5. Courson R et al. Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges. J Athletic Training 2014; 49:128-137. 6. Herring SA, Kibler WB, Putukian M. Team Physician Consensus Statement: 2013 update. Med Sci Sports Exerc. 2013 Aug;45(8):1618-22. 7. National Collegiate Athletic Association. (2013). 2013-14 NCAA Sports Medicine Handbook. Indianapolis, IN: NCAA. 8. Delany J, Goodson P, Makeoff R, Perko A, Rawlings H [Chair]. Rawlings panel on intercollegiate athletics at the University of North Carolina at Chapel Hill. Aug 29 ‘13. [Available online] http://rawlingspanel.web.unc.edu/files/2013/09/RawlingsPanel_Intercollegiate-Athletics-at-UNC-Chapel-Hill.pdf *This Consensus Best Practice, Independent Medical Care for College Student-Athletes, has been endorsed by: • American Academy of Neurology • American College of Sports Medicine • American Association of Neurological Surgeons • American Medical Society for Sports Medicine • American Orthopaedic Society for Sports Medicine • American Osteopathic Academy for Sports Medicine • College Athletic Trainers’ Society • Congress of Neurological Surgeons • National Athletic Trainers’ Association • NCAA Concussion Task Force • Sports Neuropsychological Society Page 2 of 2 FOOTBALL PRACTICE GUIDELINES Year-Round Football Practice Contact Guidelines Purpose: The Safety in College Football Summit resulted in inter-association consensus guidelines for three paramount safety issues in collegiate athletics: 1. Independent medical care in the collegiate setting; 2. Concussion diagnosis and management; and 3. Football practice contact. This document addresses year-round football practice contact. Background: Enhancing a culture of safety in collegiate sport is foundational. Football is an aggressive, rugged, contact sport,1 yet the rules clearly state that there is no place for maneuvers deliberately designed to inflict injury on another player.1 Historically, rules changes and behavior modification have reduced catastrophic injury and death. Enforcement of these rules is critical for improving player safety.2 Despite sound data on reducing catastrophic football injuries, there are limited data that provide a strong foothold for decreasing injury risk by reducing contact in football practice.3-8 Regardless of such scientific shortcomings, there is a growing consensus that we must analyze existing data in a consensus-based manner to develop guidelines that promote safety. “Safe” football means “good” football. NCAA regulations currently do not address in season, full-contact practices. The Ivy League and Pac-12 Conference have limited in season, full-contact practices to two per week and have established policies for full-contact practices in spring and preseason practices through their Football Practice Standards and Football Practice Policy, respectively. Neither address full-pad practice that does not involve live contact practice, as defined below. Both conferences cite safety concerns as the primary rationale for reducing full-contact practices; neither conference has published or announced data analysis based on their new policies. In keeping with the intent of both conferences and other football organizations, the rationale for defining and reducing live contact practice is to improve safety, including possibly decreasing studentathlete exposure for concussion and sub-concussive impacts. Reduced frequency of live contact practice may also allow even more time for teaching of proper tackling technique. The biomechanical threshold (acceleration/deceleration/rotation) at which sport-related concussion occurs is unknown. Likewise, there are no conclusive data for understanding the short- or long-term clinical impact of sub-concussive impacts. However, there are emerging data that football players are more frequently diagnosed with sport-related concussion on days with increased frequency and higher magnitude of head impact (greater than 100g linear acceleration).9-11 Traditionally, the literature addressing differing levels of contact in football practice correlated with the protective equipment (uniform) worn. This means that full-pad practice correlated with full-contact and both half-pad (shell) and helmet-only practice correlated with less contact. However, coaches, administrators and athletics health care providers who helped to shape these guidelines have noted that contact during football practice is not determined primarily by the uniform, but rather by whether the intent of practice is centered on live contact versus teaching and conditioning. There are limited data that address this issue, and such data do not differentiate whether the intent of the practice is live tackling or teaching/conditioning. Within these limitations, non-published data from a single institution reveal the following:10 • The total number of non-concussive head impacts sustained in helmets-only and full-pad practices is higher than those sustained in games/scrimmages. • Mild- and moderate-intensity head impacts occur at an essentially equal rate during full-pad and half-pad practices when the intent of practice is not noted. • Severe-intensity head impacts are much more likely to occur during a game, followed by full-pad practices and half-pad practices. • There is a 14-fold increase in concussive impacts in full-pad practices when compared to half-pad or helmets-only practices. • Offensive linemen and defensive linemen experience more head impacts during both full-pad and half-pad practices relative to all other positions. Page 1 of 3 APPENDIX B The guidelines below are based on: expert consensus from the two day summit referenced above; comments and recommendations from a broad constituency of the organizations listed; and internal NCAA staff members. Importantly, the emphasis is on limiting contact, regardless of whether the student-athlete is in full-pad, half-pad, or is participating in a helmet-only practice. Equally importantly, the principles of sound and safe conditioning are an essential aspect of all practice and competition exposures. These guidelines must be differentiated from legislation. For each section below that addresses a particular part of the football calendar, any legislation for that calendar period is referenced. As these guidelines are based on consensus and limited science, they are best viewed as a “living, breathing” document that will be updated, as we have with other health and safety guidelines, based on emerging science or sound observations that result from application of these guidelines. The intent is to reduce injury risk, but we must also be attentive to unintended consequences of shifting a practice paradigm based on consensus. For example, football preseason must prepare the student-athlete for the rigors of an aggressive, contact, rugged sport. Without adequate preparation, which includes live tackling, the student-athlete could be at risk of unforeseen injury during the in season because of inadequate preparation. We plan to reanalyze these football practice contact guidelines at least annually. Additionally, we recognize that NCAA input for these guidelines came primarily from Division I Football Bowl Subdivision schools. Although we believe the guidelines can also be utilized for football programs in all NCAA divisions, we will be more inclusive in the development of future football contact practice guidelines. Definitions: Live contact practice: Any practice that involves live tackling to the ground and/or full-speed blocking. Live contact practice may occur in fullpad or half-pad (also known as “shell,” in which the player wears shoulder pads and shorts, with or without thigh pads). Live contact does not include: (1) “thud” sessions, or (2) drills that involve “wrapping up;” in these scenarios players are not taken to the ground and contact is not aggressive in nature. Live contact practices are to be conducted in a manner consistent with existing rules that prohibit targeting to the head or neck area with the helmet, forearm, elbow, or shoulder, or the initiation of contact with the helmet. Full-pad practice: Full-pad practice may or may not involve live contact. Full-pad practices that do not involve live contact are intended to provide preparation for a game that is played in a full uniform, with an emphasis on technique and conditioning versus impact. Legislation versus guidelines: There exists relevant NCAA legislation for the following: 1. Preseason practice a. DI FBS/FCS – NCAA Bylaws 17.9.2.3 and 17.9.2.4 b. DII – NCAA Bylaws 17.9.2.2 and 17.9.2.3 c. DIII – NCAA Bylaws 17.9.2.2 and 17.9.2.3 2. In-season practice: No current NCAA legislation addresses contact during in season practices. 3. Postseason practice: No current NCAA legislation addresses contact during postseason practices. 4. Bowl practice: No current NCAA legislation addresses contact during bowl practice. 5. Spring practice: a. DI FBS/FCS – NCAA Bylaw 17.9.6.4 b. DII – NCAA Bylaw 17.9.8 c. DIII – NCAA Bylaw 17.9.6 – not referenced to as spring practice, but allows five (5) week period outside playing season. The guidelines that follow do not represent legislation or rules. As noted in the appendix, the intent of providing consensus guidelines in year one of the inaugural Safety in College Football Summit is to provide consensus-based guidance that will be evaluated “real-time” as a “living and breathing” document that will become solidified over time through evidence-based observations and experience. Preseason practice guidelines: For days in which institutions schedule a two-a-day practice, live contact practices are only allowed in one practice. A maximum four (4) live contact practices may occur in a given week, and a maximum of 12 total may occur in preseason. Only three practices (scrimmages) would allow for live contact in greater than 50 percent of the practice schedule. In season practice guidelines: In season is defined as the period between six (6) days prior to the first regular-season game and the final regular-season game or conference championship game (for participating institutions). There may be no more than two (2) live contact practices per week. Postseason guidelines: (FCS/DII/DIII) There may be no more than two (2) live contact practices per week. Bowl practice guidelines: (FBS) There may be no more than two (2) live contact practices per week. Page 2 of 3 Spring practice guidelines: Of the 15 allowable sessions that may occur during the spring practice season, eight (8) practices may involve live contact; three (3) of these live contact practices may include greater than 50 percent live contact (scrimmages). Live contact practices are limited to two (2) in a given week and may not occur on consecutive days. References: 1. NCAA Football: 2013 and 2014 Rules and Interpretations. 2. Cantu RC, Mueller FO. Brain injury-related fatalities in American football, 1945-1999. Neurosurgery 2003; 52:846-852. 3. McAllister TW et al. Effect of head impacts on diffusivity measures in a cohort of collegiate contact sport athletes. Neurology 2014; 82:1-7. 4. Bailes JE et al. Role of subconcussion in repetitive mild traumatic brain injury. J Neurosurg2013: 1-11. 5. McAllister TW et al. Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes. Neurology 2012; 78:1777-1784. 6. Beckwith JG et al. Head impact exposure sustained by football players on days of diagnosed concussion. Med Sci Sports Exerc 2013; 45:737-746. 7. Talavage TM et al. Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion. J Neurotrauma 2014; 31:327-338 8. Miller JR et al. Comparison of preseason, midseason, and postseason neurocognitive scores in uninjured collegiate football players. Am J Sports Med 2007; 35:1284-1288. 9. Mihalik JP, Bell DR, Marshall SW, Guskiewicz KM. Measurement of head impacts in collegiate football players: an investigation of positional and event-type differences. Neurosurgery 2007; 61:1229-1235. 10. Trulock S, Oliaro S. Practice contact. Safety in College Football Summit. Presented January 22, 2014, Atlanta, GA. 11. Crison JJ et al. Frequency and location of head impact exposures in individual collegiate football players. J Athl Train 2010; 45:549559. *This Inter-Association Consensus: Year-Round Football Practice Contact Guidelines, has been endorsed by: • American Academy of Neurology • American College of Sports Medicine • American Association of Neurological Surgeons • American Football Coaches Association • American Medical Society for Sports Medicine • American Orthopaedic Society for Sports Medicine • American Osteopathic Academy for Sports Medicine • College Athletic Trainers’ Society • Congress of Neurological Surgeons • Football Championship Subdivision Executive Committee • National Association of Collegiate Directors of Athletics • National Athletic Trainers’ Association • National Football Foundation • NCAA Concussion Task Force • Sports Neuropsychological Society Page 3 of 3 CONCUSSION A fact sheet for student-athletes What is a concussion? A concussion is a brain injury that: • Is caused by a blow to the head or body. – From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. • Can change the way your brain normally works. • Can range from mild to severe. • Presents itself differently for each athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness. How can I prevent a concussion? Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport. What are the symptoms of a concussion? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. What should I do if I think I have a concussion? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. It’s better to miss one game than the whole season. When in doubt, get checked out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. APPENDIX C STUDENT-ATHLETE CONCUSSION STATEMENT ACKNOWLEDGEMENT The NCAA Executive Committee has developed a consistent, association-wide approach to Concussion Management. It is the responsibility of all student-athletes to report injuries and illnesses to their Athletic Trainer. This includes, but is not limited to, signs and symptoms related to concussions. The Clemson University Sports Medicine Department recognizes and acknowledges that concussions or traumatic brain injuries (TBI) need immediate attention. A concussion is defined as a generally short-lived impairment of neurological function brought on by a traumatic force applied to the head or body. Symptoms are usually rapid in onset, but of short duration and generally resolve spontaneously. It is usually a functional disturbance and not a structural one. Loss of consciousness may or may not be involved. The Clemson Sports Medicine team will determine whether or not a concussion has occurred, realizing that each concussion and each student athlete is different, and individual treatment plans are necessary. SIGNS AND SYMPTOMS OF A POSSIBLE CONCUSSION (including but not limited to): • • • • • • • • • • • • • Headache Nausea Balance Problems Dizziness Diplopia - Double Vision Confusion Photophobia – Light Sensitivity Difficulty Sleeping Misophonia – Noise Sensitivity Blurred Vision Feeling Sluggish or Groggy Memory Problems Difficulty Concentrating As a Clemson University Student-Athlete, I acknowledge that I am responsible for reading and understanding the following as it relates to my physical and mental well-being: • • • • • • • • A concussion is a brain injury. A concussion cannot be seen, but symptoms may be seen immediately. Other symptoms can show up hours or days after injury. If I suspect I have a concussion, it is my responsibility to promptly report it to the Sports Medicine staff. I will not be allowed to return to practice, play, or academic activities that same day if I have a blow to the head or body and/or exhibit signs or symptoms consistent with a concussion, and will not be allowed to return to play until cleared by the Clemson University Team Physician. I am responsible to report any suspected injuries or illness to the Sports Medicine staff, including signs or symptoms of a concussion. I will promptly notify the Clemson Sports Medicine staff if I suspect a teammate has a concussion. Following a concussion the brain needs time to heal. An individual is much more likely to sustain another concussion or more serious brain injury if they return to athletic activities before symptoms have resolved. Repeat concussions can lead to longer recovery time, All incoming student-athletes will participate in baseline testing. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE INFORMATION REGARDING CONCUSSIONS AND THAT I HAVE RECEIVED THE NCAA CONCUSSION FACT SHEET. The NCAA Concussion Fact Sheet is also posted on the Clemson Sports Medicine Department at www.ClemsonTigers.com. SIGN AND RETURN THIS PAGE TO SPORTS MEDICINE. KEEP THE NCAA FACT SHEET. Print Full Name of Student-Athlete Date Print Full Name of Parent / Guardian Signature of Student-Athlete Date Signature of Parent / Guardian or Legal Representative* (if student-athlete is under 18 years of age) or Legal Representative* Date Capacity of Legal Representative* (if applicable):__________________________________________________ *May be requested to provide verification of representative status Page 1 of 1 APPENDIX D BASELINE ASSESSMENT Student-Athlete’s Name (last, first, middle) Today’s Date Athletic Trainer / Team Physician / Examiner SYMPTOM SCALE (Circle Appropriate Number for Each Symptom) SYMPTOM NONE MILD MODERATE SEVERE HEADACHE 0 1 2 3 4 5 6 NAUSEA 0 1 2 3 4 5 6 VOMITING 0 1 2 3 4 5 6 DIZZINESS 0 1 2 3 4 5 6 POOR BALANCE 0 1 2 3 4 5 6 SENSITIVITY TO NOISE 0 1 2 3 4 5 6 RINGING IN THE EARS 0 1 2 3 4 5 6 SENSITIVITY TO LIGHT 0 1 2 3 4 5 6 BLURRED VISION 0 1 2 3 4 5 6 POOR CONCENTRATION 0 1 2 3 4 5 6 MEMORY PROBLEMS 0 1 2 3 4 5 6 TROUBLE SLEEPING 0 1 2 3 4 5 6 DROWSINESS/SLEEPY 0 1 2 3 4 5 6 FATIGUE 0 1 2 3 4 5 6 SADNESS/DEPRESSION 0 1 2 3 4 5 6 IRRITABILITY 0 1 2 3 4 5 6 NECK PAIN 0 1 2 3 4 5 6 BALANCE ERROR SCORING SYSTEM (BESS) Balance Error Scoring System- Types of Errors (The BESS is performed with eyes closed and hands on iliac crests) • Hands lifted off iliac crest • Opening eyes • Step, stumble, or fall • Moving hip into > 30° abduction • Lifting forefoot or heel • Remaining out of testing position > 5 seconds STANCE DOUBLE LEG STANCE (FEET TOGETHER) ERROR POINTS SINGLE LEG STANCE (NON-DOMINANT FOOT) TOTAL The BESS is calculated by adding one error point for each error during the 2- 20-second tests APPENDIX E CONCUSSION A fact sheet for Coaches The Facts • A concussion is a brain injury. • All concussions are serious. • Concussions can occur without loss of consciousness or other obvious signs. • Concussions can occur from blows to the body as well as to the head. • Concussions can occur in any sport. • Recognition and proper response to concussions when they first occur can help prevent further injury or even death. • Athletes may not report their symptoms for fear of losing playing time. • Athletes can still get a concussion even if they are wearing a helmet. • Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries, depending on the sport. What is a concussion? A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Recognizing a possible concussion To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; -AND2. Any change in the student-athlete’s behavior, thinking or physical functioning (see signs and symptoms). Signs and Symptoms Signs Observed By Coaching Staff • Appears dazed or stunned. • Is confused about assignment or position. • Forgets plays. • Is unsure of game, score or opponent. • Moves clumsily. • Answers questions slowly. • Loses consciousness (even briefly). • Shows behavior or personality changes. • Can’t recall events before hit or fall. • Can’t recall events after hit or fall. Symptoms Reported By Student-Athlete • Headache or “pressure” in head. • Nausea or vomiting. • Balance problems or dizziness. • Double or blurry vision. • Sensitivity to light. • Sensitivity to noise. • Feeling sluggish, hazy, foggy or groggy. • Concentration or memory problems. • Confusion. • Does not “feel right.” APPENDIX F PREVENTION AND PREPARATION As a coach, you play a key role in preventing concussions and responding to them properly when they occur. Here are some steps you can take to ensure the best outcome for your student-athletes: • Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to-play. – Review and practice your emergency action plan for your facility. – Know when you will have sideline medical care and when you will not, both at home and away. – Emphasize that protective equipment should fit properly, be well maintained, and be worn consistently and correctly. – Review the Concussion Fact Sheet for Student-Athletes with your team to help them recognize the signs of a concussion. – Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete. • Insist that safety comes first. – Teach student-athletes safe-play techniques and encourage them to follow the rules of play. – Encourage student-athletes to practice good sportsmanship at all times. – Encourage student-athletes to immediately report symptoms of concussion. • Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death. IF YOU THINK YOUR STUDENT-ATHLETE HAS SUSTAINED A CONCUSSION: IF A CONCUSSION IS SUSPECTED: Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion. 1. Remove the student-athlete from play. Look for the signs and symptoms of concussion if your student-athlete has experienced a blow to the head. Do not allow the student-athlete to just “shake it off.” Each individual athlete will respond to concussions differently. An athlete who exhibits signs, symptoms or behaviors consistent with a concussion, either at rest or during exertion, should be removed immediately from practice or competition and should not return to play until cleared by an appropriate health care professional. Sports have injury timeouts and player substitutions so that student-athletes can get checked out. 2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the studentathlete to the appropriate athletics medical staff, such as a certified athletic trainer, team physician or health care professional experienced in concussion evaluation and management. 3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return-to-play progression should occur in an individualized, step-wise fashion with gradual increments in physical exertion and risk of contact. 4. Develop a game plan. Student-athletes should not return to play until all symptoms have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact, as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change. It’s better they miss one game than the whole season. When in doubt, sit them out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. APPENDIX F ATHLETIC STAFF CONCUSSION STATEMENT ACKNOWLEDGEMENT The NCAA Executive Committee has developed a consistent, association-wide approach to Concussion Management. The Clemson University Sports Medicine Department recognizes and acknowledges that concussions or traumatic brain injuries (TBI) need immediate attention. A concussion is defined as a generally short-lived impairment of neurological function brought on by a traumatic force applied to the head or body. Symptoms are usually rapid in onset, but of short duration and generally resolve spontaneously. It is usually a functional disturbance and not a structural one. Loss of consciousness may or may not be involved. The Clemson Sports Medicine team will determine whether or not a concussion has occurred, realizing that each concussion and each studentathlete is different and individual treatment plans are necessary. SIGNS AND SYMPTOMS OF A POSSIBLE CONCUSSION (including but not limited to): • • • • • • • • • • • • • Headache Nausea Balance Problems Dizziness Diplopia - Double Vision Confusion Photophobia – Light Sensitivity Difficulty Sleeping Misophonia – Noise Sensitivity Blurred Vision Feeling Sluggish or Groggy Memory Problems Difficulty Concentrating As a Clemson University Athletic Staff member, I acknowledge that I am responsible for reading and understanding the following as it relates to the physical and mental well-being of all student-athletes: • • • • • • • A concussion is a brain injury. A concussion cannot be seen, but symptoms may be seen immediately. Other symptoms can show up hours or days after injury. If I suspect a student-athlete has a concussion, it is my responsibility to promptly report it to the Sports Medicine staff. I will not allow any student-athlete to return to practice, play, or academic activities that same day if I suspect that he/she has received blow to the head or body and/or exhibit signs or symptoms consistent with a concussion, and will not be allowed to return to play until cleared by the Clemson University Team Physician. I will encourage all student-athletes to report any suspected injuries or illness to the Sports Medicine staff, including signs or symptoms of a concussion. Following a concussion the brain needs time to heal. A student-athlete is much more likely to sustain another concussion or more serious brain injury if they return to athletic activities before symptoms have resolved. Repeat concussions can lead to longer recovery time, and in rare cases, can cause permanent brain damage or even death. All incoming student-athletes will participate in baseline testing. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE INFORMATION REGARDING CONCUSSIONS AND THAT I HAVE RECEIVED THE NCAA CONCUSSION FACT SHEET. SIGN AND RETURN THIS PAGE TO COMPLIANCE, KEEP THE NCAA FACT SHEET. Print Full Name of Athletic Staff Member Date Signature of Athletic Staff Member Date Page 1 of 1 APPENDIX G CONCUSSION HEAD INJURY INFORMATION TAKE-HOME INSTRUCTIONS You have received an injury to the head. No signs of serious complications have been found and a rapid recovery is expected. However, you will need further monitoring for a period of time by a responsible adult. The sports medicine staff will provide guidance for this. If you notice any changes in behavior, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, contact your Athletic Trainer or report to the Athletic Training Room immediately. If you are unable to reach the Sports Medicine staff and it is after Athletic Training Room hours, then you may activate emergency medical services by either having someone drive you to Oconee Memorial Hospital, or call (864) 656-2222 for an ambulance to Oconee Memorial Hospital. DO NOT ignore any changes in the symptoms of your concussion. OTHER IMPORTANT POINTS: • • • • • • Rest and avoid strenuous activity for at least 24 hours NO alcohol NO drugs/painkillers that may alter awareness NO driving until cleared by sports medicine staff You may take Tylenol if instructed to do so by the Sports Medicine Staff LIMIT use of electronic devices (Cell Phone, Computer, TV, Etc.) Report to the athletic training room at _____________ am/pm to be re-evaluated prior to Team or Academic activity. Phone Numbers: Athletic Trainer Signature of Student-Athlete Team Physician Date Signature of Clemson University Athletic Trainer or M.D Date APPENDIX H CONCUSSION ASSESSMENT Student-Athlete’s Name (last, first, middle) Today’s Date Student-Athlete Signature Injury Date Athletic Trainer / Team Physician Post-Injury Day POST-CONCUSSION SYMPTOM SCALE (Circle Appropriate Number for Each Symptom) Symptom None Mild Moderate Severe HEADACHE 0 1 2 3 4 5 6 NAUSEA 0 1 2 3 4 5 6 VOMITING 0 1 2 3 4 5 6 DIZZINESS 0 1 2 3 4 5 6 POOR BALANCE 0 1 2 3 4 5 6 SENSITIVITY TO NOISE 0 1 2 3 4 5 6 RINGING IN THE EARS 0 1 2 3 4 5 6 SENSITIVITY TO LIGHT 0 1 2 3 4 5 6 BLURRED VISION 0 1 2 3 4 5 6 POOR CONCENTRATION 0 1 2 3 4 5 6 MEMORY PROBLEMS 0 1 2 3 4 5 6 TROUBLE SLEEPING 0 1 2 3 4 5 6 DROWSINESS/SLEEPY 0 1 2 3 4 5 6 FATIGUE 0 1 2 3 4 5 6 SADNESS/DEPRESSION 0 1 2 3 4 5 6 IRRITABILITY 0 1 2 3 4 5 6 NECK PAIN 0 1 2 3 4 5 6 APPENDIX I CONCUSSION AWARENESS LETTER The Clemson University Sports Medicine Department would like to inform you that _________________________________ sustained a concussion on ___ /___ /___. The student-athlete will undergo continued follow-up/testing with the Sports Medicine department. A concussion can cause a variety of physical, cognitive, and emotional symptoms. Concussions range in significance from minor to major, but they all share one common factor — temporary interference with the way the brain works. We would like to inform you that during the next few weeks this student-athlete may experience one or more of these signs and symptoms: • • • • • • • Headache Nausea Balance Problems Dizziness Diplopia - Double Vision Confusion Photophobia – Light Sensitivity • • • • • • Difficulty Sleeping Phonophobia – Noise Sensitivity Blurred Vision Feeling Sluggish or Groggy Memory Problems Difficulty Concentrating As a department, we wanted to make you aware of this injury and the related symptoms that the student-athlete may experience. Although the student may be attending class, please be aware that the side effects of the concussion may adversely impact his/her academic performance, including difficulties using electronic devices, including computer, cell phone, television, etc. Any consideration you may provide academically during this time would be greatly appreciated. We will continue to monitor the progress of this student-athlete and will be in constant communication with the Vickery Hall academic advisor regarding their academic progress and status. Should you have any questions or require further information, please do not hesitate to contact us or Vickery Hall. Thank you in advance for your time and understanding. Sincerely, Douglas A. Reeves, Jr. MD Team Physician (864) 656-1952 reeves@clemson.edu APPENDIX J EMERGENCY ACTION PLAN INTRODUCTION Emergency situations may arise at any time during athletic events. Expedient action must be taken in order to provide the best possible care to the athletes experiencing emergency and/or life threatening conditions. The development and implementation of an emergency plan will help ensure that the best care will be provided. Athletic organizations have a duty to develop an emergency plan that may be implemented immediately when necessary and to provide appropriate standards of health care to all sports participants. As athletic injuries may occur at any time and during any activity, the sports medicine team must be prepared. This preparation involved formulation of an emergency plan, proper coverage of events, maintenance of appropriate emergency equipment and supplies, utilization of appropriate emergency medical personnel, and continuing education in the area of emergency medicine. Hopefully, through careful pre-participation physical screenings, adequate medical coverage, safe practice and training techniques and other safety avenues, some potential emergencies may be averted. However, accidents and injuries are inherent with sports participant, and proper preparation on the part of the sports medicine team will enable each emergency situation to be managed appropriately. COMPONENTS OF THE EMERGENCY PLAN There are three basic components of this plan: 1. Emergency personnel 2. Emergency communication 3. Emergency equipment EMERGENCY PLAN PERSONNEL With athletic practice and competition, the first responder to an emergency situation is typically a member of the sports medicine staff, most commonly a certified athletic trainer. A team physician may not always be present at every organized practice or competition. The type and degree of sports medicine coverage for an athletic event may vary widely, based on such factors as the sport or activity, the setting, and the type of training or competition. The first responder in some instances may be a coach or other institutional personnel. Certification in cardiopulmonary resuscitation (CPR), first aid, prevention of disease transmission, and emergency plan review is required for all athletics personnel associated with practices, competitions, skills instruction, and strength and conditioning. The development of an emergency plan cannot be complete without the formation of an emergency team. The emergency team may consist of a number of healthcare providers including managers; and, possibly, bystanders. Roles of these individuals within the emergency team may vary depending on various factors such as the number of members on the team, the athletic venue itself, or the preference of the head athletic trainer. There are four basic roles within the emergency team. The first and most important role is immediate care of the athlete. The most qualified individual on the scene should provide acute care in an emergency situation. Individuals with lower credentials should yield to those with more appropriate training. The second role, equipment retrieval, may be done by anyone on the emergency team who is familiar with the types and location of the specific equipment needed. Student athletic trainers, managers, strength coaches and coaches are good choices for this role. The third role, EMS activation, may be necessary in situations where emergency transportation is not already present at the sporting event. This should be done as soon as the situation is deemed an emergency or a life-threatening event. Time is the most critical factor under emergency conditions. Activating the EMS system may be done by anyone on the team. However, the person chosen for this duty should be someone who is calm under pressure and who communicates well over the telephone. This person should also be familiar with the location and address of the sporting event. After EMS has been activated, the fourth role within the emergency team should be performed. That consists of directing EMS to the scene. One member of the team should be responsible for meeting emergency medical personnel as they arrive at the site of the contest. Depending on ease of access, this person should have keys to any locked gates or doors that may slow the arrival of medical personnel. A student athletic trainer, manager, strength coach, or coach may be appropriate for this role. Page 1 of 3 APPENDIX K ROLES WITH IN THE EMERGENCY TEAM • • • • • Immediate care of the athlete Emergency equipment retrieval Activation of the Emergency Medical System Direction of EMS to scene Call Athletic Training Room to alert Team Physician of situation ACTIVATING THE EMS SYSTEM Making the Call: • • 911 (if available) Telephone numbers for local police, fire department, and ambulance service Providing Information: • • • • • • Name, address, telephone number of caller Number of athletes Condition of athlete(s) First aid treatment initiated by first responder Specific directions as needed to locate the emergency scene (i.e. come to south entrance of coliseum) Other information as requested by dispatcher When forming the emergency team, it is important to adapt the team to each situation or sport. It may also be advantageous to have more than one individual assigned to each role. This allows the emergency team to function even though certain members may not always be present. EMERGENCY COMMUNICATION Communication is the key to quick delivery of emergency care in athletic trauma situations. Athletic trainers and emergency medical personnel must work together to provide the best possible care to injured athletes. Communication prior to the event is a good way to establish boundaries and to build rapport between both groups of professionals. If emergency medical transportation is not available on site during a particular sporting event then direct communication with the emergency medical system at the time of injury or illness is necessary. Access to a working telephone or other telecommunications device, whether fixed or mobile, should be assured. The communications system should be checked prior to each practice or competition to ensure proper working order. A back-up communication plan should be in effect should there be failure of the primary communication system. The most common method of communication is a public telephone. However, a cellular phone is preferred if available. At any athletic venue, whether home or away, it is important to know the location of a workable telephone. Pre-arranged access to the phone should be established if it is not easily accessible. EMERGENCY EQUIPMENT All necessary emergency equipment should be at the site and be quickly accessible. Personnel should be familiar with the function and operation of each type of emergency equipment. Equipment should be in good operating condition, and personnel must be trained in advance to use it properly. Emergency equipment should be checked on a regular basis and use rehearsed by emergency personnel. The emergency equipment available should be appropriate for the level of training for the emergency medical providers. It is important to know the proper way to care for and store the equipment as well. Equipment should be stored in a clean and environmentally controlled area. It should be readily available when emergency situations arise. TRANSPORTATION Emphasis is placed at having an ambulance on site at high risk sporting events. EMS response time is additionally factored in when determining on site ambulance coverage. The Clemson University Athletic Department and Sports Medicine coordinate on site ambulances for competition in football, and men and women’s basketball. Ambulances may be coordinated on site for other special events/sports, such as major tournaments or ACC/NCAA regional or championship events. Consideration is given to the capabilities of transportation service available (i.e., Basic Life Support or Advanced Life Support) and the equipment and level of trained personnel on board the ambulance. In the event that the ambulance is on site, there should be a designated location with rapid access to the site and a cleared route for entering/exiting the venue. Page 2 of 3 In the emergency evaluation, the primary survey assists the emergency care provider in identifying emergencies requiring critical intervention and in determining transport decisions. In an emergency situation, the athlete should be transported by ambulance. Care must be taken to ensure that the activity areas are supervised should the emergency care provider leave the site in transporting the athlete. Clemson University Sports Medicine personnel will execute the Clemson University Sports Medicine Emergency Action Plan for further medical care and/or transportation as deemed necessary. This may include injury to the neck and/or spine, headtrauma, and/or severe concussion signs and/or symptoms. The following items may be used to determine the status of the student-athlete as it pertains to transportation to a medical facility and/or initiating the Emergency Action Plan: 1. A Glasgow Coma Scale that diminishes below a 13 2. Prolonged loss of consciousness as it relates to the concussion 3. A neurological exam deficit that may suggest intracranial trauma 4. Repetitive/Uncontrolled vomiting (Emesis) 5. A persistent decline of the student-athlete's mental status and/or neurological signs/symptoms 6. Significant spinal related trauma/injury Normally in the afternoons, when most practices are occurring, the Team Physician is in the Athletic Training Room. A special parking place has been provided for the Team Physician at Jervey, which allows for quick access to all athletic venues. Therefore the Athletic Training Room should be notified immediately in an emergency situation so the Team Physician can respond appropriately. CONCLUSION The importance of being properly prepared when athletic emergencies arise cannot be stressed enough. An athlete’s survival may hinge on the training and preparedness of athletic healthcare providers. It is prudent to invest athletic department “ownership” in the emergency plan by involving the athletic administration and sport coaches, as well as sports medicine personnel. The emergency plan should be reviewed at least once a year with all athletic personnel, along with CPR refresher training. Through development and implementation of the emergency plan, the athletic association helps ensure that the athlete will have the best care provided when an emergency situation does arise Page 3 of 3 DOUG KINGSMORE BASEBALL VENUE Emergency Personnel: Certified Athletic Trainer and/or Student Athletic Trainer on site for practice and competition: Additional sports medicine staff accessible from Jervey Athletic Training Facility (656-1952). Emergency Communication: A fixed telephone line (656-0307) is located in the clubhouse at Doug Kingsmore Stadium. Emergency Equipment: Supplies maintained per Athletic Trainer assigned to work the sport; this would include an AED. Roles of First Responders: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location: Doug Kingsmore Baseball stadium please specify either Right field entrance (player down on field), Left field entrance, or home plate entrance 3. Address (Off Perimeter Road Behind Jervey Gym) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Doug Kingsmore Baseball Stadium has two means of access. 1. Take Perimeter Road to Jervey Athletic Center Parking Lot. Follow the moat road around to the Right and enter the Baseball Field at the Right Field entrance (For player down on field use this entrance) 2. Main entrance, take Perimeter Road to East Beach Road, after you are at East Beach Road, you will see the stadium entrance on your left. 3. Take Perimeter Road to Jervey Athletic Center Parking Lot area and you can access the stadium a. Have someone open the access b. Designate individual to “flag down” EMS to the scene (Make sure to designate EMS entrance Right field, left field or home plate) 4. Scene control: Limit scene to First Aid Responder and move bystanders away from area. Page 1 of 17 LITTLEJOHN COLISEUM VENUE Emergency Personnel: Certified Athletic Trainer and student athletic trainer on site for practice and competition. A Primary Care/Sports Medicine Physician will be at all home contests. The Orthopedic Physician will also be in attendance at most competitions. There will be an ambulance located at Gate 7 for First Aid purposes. Emergency Communication: Fixed telephone line is located in the Athletic Training Room (656-2111). Emergency Equipment: Supplies including an AED kept in the Athletic Training Room in Littlejohn Coliseum. In addition an AD is located in the Littlejohn Coliseum Weight Room on the 3rd floor. Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location (Littlejohn Coliseum) 3. Address 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Littlejohn Coliseum is located on Perimeter Road. Access to the tunnel is from Perimeter Road to the Avenue of Champions and turn left down the tunnel driveway. a. Have open access b. Designate individual to “flag down” EMS to the scene.(Meet EMS at the top of the tunnel and direct to the main floor or the Annex gym) c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 2 of 17 FIKE RECREATION CENTER MCCUE NATATORIUM VENUE Emergency Personnel: Graduate Assistant Athletic Trainer and/or student athletic trainer on site for practice and competition: Additional sports medicine staff accessible from Jervey Athletic Training facility. Emergency Communication: A fixed telephone line (656-2327) is located on the pool deck. Emergency Equipment: Supplies maintained per Athletic Trainer assigned to work the sport. An AED is located on the Pool Deck between the lap pool and diving well, on the back wall. Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location ( Swimming Pool at Fike Recreation ) 3. Address (Heisman St) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Fike Recreation Center Natatorium Venue is located on the corner of Heisman Street and Williamson Road. Access to this area is from Perimeter Road to Williamson Road to Heisman Street. After turning onto Heisman Street, turn right into the parking lot between Fike and Williamson Road. Drive parallel to the building to the sidewalk leading to the sundeck on the backside of Fike. Take the sidewalk to the sundeck and enter through the double glass doors. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 3 of 17 CLEMSON UNIVERSITY SPORTS MEDICINE DIVING ACCIDENT POLICY Policy and procedures pertaining to an athlete who hits his/her head on the diving board during practice or competition: • • • • • • • • • I accordance with Fike Recreation Policy lifeguards are required to be on duty during practice and meets. In addition all swimming and diving coaches are safety certified and therefore qualified to spine board in and out of the water. Depending on the severity of the incident activate Campus EMS - 656-2222. If the answer to either or both of the following questions is no then activate Campus EMS ---- Is athlete conscious? Can they get out of the water? If athletic trainers are not present at the pool, please contact them. If spine boarding in the water is required activate EMS first then notify athletic trainers. If athlete is able and wants to get out of the water allow them to do so. If athlete is unable to get out of water or does not want to -- spine boarding must occur in the water. In this case the coaches or lifeguard (if present) are qualified to do so. Athletic trainer will assist as needed. If athlete is able to get out of the pool on their own, have them sit at the side of the pool until the athletic trainer is present. Watch how they swim over to the side and get out. Be able to report if they are not using or can’t use a certain body part. Provide first aid until athletic trainer arrives. Follow OSHA procedures for BBP exposure. If athlete is able to get out of the pool on their own and has neck pain combined with any of the following: decreased motor function, numbness or tingling, obvious deformity, loss of motion or their condition rapidly deteriorates then immobilize and proceed with spine boarding. Make sure Campus EMS is activated. Athletic trainer will continue first aid and perform a thorough assessment of athlete including: evaluate for motor and sensory function in all extremities, signs of concussion, any neck, facial or dental injuries and any other injuries present. Skin injuries to the head and face region tend to bleed a lot; they will also be wet which will spread the blood. With this amount of blood it may be easy to overlook other injuries -- don’t forget there may also be neck or spine injuries. If athlete has full motor function in all extremities, no tingling/numbness or decreased sensation, no loss of consciousness and no significant neck, facial or dental injuries that require emergency care - notify team physician and monitor for any changes. If athlete has neck pain place in cervical collar. (There are 2 located in the lockers on the pool deck.) Depending on severity and any other injuries activate EMS or contact team physician and develop plan. Clean all bloody surfaces following OSHA procedures. Dispose of hazardous materials in the appropriate manner. THIS IS INTENDED AS A GUIDE. EVERY CIRCUMSTANCE WILL BE DIFFERENT SO USE YOUR BEST JUDGMENT. IF IN DOUBT, ERROR ON THE SIDE OF CAUTION. Page 4 of 17 JERVEY MEADOWS FOOTBALL PRACTICE FIELDS & INDOOR PRACTICE FACILITY Emergency Personnel: Jervey Athletic Training Center, Certified Athletic Trainers, Student athletic trainers and Physicians are on site in the Athletic Training Facility. Certified Athletic Trainer and Student Athletic Trainers are at practice field for practices and workouts. Emergency Communications: The Athletic Trainers on site have cell phone communications while at the practice field/indoor practice facility as well as direct radio communication with CU police dispatch. Emergency Equipment: Emergency equipment includes an AED that is mounted on the west wall of the indoor practice facility, additionally a back pack AED is brought to all practices and workouts. There is a motorized medical cart and also a van for the sports medicine staff to use. Roles of First Responders: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location ( Football Practice Fields in Jervey Meadows) 3. Address 4. Phone number you are calling from 5. Number of victims and specific injuries 4. Direction of EMS to scene. Venue Directions: The Football Practice Fields are located off of Perimeter Road. Access to this area is from Perimeter Road to Jervey Meadows Rd. Then take a left onto the Football Practice Field Access Road. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 5 of 17 DEATH VALLEY MEMORIAL STADIUM VENUE Emergency Personnel: Certified Athletic Trainer, Graduate Assistant Athletic Trainers, and student athletic trainers on both Home and Visiting Team sidelines. Also, Primary Care/Sports Medicine Physicians, Orthopedic Physician and a Nurse Practitioner will be on the home sideline. There is a Paramedic crew on the Home sideline that has sole responsibility for the teams and officials. The Ambulance will be located in the West End zone area. Emergency Communication: Fixed telephone lines are located in the home team athletic training room and visitors’ locker room at Death Valley (Home: 656-2113, Visitor 656-2908). These numbers are to be used in emergency situations only and are confidential information. Emergency Equipment: Emergency equipment including AED will be located on Home Team Sideline. Additional equipment will be with the Paramedics. Roles of First Responders: 2. Immediate care of the injured or ill student athlete. 3. Emergency equipment retrieval. 4. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location (Death Valley Football Stadium) 3. Address 4. Phone number you are calling from 5. Number of victims and specific injuries. 5. Direction of EMS to scene. Venue Directions: Death Valley Memorial Stadium is located on the West end of Campus. Access is by Perimeter Road and Highway 93. For access to the field, enter the gate just in front of the police station. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 6 of 17 LARRY B. PENLEY JR. GOLF FACILITY VENUE Emergency Personnel: There are no athletic trainers assigned to cover Golf during practice or competition. The Clemson University Sports Medicine staff covers Golf from the Jervey Athletic Training Facility (6561952). Emergency Communication: If a cell phone is unavailable, there is an Emergency Call Box located at the main entrance to the Rock Norman Track Complex, which is adjacent to the Golf Practice Venue. Emergency Equipment: Access from Jervey Athletic Training Facility. In addition an AED is mounted on the wall on the first floor of the facility located near the stairwell. Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location (Larry B. Penley Jr. Golf Facility) 3. Address (East Beach Drive) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Clemson Larry B. Penley Jr. Golf facility is located in the Jervey Bottom area. Access to this is via Perimeter Road to E Beach Dr., follow past the intramural field, the facility will be immediately on the left. Have open access a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 7 of 17 CLEMSON GOLF PRACTICE FACILITY VENUE Emergency Personnel: There are no athletic trainers assigned to cover Golf during practice or competition. The Clemson University Sports Medicine staff covers Golf from the Jervey Athletic Training Facility (6561952) Emergency Communication: If a cell phone is unavailable, there is an Emergency Call Box located at the main entrance to the Rock Norman Track Complex, which is adjacent to the Golf Practice Venue. Emergency Equipment: Access from Jervey Athletic Training Facility. In addition an AED is mounted on the wall on the first floor near the stairwell of the Larry B. Penely, Jr Golf facility. Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location (Golf Practice Complex near the track) 3. Address (Track Drive across from the Track Complex) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Clemson Golf practice facility is located in the Jervey Bottom area. Access to this is via Perimeter Road to the Jervey Parking Lot Road, then follow the Jervey Meadows Road to Track Drive the Golf Complex on the right, across from the Rock Norman Track Complex a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 8 of 17 WALKER GOLF COURSE PRACTICE FACILITY Emergency Personnel: There are no athletic trainers assigned to cover Golf during practice or competition. The Clemson University Sports Medicine staff covers Golf from the Jervey Athletic Training Facility (6561952). Emergency Communication: There is a local land line located inside the facility. (656- 0236) Emergency Equipment: Access from Jervey Athletic Training Facility. Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location (Walker Golf Course) 3. Address (230 Madren Center Drive) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Clemson Madren Center is located off of Madren Center Drive. Take Highway 93 to Perimeter Rd. From Perimeter Road Turn onto Old Stadium Drive. Take Old Stadium Drive to Madren Center Drive. The Madren Center will be located on your right. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 9 of 17 EAST BEACH ROWING VENUE Emergency Personnel: Graduate Assistant Athletic Trainer on site for practice and competition: additional Sports Medicine staff accessible from Jervey Athletic Training facility (656-1952). Emergency Communication: Two fixed telephone lines are located at the Boat House (656-4573 and 6564574). Emergency Equipment: Supplies maintained per Athletic Trainer assigned to the sport. An AED is located on the wall of the Erg Room. Roles of First Responders: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location (East Beach Boat House) 3. Address (End of East Beach Drive) 4. Phone number you are calling from 5. Number of victims and specific injuries 4. Direction of EMS to scene. Venue Direction: The East Beach Rowing Venue is located on East Beach Road on Lake Hartwell. Access to this area is via Perimeter Road. Follow it to the East Beach Rowing Venue. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 10 of 17 JERVEY MEADOWS MEN AND WOMEN’S SOCCER PRACTICE FIELDS Emergency Personnel: Graduate Assistant Athletic Trainer and/or Student Athletic Trainer on site for practice and competition: Additional Sports Medicine staff accessible from Jervey Athletic Training Facility (656-1952). Emergency Communication: A cellular phone will be used for emergencies. Emergency Equipment: Supplies maintained per Athletic Trainer assigned to work the sport. This would include AED taken by AT during practices. Roles of First Responders: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location ( Soccer practice fields in Jervey meadows) 3. Address (in Front of the Indoor track off of Jervey Meadows Road) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Men’s and Women’s Soccer Practice fields are located in the Jervey Bottom area. Access to this area is via Perimeter Road. Enter the Jervey parking lot and then follow the Jervey Meadows Road to the Men and Women’s Soccer Practice fields on left. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 11 of 17 RIGGS SOCCER STADIUM VENUE Emergency Personnel: Graduate Assistant Athletic Trainer and/or student athletic trainer on site for practice and competition: Additional sports medicine staff accessible from Jervey Athletic Training facility (656-1952). Emergency Communications: Athletic Trainers will have a cell phone. A fixed line telephone (656-4303) is located in the press box during competition. Emergency Equipment: Supplies maintained per Athletic Trainer assigned to work the sport. This would include an AED. Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: a. Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location ( Riggs Soccer Field ) 3. Address (Heisman Street/Alpha Beta Circle) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Riggs Soccer Stadium Venue is located just off Heisman Street and Alpha Beta Circle. Access to this area is from Highway 93 to Williamson Road. Then turn left on Heisman Street the left on to Alpha Beta Circle and the Soccer Venue is located on the left. For emergency access: Make an immediate right after entering the gate at the stadium. Follow the road around and enter the field at the flagpoles, just before the bleachers. This entrance is on the Highway 93 side of the stadium a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 12 of 17 HOKE SLOAN INDOOR TENNIS CENTER VENUE Emergency Personnel: Graduate Assistant Athletic Trainer and/or student athletic trainer on site for practice and competition: Additional sports medicine staff accessible from Jervey Athletic Training facility (656-1952). Emergency Communication: There is a fixed telephone line (656-1536) located in the Indoor Tennis facility. This is located in office on the lower level. The assigned Graduate Assistant has access to this office. Emergency Equipment: Supplies maintained per Athletic Trainer assigned to work the sport. In Addition a AED is mounted on the first floorof Main Hoke Sloan Outdoor facility. Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location ( Indoor Tennis Center ) 3. Address (Heisman Street/Alpha Beta Circle) 4. Phone number you are calling from 5. Number of victims and specific injuries 4. Direction of EMS to scene. Venue Directions: The Hoke Sloan Indoor Tennis Center Venue is located on Heisman Street. Access to this area is from Highway 93 to Williams Road. Then turn left on Heisman Street and Alpha Beta Circle the Indoor Tennis Venue is located on the left. a. Have open access b. Designate individual to “flag down” EMS to the scene (have EMS enter through Soccer stadium entrance and turn Left). c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 13 of 17 HOKE SLOAN OUTDOOR TENNIS VENUE Emergency Personnel: Graduate Assistant Athletic Trainer and/or student athletic trainer on site for practice and competition: Additional sports medicine staff accessible from Jervey Athletic Training facility (656-1952). Emergency Communication: There are 5 extensions that ring into the Outdoor Tennis Venue. Four of these rings into coaches’ offices (656-2252, 656-2253, 656-1323, 656-4279) and one is located in the main lounge area (656-7925). Emergency Equipment: Supplies maintained per Athletic Trainer assigned to work the sport. An AED is mounted in the first floor lounge area of the main facility Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: a. Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location ( Outdoor Tennis Center ) 3. Address (HWY 93 across from Mellow Mushroom) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Hoke Sloan Tennis Center Venue is located on Highway 93. There is a private drive off Highway 93 that is to be used by emergency medical personnel. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 14 of 17 THE INDOOR TRACK VENUE Emergency Personnel: Graduate Assistant Athletic Trainer and/or Student Athletic Trainer on site for practice and competition: Additional Sports Medicine staff accessible from Jervey Athletic Training Facility. Emergency Communication: The Emergency Call Box for Outdoor Track is close between the Indoor and Outdoor Tracks Emergency Equipment: Supplies maintained per Athletic Trainer assigned to work the sport. There is an AED mounted to the wall next to the Athletic Training Room located in the northwest corner of the facility. Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location (Indoor Track) 3. Address (Track Drive In front of the Outdoor Track) 4. Phone number you are calling from 5. Number of victims and specific injuries. 4. Direction of EMS to scene. Venue Directions: The Rock Norman Track Complex is located in the Jervey bottom area. Access to this area is via Perimeter Road, to the Jervey parking lot, and then follows the Jervey Meadows road to the Track complex on the left. a. Have open access b. Designate individual to “flag down” EMS to the scene(direct EMS to the Garage Door for entry) c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 15 of 17 ROCK NORMAN TRACK COMPLEX VENUE Emergency Personnel: Graduate Assistant Athletic Trainer and/or Student Athletic Trainer on site for practice and competition: Additional Sports Medicine staff accessible from Jervey Athletic Training Facility (656-1952). Emergency Communication: There is an emergency call box located at the main entrance of the Track Complex. Emergency Equipment: Supplies maintained per Athletic trainer assigned to work the sport. This would include AED for practice and competitions. In addition, there is an AED mounted to the wall next to the Athletic Training Room located in the northwest corner of the indoor facility. Roles of First Responders: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222 (this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location (Outdoor Track or Indoor Track) 3. Address (Track Drive) 4. Phone number you are calling from 5. Number of victims and specific injuries 4. Direction of EMS to scene. Venue Directions: The Rock Norman Track Complex is located in the Jervey bottom area. Access to this area is via Perimeter Road, to the Jervey parking lot, and then follows the Jervey Meadows road to the Track complex on the left. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Outdoor Track (Direct EMS to the back entrance to the Track At the end of Track Drive so they have access to enter the field with the ambulance) Indoor Track (Direct EMS to the Garage door entrance to the Track so they have access to enter the field with the ambulance) d. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 16 of 17 JERVEY VOLLEYBALL VENUE Emergency Personnel: Graduate Assistant Athletic Trainer and/or student athletic trainer on site for practice and competition: additional sports medicine staff accessible from Jervey Athletic Training facility. Emergency Communication: The Jervey Athletic Training facility is located in the same building as the Volleyball Venue with telephone line at the main desk ( 656-1952). Emergency Equipment: Supplies maintained per Athletic Trainer assigned to work the sport. This would include an AED. In addition access to the Jervery Athletic Training Room which has an AED located on the wall on the main entrance Roles of the First Responder: 1. Immediate care of the injured or ill student athlete. 2. Emergency equipment retrieval. 3. Activation of emergency medical system: • Call 656-2222(this is the emergency dispatcher on campus) Provide the following information: 1. Your Name 2. Location ( Jervey Gym ) 3. Address (Perimeter Road) 4. Phone number you are calling from 5. Number of victims and specific injuries 4. Direction of EMS to scene. Venue Directions: The Jervey Volleyball Venue is located on Perimeter Road. Access to this area is from Perimeter Road. Enter the Jervey parking lot through the north entrance. The Volleyball Venue will be on your right after you turn on to the road. For emergency access: After entering making the turn into Jervey parking area, Take the first right (Athletic Service Road) turn and proceed up the access road to the loading dock area. From there, enter the building through the glass doors and make a right. Jervey Gym will directly in front of you. a. Have open access b. Designate individual to “flag down” EMS to the scene. c. Scene control: limit scene to First Aid responder and move bystanders away from area. Page 17 of 17 Concussion Safety Protocol Checklist Below is a checklist that can be used as a resource when evaluating institutional concussion management plans. The NCAA Sport Science Institute staff will offer guidance and education to member schools requesting assistance and that guidance will be based on this checklist and other Sport Science Institute resources. Concussion management plans should be consistent with the Inter-Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines; these guidelines, and the two guidelines referenced under “Reducing Head Trauma Exposure Management Plan,” can be found at: http://www.ncaa.org/about/resources/media-center/news/new-guidelines-aim-improve-student-athletesafety. Pre-Season Education: Education management plan that specifies (Appendix C, F): Institutions have provided NCAA concussion fact sheets (NCAA will make material available) or other applicable material annually to the following parties: Student-athletes. Coaches. Team physicians. ATCs. Directors of athletics. Each party provides a signed acknowledgement of having read and understood the concussion material (Appendix D, G). 1 APPENDIX L Concussion Safety Protocol Checklist Pre-Participation Assessment: Pre-participation management plan that specifies (Section II, Paragraph 2): Documentation that each varsity student-athlete has received at least one pre-participation baseline concussion assessment, that addresses: Brain injury and concussion history. Symptom evaluation. Cognitive assessment. Balance evaluation. Team Physician determines pre-participation clearance and/or the need for additional consultation or testing.* *Consider a new baseline concussion assessment six months or beyond for any varsity student-athlete with a documented concussion, especially those with complicated or multiple concussion history. Recognition and Diagnosis of Concussion: Recognition and diagnosis of concussion management plan that specifies (Section III, Paragraph 3): Any student-athlete with signs/symptoms/behaviors consistent with concussion: Must be removed from practice or competition. Must be evaluated by ATC or team physician with concussion experience. Must be removed from practice/play for that calendar day if concussion is confirmed. 2 Concussion Safety Protocol Checklist Initial suspected concussion evaluation management plan that specifies (Section III, Appendix E, I): Symptom assessment. Physical and neurological exam. Cognitive assessment Balance exam. Clinical assessment for cervical spine trauma, skull fracture and intracranial bleed. Post-Concussion Management: Post-concussion management plan that specifies: Emergency action plan, including transportation for further medical care, for any of the following (Section IV, Appendix K): Glasgow Coma Scale < 13. Prolonged loss of consciousness. Focal neurological deficit suggesting intracranial trauma. Repetitive emesis. Persistently diminished/worsening mental status or other neurological signs/symptoms. Spine injury. Mechanism for serial evaluation and monitoring following injury (Section III, Paragraph 4). Documentation of oral and/or written care to both student-athlete and another responsible adult (Section IV, Paragraph 3, Appendix H).* *May be parent or roommate. 3 Concussion Safety Protocol Checklist Evaluation by a physician for student-athlete with prolonged recovery in order to consider additional diagnosis* and best management options (Section V, VI). *Additional diagnoses include, but are not limited to:  Post- concussion syndrome.  Sleep dysfunction.  Migraine or other headache disorders.  Mood disorders such as anxiety and depression.  Ocular or vestibular dysfunction. Return to Play: Return-to-Play management plan that specifies (Section V): Final determination of return-to-play is from the team physician or medically qualified physician designee. Each student-athlete with concussion must undergo a supervised stepwise progression management plan by a health care provider with expertise in concussion that specifies: Student-athlete has limited physical and cognitive activity until he/she has returned to baseline, then progresses with each step below without worsening or new symptoms: Light aerobic exercise without resistance training. Sport-specific exercise and activity without head impact. Non-contact practice with progressive resistance training. Unrestricted training. Return-to-competition. 4 Concussion Safety Protocol Checklist Return-to-Learn: Return-to-learn management plan that specifies (Section VI, Appendix J): Identification of a point person within athletics who will navigate return-to-learn with the student-athlete. Identification of a multi-disciplinary team* that will navigate more complex cases of prolonged return-to-learn: *Multi-disciplinary team may include, but not be limited to:  Team physician.  Athletic trainer.  Psychologist/counselor.  Neuropsychologist consultant.  Faculty athletic representative.  Academic counselor.  Course instructor(s).  College administrators.  Office of disability services representatives.  Coaches. Compliance with ADAAA. No classroom activity on same day as concussion. Individualized initial plan that includes: Remaining at home/dorm if student-athlete cannot tolerate light cognitive activity. Gradual return to classroom/studying as tolerated. Re-evaluation by team physician if concussion symptoms worsen with academic challenges. 5 Concussion Safety Protocol Checklist Modification of schedule/academic accommodations for up to two weeks, as indicated, with help from the identified point-person. Re-evaluation by team physician and members of the multi-disciplinary team, as appropriate, for student-athlete with symptoms > two weeks. Engaging campus resources for cases that cannot be managed through schedule modification/academic accommodations. Such campus resources must be consistent with ADAAA, and include at least one of the following: Learning specialists. Office of disability services. ADAAA office. Reducing Exposure to Head Trauma: Reducing head trauma exposure management plan (Section I, Paragraph 3, Appendix A, B).* *While ‘reducing’ may be difficult to quantify, it is important to emphasize ways to minimize head trauma exposure. Examples of minimizing head trauma exposure include, but are not limited to: Adherence to Inter-Association Consensus: Year-Round Football Practice Contact Guidelines. Adherence to Inter-Association Consensus: Independent Medical Care Guidelines. Reducing gratuitous contact during practice. Taking a ‘safety first’ approach to sport. Taking the head out of contact. Coaching and student-athlete education regarding safe play and proper technique. 6 1? UNIVERSITY OF COLORADO SPORTS MEDICINE DEPARTMENT OF INTERCOLLEGIATE ATHLETICS 368 UCB, Boulder, Colorado 80309?0368 (303)492?3801 Concussion Plan Overview Pursuant to the NCAA Concussion Policy and Legislation mandate, the University of Colorado Athletic Department has implemented the following procedures: 1. A pre-season education program: This is an annual process that ensures student-athletes, coaches, team physicians, certified athletic trainers, and directors of athletics will be educated about of concussion. Annually written training material will be provided in conjunction with an oral presentation which addresses concussion, common as well as protocol. All individuals sign a statement acknowledging their responsibility with that information. Signed acknowledgements are maintained in the Sports Medicine Department. Pre?participation assessment: A pre-participation assessment will be performed annually on all student-athletes at the University of Colorado. The team physician will determine pre- participation clearance for all student-athletes prior to the student-athlete being allowed to participate in training, conditioning, or competition. All documentation is maintained in each student-athlete?s medical record in the Sports Medicine Department. A process that ensures a student?athlete who exhibits the signs, or behaviors consistent with concussion shall be removed from athletics activities and evaluated by a medical staff member with experience in the evaluation and management of concussion. Initial evaluation includes assessment, physical and neurological examination, cognitive assessment, balance examination as well as clinical assessment for cervical spine trauma, skull fracture, and intracranial bleeding. The University of Colorado Emergency Action Plan will be initiated for any of the following post-concussion/head trauma manifestations: Glasgow Coma Scale 13; prolonged loss of consciousness; focal neurological deficit suggesting intracranial trauma; repetitive emesis; persistently diminished/worsening mental status or other neurological spine injury. A policy that precludes a student-athlete who is suspected of having a concussion from returning to athletic activities for at least the remainder of that calendar day. This policy also requires medical clearance for a student?athlete diagnosed with a concussion to return to athletics activities under the direction of a physician or physician?s designee. A process that ensures that a student?athlete with a prolonged recovery course from concussion will undergo additional evaluation by a team physician or consultant. A policy in which our athletics health care providers have the unchallengeable authority to determine management and return to play of any ill or injured student-athlete as he or she deems appropriate. A policy that adheres to the PAC12 guidelines on contact during football practice. This policy ensures the following for practices throughout the year: Preseason: For days when schools schedule a two-a-day practice, live contact practices are only allowed in one practice. A maximum four live contact practices may occur in a given week, and a maximum of 12 total may occur in the preseason. Only three practices (scrimmages) would allow for live contact in greater than 50 percent of the practice schedule. In season, postseason and bowl season: There may be no more than two live contact practices per week. Spring practice: Of the 15 allowable sessions that may occur during the spring practice season, eight practices may involve live contact; three of these live contact practices may include greater than 50 percent live contact (scrimmages). Live contact practices are limited to two in a given week and may not occur on consecutive days. it? UNIVERSITY OF COLORADO SPORTS MEDICINE DEPARTMENT OF INTERCOLLEGIATE ATHLETICS 368 UCB, Boulder, Colorado 80309?0368 (303)492?3801 Ooncuss?ion Evaluation Retuintoli?lay Guidelines University of Colorado Sports Medicine personnel will serially evaluate possible mild traumatic brain injured concussive student-athletes as per the following guidelines- I. Baseline Testing - Baseline testing will be done prior to the student athlete ?s pre- participation examination. Results will be reviewed by the team physician prior to clearance. Only the team physician will determine pie-participation clearance. All Varsity Student Athletes will undergo baseline testing at least once. A. Assessment B. Sports Concussion Assessment Tool 3 (SCAT3) Time of Injury For any athlete with a Glasgow Coma Scale 13, prolonged loss of consciousness, focal neurological deficit, repetitive emesis, deteriorating mental status or spinal injury the Emergency Action Plan (EAP) should be followed. If a concussion is suSpected, the following shall be performed; Mild Traumatic Brain Injury Evaluation Scale Physician and/or designee evaluation (if applicable and available) SCAT3 (cognitive and balance evaluation) Evaluation for cervical spine trauma, intracranial bleed, skull fracture Take Home Concussion Fact Sheet (given to student athlete and accompanying responsible person if applicable) anon? Note Any student?athlete that serially exhibits signs, or behaviors consistent with a concussive injury will be removed from participation. These include, but are not limited to: Altered level and/or loss of consciousness: Confusion. as evidenced by disorientation to person, time, or place; inability to respond appropriately to questions: inability to process information correctly and/or respond appropriately analytical questions; or inability to remember assignments and/or plays; Amnesia (anterograde and/or retrograde; immediate or delayed): Abnormal neurological examination (Le. abnormal pupillary response, persistent dizziness or vertigo, abnormal balance, etc.) New and persistent headache, particularly if accompanied by photosensitivity or other visual disturbances, tinnitus, nausea, vomiting, or dizziness; and/or Revised Ti2015 Concussion and Return to Play Guidelines a Any other persistent signs or of a concussive injUry should be withheld from participation for the remainder of that day. Once removed from participation, the student-athlete must be evaluated by an ATC or team physician and will not be allowed to return to participation that same day. The student-athlete will follow the outlined guidelines for management of his/her injury and will not be considered for return to participation until he/she has fully returned to self- reported baseline (SRBS) at both rest and exertion, physical exam and cognitive assessments are within normal baseline limits, and he/she has been cleared for participation by the University of Colorado Team Physician and/or his/her designee. Progression through stages of returned to play guidelines may be individualized by the team physician. ll. Post~ Concussion Follow-Up (24-48 hours post-injury) A. Mild Traumatic Brain Injury Evaluation Scale I. The Mild Traumatic Brain Injury Evaluation Scale should be repeated every day until the student athlete Sear-Reports back to baseline at which time the student-athlete will begin with Step 1 Procedures. B. Physician and/or his/her designee evaluation and/or consultation Note During the period of recovery and while the student-athlete is following injury. the student?athlete should engage in physical AND cognitive rest as much as possible until such time that he/she is at SRBS or allowed to return to cognitive/physical activity by the physician and/or his/her designee. Any student?athlete demonstrating prolonged recovery shall undergo additional evaluation by the Team Physician. RETURN TO PLAY 111. Step 1 Self-Report Baseline (SRBS) A. Mild Traumatic Brain Injury Evaluation Scale B. SCATS C. Assessment I. Can proceed to light aerobic exertion testing when at SRBS after assessment if prescribed by physician. D. Exertion Testing Procedure 1. Activity may consist of exercise bike, elliptical, walking or jogging lasting up to 20 minutes while conducted in a controlled setting under the direction of a certified athletic trainer. Revised 7i2015 Concussion and Return to Play Guidelines Note The student-athlete should not proceed to exertion testing if he/she is a?cr taking the or SCAT3 test. If the SA develops recurrent after taking the or SCAT3 test they must wait until return to baseline to begin Step 1 procedure per physician direction. If the student?athlete develops recurrent during exertion testing, the student-athlete should immediately stop exertional testing and wait at minimum until the next day and until at SRBS. Physician should be consulted as to where student-athlete should resume testing within the Step 1 procedure IV. Step 2 SRBS A. Sports-Specific Exercise 1. Examples include running and agility drills (We head impact activities) 2. Conducted in a controlled setting under the direction of a certified athletic trainer. Note If the student-athlete develops any post-concussion during the Step 2 procedure, the student-athlete should immediately stop all activity wait at minimum until the next day and until at SRBS. After the rest period and once the student athlete is at SRBS, he/she may resume testing at the Step 2 level. V. Step 3 SRBS Oil-Contact Training Drills A. Return to practice in a non-contact capacity B. Progressive resistance training Note If the student-athlete develops any post-concussion during the Step 3 procedure. the student-athlete should immediately stop all activity and wait at minimum until the next day and until at SRBS. Alter the rest period and once the student athlete is at SRBS. he/she may resume testing at the Step 3 level. If the student?athlete is at SRBS with all activity on Step 3. consult with the Team Physician for return to full contact practice clearance. VI. Step 4 SRBS O?-Modi?ed Practice A. Return to full practice without restrictions Note If the student-athlete develops any post-concussion during the Step 4 procedure. the student-athlete should be immediately pulled from activity and allowed to rest and recover. The team physician should be consulted. Revised 7l2015 Concussion and Return to Play Guidelines VII. Step 5 SRBS - Return to Play/Competition In order to be considered for return to play, the student-athlete must A. I. 2. 3. 4. Follow the outlined guidelines for management of his/her injury; Be at SRBS at rest, with exertion testing, and with supervised contact sports-speci?c activities. Be within normal baseline range on all post-exertion assessments; and Be cleared for participation by the University of Colorado Team Physician and/or his/her designee. 5% Revised 7f2015 Cancussion and Return to Play Guidelines Return-to-Learn Plan University of Colorado Boulder Department of In tercollegia te Athletics The purpose ofthis plan is to establish general guidelines for medical, and academic personnel to follow after a student-athlete has been diagnosed with a concussion or mild traumatic brain injury. Collaboration of, and communication between, the aforementioned groups and the student-athlete is essential. Further, this plan is intended to be in line with the Americans with Disabilities Act Amendments Act 2008). Once a concussion has been diagnosed, the medical staff member will communicate with the care provider who will act as an advocate for the student- athlete. Student-athletes with concussion are to have no classroom activity on the same day as their concussion and may remain at home if they cannot tolerate light cognitive activity. A meeting between the care provider and student- athlete should take place within 48 hours of the diagnosis when possible. This initial meeting is meant to allow the student-athlete and care provider to discuss the injury, as well as the plans to return to participate in academics and athletics. The care provider and/or medical staff member will alert the athletic academic staff so that the academic staff can notify all related parties on a need-to- know basis. This would include, but not be limited to, individuals directly involved in the academic success of the student-athlete academic coordinators, learning specialists, academic mentors, tutors, office of disability services, etc). Together, the medical staff member, athletic academic staff member, and the care provider will coordinate efforts for the student?athlete such that a mental exertion threshold is established and reevaluated over the days and weeks following the diagnosis. The chart on the following page is meant to provide some guidance as to the progression of the student-athlete?s return-to-learn. The speed with which each individual progresses will be different and the individualized nature of this injury is important to understand. Additionally, it is recommended that the return-to?learn plan and return-to-play protocol be initiated simultaneously with possible preference going to the return-to-learn plan. NOTES: 0 Please consult the ?Concussed Athlete Take Home Instructions? handout for post-injury direction. Created: 04/2015; Updated: 06f2015 This document is meant to be given changes in the science and understanding ofthe nature ofconcussions If persist beyond 2-3 weeks, the academic, medical, and staff will re-evaluate the student-athlete and will then plan for the preservation of the student?athlete?s academic, athletic, and social standing given the extreme nature of their particular injury. Return-to-Learn Progression Chart Step Progression General Guidelines 0 Little to no mental exertion - to include computers, mobile devices, video games and/or related academic activities 1 Tom] - No classroom activity on the same day as the concussion - Remain at home if light cognitive activity is not tolerated 2 Light Mental - Up to 30 minutes of mental exertion Activity 0 No prolonged concentration activities When 30 minutes of mental exertion does not break the threshold, progress to the next step. If worsen with academic challenges, the student- athlete will be re-evaluated by the medical staff 0 Establish a quiet place for periodic mental rest Part Time Max 0 No significant classroom testing Accommodations 0 Modify [as opposed to postpone) academics 0 Provide extra time, help, and/or modified assignments When 30-40 minutes of mental exertion does not break the threshold, progress to the next step No full exam weeks [limit exams as possible] 4 Part Time Mod 0 Modify academics Accommodations 0 Moderate decreases in extra time, help, and/or assignments When up to 60 minutes of mental exertion does not break the threshold, progress to the next step 0 No full exam weeks; general exams are acceptable Full Time Min 0 Continue to decrease extra time, help, and/or Accommodations assignments 0 Monitor possible needs in higher demand courses When 60 minutes of mental exertion does not break the threshold, progress to the next step . 0 Back to baseline levels of academic functioning while Full Tlme Full . . . 6 . continuing to monitor Academics - Full homework and exam loads are acceptable Please encourage the student-athlete to report any changes in to her/his athletic trainer as changes in could change their progression Created: 04/2015; Updated: 06/2015 This document is meant to be malleable given changes in the science and understanding ofthe nature ofconcassions Duke Athletic Medicine Concussion Policy and Management Plan Background: A concussion is an injury to the brain which can cause immediate and prolonged deficits and, in extreme cases, death. Though there are over 42 working definitions of concussion, The 4th International Conference on Concussion in Sport defined concussion as follows: Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck, or elsewhere on the body with an ‘‘impulsive’ force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged. There are many different symptoms associated with concussion. A list of the most commonly reported and acknowledged signs and symptoms is located in the table below. Physical • • • • • • • • • Headache Nausea Vomiting Balance problems Fatigue Sensitivity to light Numbness/tingling Dazed Stunned Signs and Symptoms of Concussion Cognitive • Feeling mentally “Foggy” • Feeling slowed down • Difficulty concentrating • Difficulty remembering • Forgetful of recent information and conversations • Confused about recent events • Answers questions slowly Emotional • Irritable • Sad • More emotional • Nervous Sleep • Drowsiness • Sleeping more than usual • Sleeping less than usual • Difficulty falling asleep Concussions are challenging injuries for student-athletes and healthcare professionals to manage; unlike other injuries the timeline for full recovery is usually difficult to predict. The majority of concussions will resolve in a relatively short time (7-10 days), though the recovery time frame may last longer with persistent symptoms in 10-15% of concussions. There are potential health risks associated with returning to sport before symptoms have subsided and brain healing has occurred. Proper management of concussions is vital to ensuring full and timely recovery and avoidance of prolonged issues. Studies support the possibility of post concussive vulnerability, meaning that a second blow to the head before Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 the brain has recovered may result in a prolonged recovery time and worsening symptoms. Further studies also suggest that when premature activity, mental and physical, begins prior to being asymptomatic the brain may be vulnerable to prolonged symptoms and dysfunction. Returning an athlete to play prior to resolution of symptoms may also decrease reaction time and cognitive ability; theoretically this could increase the risk of another blow to the head or injury to other body parts. Concussion Policy The Duke Athletic Medicine staff recognizes that concussions pose significant health risks to studentathletes. In order to uphold our mission of providing quality healthcare services and assure the wellbeing of each student-athlete (SA) a policy and management plan has been created to assist in the assessment and management of those student-athletes who present with concussion. The following recommendations in this concussion policy and management plan are based on a review of current medical literature, including, but not limited to, statements by the NCAA Manual of Sports Medicine 2014-2015, 2012 Consensus Statement on Concussion in Sport from the 4th International Conference on Concussion in Sport, and the American Medical Society for Sports Medicine position statement: Concussion in Sport 2013. Please see references for a more complete list. Education: Education is an important aspect of the program as studies have shown that both coaches and athletes are not always aware of the symptoms as well as the seriousness of concussions. The first step in treating concussions is being able to identify one; thus education ensures the best chance for early concussion identification and activation of the concussion management plan. 1. Student-athlete education will occur on an annual basis prior to the beginning of athletic activities. Each SA will be given a copy of the NCAA Concussion Fact Sheet for Student-Athletes. Team discussions will be led by Duke Certified Athletic Trainers with each individual team and will include a review of the signs and symptoms of concussion, a review of risks of not reporting, and emergency contact information for sports medicine staff. SAs will sign a copy of Student-Athlete Concussion Statement which acknowledges that they: a. Received, read, and understood the NCAA Concussion Fact Sheet for Student-Athletes b. Accept the responsibility of reporting their injuries and illnesses to Duke medical staff immediately, including concussion Signed documents will be kept in the athlete’s medical file with his or her respective team’s athletic trainer. A copy will also be filed in the Duke University Athletic Association compliance office. 2. Coach education will occur on an annual basis at the beginning of each academic year or athletic season, whichever comes first. Each coach (head and assistant) will receive a copy of the NCAA Concussion Fact Sheet for Coaches and will also receive an electronic copy of the Duke Concussion Policy and Management Plan. Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 Each coach will sign the Coaches’ Concussion Statement which acknowledges that they: a. Have read and understood the NCAA Concussion Fact Sheet for Coaches b. Will encourage their athletes to report signs and symptoms of any injury, including concussions c. Accept responsibility for referring athletes whom they may suspect of having a concussion to the medical staff d. Are educated regarding safe play and proper technique, and will encourage a “safety first” approach to sport e. Acknowledge that the Duke Athletic Medicine Staff has autonomous authority on return-to-play decisions f. Have read and understood the Duke Concussion Policy and Management Plan The Executive Director of Sports Medicine, or designated staff member, is responsible for the delivery of all signed documents to the Duke University Athletic Association Compliance offices where they will be kept in appropriate files. 3. All DUAA athletic trainers and team physicians must read and sign the attached Medical Provider Statement on an annual basis stating that they: a. Will provide the above listed fact sheets to student-athletes and coaches and will encourage their SA’s to report any suspected injuries and illnesses to the Athletic Medicine staff, including signs and symptoms of concussion. b. Have read, understood, and will follow the Duke Concussion Protocol and Management Plan The Executive Director of Sports Medicine, or designated staff member, is responsible for the collection of the signed documents, which will be maintained in their staff files and in the Duke University Athletic Association Compliance office. 4. The Athletic Director will receive annually an electronic or hard copy of the NCAA Concussion Fact Sheet for Coaches as well as an electronic or hard copy of the Duke Concussion Policy and Management Plan . The Athletic Director will sign or e-mail a statement acknowledging that he has read and understood the Duke Concussion Policy and Management Plan to the DUAA Compliance office. Pre-Participation Assessment: All first-year Duke SA’s, freshmen and transfers will complete baseline testing as part of the preparticipation physical exams prior to clearance to participate in athletically related activities. Some of these tests may be repeated annually or every other year, as directed by Neuropsychology. The following tests and specific procedures will be conducted or coordinated by each team’s athletic trainer. • The Sway Balance system o Using the Baseline Score Card the team athletic trainer will record baseline scores for student-athletes’ balance and reaction time. Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 Each team will complete this baseline testing 3 tests are required to establish a baseline to assure a 95% confidence interval of accuracy o Baseline scores will be kept on file where appropriate to facilitate comparison as needed King-Devick o Using the Baseline Score Card the team’s athletic trainer will complete baseline testing using the King-Devick score card o Each team will complete this baseline testing o Baseline scores will be kept on file where appropriate to facilitate comparison as needed ImPACT™ o Using the web based interface on www.impacttestonline.com, all teams will complete this testing. Location of testing is dependent on each team’s individual needs based on their impact expectation by sport as outlined by the NCAA  Collision and contact sports will complete testing on-site in a quiet place. • Teams in this category include field hockey, football, lacrosse, pole vault, soccer, wrestling, baseball, basketball, cheerleading, diving, volleyball, and softball  Limited contact sports will complete testing on their own in a quiet and nondistracting place. • A link will be sent via e-mail with instructions to complete testing • Each student-athlete must e-mail confirmation or bring a printed copy of testing confirmation to the team’s athletic trainer • Teams in this category include: cross country, fencing, golf, rowing, swimming, tennis, and track and field • The team’s athletic trainer should verify the validity of the test on the ImPACT website once the student-athlete confirms he or she has taken it o If a concussion is diagnosed, retesting will take place six months following resolution of symptoms or prior to the beginning of the next competitive season, whichever is first, to set a new baseline. Duke Athlete Cognitive Tracking (ACT) program o Administered by a trained technician overseen by a board-certified clinical neuropsychologist o Baseline testing is established on all sports  Collision and contact sports will be repeated annually, or as established by Neuropsychology  Limited contact sports will complete testing one time o If a concussion is diagnosed, retesting will take place 6 months following the resolution of symptoms or prior to the beginning of the next competitive season, whichever is first, to establish a new baseline. Clearance to Participate o o • • • • Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 o The ultimate pre-participation clearance will be determined by the team physician, this will occur during the pre-participation physical exam. Recognition and Diagnosis of Concussion Protocol: In any circumstance where concussion or head injury is suspected the SA will be immediately removed from participation; he or she will be evaluated by an athletic trainer and if present, a physician. A physical exam for more serious injuries such as cervical spine trauma, skull fracture, or intracranial bleed will occur concurrently. The initial evaluation should include: 1. Inquiry about symptoms and an on-field mental status evaluation in addition to focused neurological exam.. a. Sway assessment with iPhone App b. King-Devick c. Clearance of cranial nerves and vestibular screen 2. If concussive symptoms are present or the SA fails any part of the exam, the Concussion Management Plan is activated. 3. If it is determined that the SA does not show signs of a concussion at time of evaluation the opportunity to go through exertional testing will be given for consideration of same day return to play. Exertional testing will include a stepwise progression of the following: general aerobic activities (jogging, skipping, biking etc.), more intense efforts (sprinting, breakdowns, etc.) and, lastly, sport specific activities. a. If the SA denies symptoms of concussion during and/or following these activities he or she may return to participation. Observation and evaluation should be carried out by a medical professional through the remainder of activity. If any symptoms should return, the SA is assumed to have a concussion and is removed from activity, activating the Concussion Management Plan. b. If the SA has return of symptoms at any point during play, it is assumed that a concussion injury is present and he or she is removed from activity for the day and activation of Concussion Management Plan occurs. Concussion Management Plan Post-Concussion Management: • No SA suspected of having a concussion is permitted to return to play on the same day, and no SA is permitted to return to play while symptomatic following a concussion. • SA should be observed for warning signs of deteriorating condition including, but not limited to: persistent nausea/vomiting, focal neurologic changes, declining level of consciousness, seizure, witnessed prolonged loss of consciousness, Glasgow Coma Scale <13, or signs of spine injury. If this occurs, the medical professional should activate the EAP and EMS response to arrange for immediate further medical care. • Following initial on field assessment the team athletic trainer will perform further in-office evaluation if deemed necessary which may include: a. Symptom Assessment Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 b. Mental Status Assessment • The team athletic trainer should notify the team physician within 24 hours of injury to coordinate follow-up assessment and care. • Each student athlete will be sent home with a take home concussion statement that will be signed by the athlete and his or her team’s athletic trainer, which contains guidelines for management of his or her condition as well as instructions for care. a. A copy of this document will be provided to another responsible adult: a parent, roommate, teammate, etc. • During the initial recovery period, the SA should adhere to relative cognitive and physical rest. a. SA should not participate in any in-classroom work or homework on day of injury b. SA should remain at home/dorm if he or she cannot tolerate light cognitive activity • The team academic coordinator should be notified by SA’s athletic trainer of the possibility for the need of academic accommodations. These accommodations can be assessed and modified as indicated based on recovery and symptomology. • Follow-up evaluations occur daily with the team athletic trainer to track symptom recovery. May use follow up Symptoms Score form to track daily symptoms. Return to Learn • It is important that the SA is not completely isolated during recovery; he or she may do mental activity as tolerated such as watching TV, texting, or talking on the phone, etc. This should be encouraged to be kept to a minimum. • Once the athlete begins to improve and does not have return of symptoms with mental activity he or she may begin the step-wise progress for Return-to-Learn Protocol; an example of this protocol can be found in the table below, and each program will fit the individual needs of the SA. • The return-to-learn progression will be monitored and guided by the team’s athletic trainer and academic coordinator, as well as the team physician. • If SA has prolonged or worsening symptoms, or is having academic challenges, a multidisciplinary team will be assembled for more prolonged return-to-learn situations. This general plan, which will be specific to each SA, is available under Complex Return-to-Learn Management. Return-to-Learn Protocol 1. Gradual reintroduction of cognitive activity (5-15’ increments) ↓ 2. Homework at Home (20-30’ increments) ↓ 3. School re-entry (partial day and homework) ↓ 4. Full Day of school ↓ 5. Resumption of full cognitive workload Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 Return to Play: • Once the SA becomes asymptomatic and has completed the return to learn protocol, they will be assessed by the team physician for consideration of clearance for the return to play (RTP) protocol. The athlete may see the team physician at any point during his or her recovery as deemed necessary by the team athletic trainer. 1. Determine where athlete is relative to the baseline measure on the following: a. Symptom Assessment and SAC b. Vestibular-Ocular testing c. BESS test d. King-Devick e. ImPACT 2. If the measures a-e are similar to baseline scores, the team physician can instruct the athletic trainer to begin a 6-step graduated exertional RTP protocol with the SA (see below). a. Symptom scores should be assessed following each step of the protocol. b. If at any point the SA becomes symptomatic the progression will be stopped. The SA will then be assessed each day until asymptomatic again, at which time the exertional protocol will be restarted at the step which had previously been completed without return of symptoms. c. No more than two steps can be completed on the same day and should be separated by a period of time at least six hours. Steps four, five, and six may not be completed on the same day. Graduated Return to Play Protocol 1. Light Aerobic Exercise ↓ 2. Moderate Aerobic/Interval exercise/Lifting ↓ 3. Sport Specific Activity (non-contact) ↓ 4. Limited, Controlled return to practice ↓ 5. Full Practice (Contact) ↓ 6. Participation in Competition • 3. During return to play progression, but prior to full return to activities (Contact), ACT testing will be repeated. In order to expedite the RTP care in a timely fashion, verbal feedback will be provided from the Clinical neuropsychologist. A brief written note will be forwarded to the team physician and ATC for documentation. The ATC will consider, and inform and discuss with the team physician, any results raising concern about cognition, to help determine progression into full return to play and learning activities. All scores on the aforementioned assessments or exertional activities will be maintained by the team’s athletic trainer in the SA’s medical file, with exception of ACT scores, which are kept with Neuropsychology. Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 • No athlete can return to full activity or competitions until he or she is asymptomatic in limited, controlled, and full contact activities, AND cleared by the team physician. Annual Review The process of identifying, removing from game or practice, and assessing a student-athlete for a possible concussion will reviewed annually by a committee appointed by the Executive Director of Sports Medicine. Prolonged Recovery and Medical Disqualification: An SA with a prolonged recovery time will be evaluated by a physician to consider additional diagnosis and best management options. Additional diagnosis or compounding factors include, but are not limited to, post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, depression, mood disorders, ocular or vestibular dysfunction, etc. The proper referrals will be coordinated through the Duke Athletic Medicine staff. Medical disqualification of a SA will be determined on a case by case basis. Prolonged recovery, ACT scores falling below expectation, and subjective symptoms or cognitive changes per the SA will be considered when determining medical disqualification. This decision would be made after consulting and gathering information from the student-athlete, family, athletic trainer, team physician, neuropsychology, and any other consultation deemed necessary. Complex Return-to-Learn Management In cases where an SA has difficulties returning to cognitive activity, a multi-disciplinary team will be assembled to help navigate care. Re-evaluation by the team physician and other members of this team will occur repeatedly as needed. 1. SA reports to athletic trainer/team physician that symptoms are increasing with cognitive activity or the presence of cognitive difficulty with difficulty concentrating, recalling information, or through return to learn or return to physical activity progressions. 2. The Duke Athletics Academic Services/team Academic Coordinator is made aware of the situation through the team’s athletic trainer. ACADEMIC SERVICES Brad Berndt M Golf Heather Ryan Football, W Basketball, Volleyball Kelly Preussner W Lacrosse, W Soccer, W Tennis, Cross Country, Track and Field Jeremiah Walker Football, M Tennis Jacqueline Bishop Football, M Soccer, Fencing Shayna Heinrich Field Hockey, Swimming and Diving Kenny King M Basketball, W Golf Khary McGhee Baseball, M Lacrosse, Rowing, Wrestling Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 3. The team’s academic coordinator may contact the SA’s dean, academic advisor, course instructors and administrators as needed. 4. All accommodations will be made in compliance with the ADAAA specifications by communication with Duke Student Disabilities Access office. 5. If requested, the team physician or athletic trainer may provide a note confirming the presence of concussion and prolonged symptoms to those involved in the education of the affected SA. 6. On a case by case basis it will be determined if referral to any of the following is needed by the team physician: a. Psychologist/counselor (CAPS or off site referral) i. CAPS appointment line: 919-660-1000 b. Clinical neuropsychologist i. Dr. Deborah Attix c. Physical therapy i. Kelly White, Brett Aefsky 7. If symptoms persist and further academic accommodation and management is needed, the Duke Student Disabilities Access Office will be contacted. 8. In cases where more assistance may be needed when the physical and mental health as well as future action of a SA is a concern, a report can be filed through the Duke Office of Student Affairs through the Duke Reach program. http://studentaffairs.duke.edu/dukereach1 Reducing Exposure to Head Trauma Encouraging a culture of safety in sport is a fundamental part of reducing potential exposure to head trauma. Although there is a considerable amount of inherent risk in all athletics, not just football, it is the responsibility of those individuals teaching technique and formatting practices to emphasize a culture which minimizes head trauma exposure by reducing gratuitous contact during practice. The NCAA provides some bylaws and general guidelines in regard to restricting contact at football practice but does not specifically address other sports. In football, adherence to the Inter-Association Consensus: Year-Round Football Practice Guidelines (http://www.ncaa.org/health-and-safety/footballpractice-guidelines) is an important step in reducing exposure to head trauma. It is important for coaches and athletic trainers to be familiar with and adhere to these guidelines. Even though there are no specific concussion risk based rules in place for other sports, there have been a number of rule changes over recent years to help reduce risks in sports other than football. It is up to the coaching staff to encourage following these rules, to teach proper and safe technique, and to promote an environment of a “safety first” approach to sport. Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 References 1. National Collegiate Athletic Association. 2014-2015 NCAA Sports Medicine Handbook 2. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Br J Sports Med 2013; 47: 15-26 3. McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich. Br J Sports Med 2013; 47:250-258 4. Broglio SP, Cantu RC, Gioia GA, et al. National Athletic Trainers’ Association Position Statement: Management of Sport Concussion. J Athl Train 2014; 49(2):245-265 5. Courson R, Goldenber M, Adams K, et al. Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges. J Athl Train 2014; 49(1):128-137 Duke Athletic Medicine Concussion Policy and Procedures Revised 6/2015 UNIVERSITY OF FLORIDA UNIVERSITY ATHLETIC ASSOCIATION Concussion Management Plan June 2015 Page 1 Table of Contents Purpose ......................................................................................................................................... 4 Authorship .................................................................................................................................... 4 Definition of Concussion .............................................................................................................. 4 Evaluation and Management of Suspected Concussive Injuries .............................................. 5 1) Baseline Assessments ................................................................................................................... 5 2) Initial Evaluation .......................................................................................................................... 6 3) Repeat Evaluations ....................................................................................................................... 7 4) Graduated Return to Play ............................................................................................................. 7 5) Graduated Return to Learn ........................................................................................................... 8 6) Prolonged Symptoms ................................................................................................................... 9 7) Athletes Injured Away From the Playing Field ........................................................................... 9 8) Visiting Athletes ........................................................................................................................... 9 9) Diagnosis and Clearance Determination ...................................................................................... 9 Computerized Neuropsychological Testing Affiliation ............................................................. 9 Specialist Consultation................................................................................................................. 9 Additional Management............................................................................................................. 10 Clinical Judgment........................................................................................................................ 10 Education .................................................................................................................................... 10 Reducing Exposure to Head Trauma ........................................................................................ 11 Administrative ............................................................................................................................ 11 Availability .................................................................................................................................. 11 References ................................................................................................................................... 11 Appendix A: UF Athletic Association Concussion History Form............................................... 12 Appendix B: SCAT3 Symptom Evaluation (S3SE) .................................................................... 13 Appendix C: Standardized Assessment of Concussion (SAC) Form A ...................................... 14 Appendix C: Standardized Assessment of Concussion (SAC) Form B ...................................... 15 Appendix C: Standardized Assessment of Concussion (SAC) Form C ...................................... 16 Appendix D: Balance Error Scoring System (BESS) .................................................................. 17 Appendix E: Brief Symptom Inventory-18 (BSI-18) .................................................................. 18 Appendix F: Pre/Post-Test Exhaustion Rating (PPTER) ........................................................... 19 Appendix G: Concussion Testing Summary............................................................................... 20 Appendix H: UF Concussion Return to Play Protocol (UFCRTPP)1,3 ...................................... 21 Appendix I: ImPACT Instructions ............................................................................................... 22 Page 2 Appendix J: Concussion Take Home Instructions ....................................................................... 26 Appendix K: NCAA Concussion Fact Sheet for Coaches ........................................................... 27 Appendix L: Acknowledgement of Concussion Education ......................................................... 29 Appendix M: NCAA Concussion Fact Sheet for Student Athletes ............................................ 30 Appendix N: Statement of Student Athlete Responsibility ........................................................ 31 Page 3 Concussion Management Plan University of Florida Athletic Association Purpose Revised March 2015 The purpose of the University of Florida Athletic Association (UAA) Concussion Management Plan (CMP) is to improve the care of concussed student athletes by standardizing the approach to concussive injuries by UAA sports health staff, facilitating the safe return to play of concussed student athletes, and protecting them from excessive cumulative brain injury. Authorship The CMP is authored and revised by the UAA Concussion Committee. All revisions must be approved by the UAA Medical Advisory Committee. Definition of Concussion The Zurich 2012 Consensus Statement on Concussion in Sport provides the following definition of concussion.1 Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ''impulsive'' force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged. Page 4 Evaluation and Management of Suspected Concussive Injuries 1) Baseline Assessments a) Past history of concussion(s) is documented on the UF Athletic Association Concussion History questionnaire that each athlete completes as part of their preparticipation evaluation (see Appendix A). b) A baseline assessment is recorded for each student-athlete prior to the first official team practice. c) After the student-athlete’s first year, baseline testing is to be performed annually. d) In rare occurrences a 6 month post-concussion assessment could also be used as the next season’s baseline. This may happen when a 6 month post-concussion assessment is completed at +/- one month of the scheduled annual assessment. e) Baseline assessment consists of the seven components listed below with the specific test used by the UAA in italics. i) Symptom checklist – SCAT3 Symptom Evaluation (S3SE), see Appendix B. ii) Cognitive assessment - Standardized Assessment of Concussion (SAC) utilizing forms “A,” “B” or “C.” See Appendix C for examples of each form. iii) Balance assessment - Balance Error Scoring System (BESS), see Appendix D. iv) Vision performance assessment – King-Devick Test (KDT) utilizing an iPad application. v) Computerized Neuropsychological testing – Immediate Post-Concussion Assessment and Cognitive Testing – (ImPACT™). vi) Psychological Distress Measurement – Brief Symptom Inventory-18 (BSI-18), see Appendix E. vii) Fatigue Measurement - Pre and Post Test Exhaustion Rating (PPTER), see Appendix F. f) After a concussive injury, the baseline assessments are repeated at appropriate time intervals postinjury (sections 2 and 3). Testing is conducted under the same conditions as the baseline whenever possible. Results of are to be recorded on the Concussion Testing Summary form (Appendix G). g) Just prior to ImPACT™ administration, the athlete will be shown a document with brief examples of each component on the ImPACT™ test. This document is referred to as the “ImPACT-Instructions” (see Appendix H). The goal of this extra instruction is to decrease test confusion and allow more accurate assessment of the athlete’s ability. h) ImPACT™ baseline assessments should be reviewed for abnormalities. Athletic trainers for each sport will alert their respective team physician when incoming athlete ImPACT™ baselines are complete. The team physician will review these results online. If a baseline has been flagged as invalid by the ImPACT™ program, the team physician will alert the athletic trainer so arrangements can be made for retesting of the athlete. All subsequent baseline ImPACT™ evaluations will be reviewed for validity in similar fashion. Page 5 i) Clearance decisions for participation regarding concussion baseline testing and need for additional testing will be made by the team physician.4 j) As concussion evaluation and management evolves, additional tests may be utilized at the discretion of the team physician. This is not intended to replace the previously named tests in section 1e. Examples of newer measures may include vestibular system measurements such as accommodation, convergence and dynamic visual acuity; objective balance measures; additional neurocognitive and reaction time measures. If these tests merit UAA-wide usage they may be submitted for consideration to the UAA Concussion Committee for inclusion in later revisions of this CMP. 2) Initial Evaluation a) Assume a C-spine injury is present until proven otherwise. This is absolutely critical if the player is unconscious. Quickly stabilize the head and neck, assess Circulation, Airway and Breathing, appropriately spine board (with adequate assistants) if needed and immobilize the neck. Proceed with emergency action plan as indicated. b) After C-spine injury has been ruled out in an athlete with a suspected concussion, remove the athlete from the field of play. c) In addition to C-spine injury an emergency action plan will be followed for the following conditions: • • • • • Glasgow Coma Scale < 13 Prolonged loss of consciousness Focal neurological deficit suggesting intracranial trauma Repetitive emesis Persistently diminished/worsening mental status or other neurological signs/symptoms d) Removal is typically performed by the supervising athletic trainer but may also be performed by a coach or teammate if concussion suspected e) After removal, evaluation will then be performed by the team physician or athletic trainer covering the event. Ideally this occurs at the time of the injury. f) The athlete will not be returned to play prior to this evaluation. g) Obtain a history of the injury. History can be obtained from the athlete, or from teammates, coaches or other observers. Try to determine the mechanism and circumstance of injury. It can be helpful to review the videotape of the contest or practice if available and practical. h) The S3SE, SAC, BESS, KDT and PPTER are to be repeated within 0-6 hours post-injury and compared to the baseline scores to aid in this initial evaluation. i) As per NCAA guidelines, if a diagnosis of concussion is made, the athlete will not return to play that day.2,4 j) It is important to keep a high index of suspicion for concussion. A concussed athlete may not present with obvious symptoms and may not realize they have a concussion. Other players may note confusion or poor execution of plays in a teammate and bring this to your attention. An athlete may also hide symptoms for fear of being removed from the contest. k) It also should be recognized that concussion symptoms may be delayed following an impact and that concussion should be seen as an evolving injury in the acute stage.1 l) No athlete with severe or unstable symptoms or findings will be released from medical care until appropriate evaluation and follow-up is obtained. Page 6 m) Verbal and/or written Concussion Take Home Instructions (Appendix I) are given to the athlete and their roommate (or similar second person) to guide care at home until seen for further follow-up in the athletic training room or physician’s office. n) Arrangements are made to have a roommate, teammate or similar person to monitor them overnight. o) The athlete’s academic advisor is notified when modifications of classroom activities are indicated. 3) Repeat Evaluations a) Repeat evaluations of the concussed athlete are performed in the athletic training facility or physician’s office and typically begin within 24-48 hours. b) The S3SE, SAC [utilizing a different form (“A,” “B” or “C”) from the previous test], BESS, KDT, BSI-18, PPTER and ImPACT™ are repeated and compared to the baseline and initial evaluation scores to aid in the repeat evaluations. c) Prior to the first post-concussive administration of ImPACT™, the athlete will be shown the ImPACT-Instructions (Appendix F). Prior to subsequent post-concussive ImPACT™ testing, the athlete may be shown the ImPACT-Instructions if desired by the athlete. d) Repeat evaluations in addition to the initial 0-6 hour post-injury testing (section 2, h) are to be performed at the time-points listed below at a minimum and at the discretion of the Sports Health Staff. These time-points have been recommended by the NCAA/Department of Defense Concussion Assessment, Research, and Education (CARE) study in which UF is participating. i) S3SE, SAC, BESS, KDT, ImPACT™, BSI-18, PPTER – 24-48 hours post injury ii) S3SE, PPTER – daily until student-athlete is asymptomatic. Asymptomatic refers to scoring at or below baseline on the S3SE. iii) S3SE, SAC, BESS, KDT, ImPACT™, BSI-18, PPTER – when allowed to begin Stage 1 of UF Concussion Return to Play Protocol (UFCRTPP) (+/- 1 day) iv) S3SE, SAC, BESS, KDT, ImPACT™, BSI-18, PPTER – when allowed to begin Stage 5 of UFCRTPP (+/- 1 day) v) S3SE, SAC, BESS, KDT, ImPACT™, BSI-18, PPTER – 6 months post injury (+/- 1 week) Some time-points may occur simultaneously. For example the 24-48 hour evaluation (time-point i) may occur at the same time the athlete becomes asymptomatic (time-point ii) which may also be the same time the athlete is started on the UFCRTPP (time-point iii). e) Results are to be recorded on the Concussion Testing Summary Form (Appendix F). f) The above time-points and specific tests are recommended but may be altered on occasion to accommodate the needs and conditions of the student athlete. Variances from the above timepoints and tests will be made at the discretion of the UAA Sports Health Staff. g) Any athlete experiencing prolonged recovery will be evaluated by a team physician, and referred to consulting physicians if necessary. 4) Graduated Return to Play a) Per NCAA guidelines there is no same day return to play for an athlete diagnosed with a concussion.2 Page 7 b) A concussed athlete is allowed to return to play only after the thorough evaluation described above and completion of the UF Concussion Return to Play Protocol (UFCRTPP). c) The UFCRTPP is described in Appendix H. d) The UFCRTPP is an incremental protocol starting with minimal cognitive, autonomic and vestibular activities in stage 1 and gradually progressing in stepwise fashion to full return to competition over stages 2-6. e) Stage 1 of the UFCRTPP may begin after the repeat evaluation (see 3a above) of the concussed athlete if deemed appropriate by the examiner. f) The athlete should not attempt to progress from stage 1 to stage 2 of the UFCRTPP if the athlete has any worsening of symptoms with stage 1 activities. If worsening symptoms have occurred, a period of rest must pass before attempting stage 1 activities again. g) If any worsening of symptoms occur while in stages 2-6 of the UFCRTPP, the athlete should drop back to the previous asymptomatic level and try to progress again after a period of rest has passed. h) Progression through UFCRTPP stages should be documented on the Concussion Testing Summary form (Appendix G). 5) Graduated Return to Learn a) Return to Learn refers to resumption of cognitive activity such as attending classes, reading, studying, taking tests, and attending team meetings. b) Return to Learn begins with a period of relative cognitive rest and progresses in a stepwise fashion to more demanding cognitive activities.4 c) There will be no academic activity on same day as concussion. d) If symptoms return, cognitive progression should be reassessed.4 e) A concussed student athlete is allowed to return to cognitive activities at the discretion of the sports health staff after the thorough medical and testing evaluation described above and after consultation with the UAA academic team. f) The UAA academic team is a multidisciplinary group of individuals who can help coordinate and plan the student athlete’s Return to Learn. g) This team typically consists of: i) ii) iii) iv) Team physicians Athletic trainers Academic advisers Learning specialists i) ii) iii) iv) v) vi) Psychologists/counselors Neuropsychologists Professors and Deans Office of disability services representatives Coaches Administrators h) As needed the team may also consist of : Page 8 i) Lead Learning Specialist at Office of Student Life will serve as the point person to navigate athletes through the return to learn process. j) Return to Learn plans are individualized to fit the needs of student athletes returning to varied sports, courses and degree programs. 4 k) The individualized Return to Learn plan, including accommodations, will comply with the Americans with Disabilities Act Amendments Act. l) If symptoms are present for > 2 weeks, the athlete will be re-evaluated by the team physician/multi-disciplinary team. 6) Prolonged Symptoms The majority (80-90%) of concussed athletes have symptom resolution within 7-10 days.1 Athletes who have symptoms for longer periods may be treated with a multidisciplinary approach (see Specialist Consultation section). This management may include light exercise which does not produce worsening symptoms and is initiated with guidance from the team physician. 7) Athletes Injured Away From the Playing Field Athletes with concussion from non-sports related activities will also be treated according to the CMP. 8) Visiting Athletes Athletes from visiting schools under the care of UAA sports health personnel will be treated according to the CMP. 9) Diagnosis and Clearance Determination The final decision for diagnosis and clearance for return to play rests with the team physician.2,4,5 Computerized Neuropsychological Testing Affiliation As suggested by the NCAA, institutions using computerized neuropsychological testing should have an affiliation with a neuropsychologist to help with test application and interpretation.2 Currently the UAA has a neuropsychologist on retainer to provide this service via phone consultation and electronic access to ImPACT™ testing results. Specialist Consultation UAA sports health staff may consult medical specialist to participate in the care of athletes with suspected brain injuries on an as needed basis. Typical consultants are: - - University of Florida Department of Neurology for complex, unusual or prolonged cases of suspected concussion. University of Florida Department of Neurosurgery University of Florida Department of Psychology for formal neuropsychological testing University of Florida Department of Otolaryngology for vestibular testing Page 9 - University of Florida Department of Physical Therapy for vestibular therapy Additional Management Further work-up and treatment including additional neuropsychological or vestibular-ocular testing and/or therapy, advanced imaging, and/or medications and prescribed supplements may be used on a case by case basis. Clinical Judgment As with many medical conditions, no single clinical factor can be used to either diagnose a concussion or determine safe return to play after a concussion. Symptoms, clinical evaluation, diagnostic studies, and testing must all be weighed in the decision. In complex cases, the team physicians may confer with consultants to discuss management before final decisions are made. As stated previously, the team physician makes the final determination regarding diagnosis and return to play.2,4,5 Education Coaches The CMP will be distributed annually to all coaches by the Athletic Director.4 The NCAA Concussion Fact Sheet for Coaches (Appendix K) is also distributed to the coaching staff. Coaches will meet with Athletic Director / UAA Administrative Representative and athletic trainer / team physician to review above materials. The coaches will acknowledge their acceptance and understanding of the policy and educational information by signature (Appendix L). Athlete A one page handout, Statement of Student Athlete Responsibility (Appendix N), which outlines the definition, symptoms and medical importance of concussion, is given to each incoming athlete. In addition, each athlete will receive a copy of the NCAA Concussion Fact Sheet for Athletes (Appendix M). This educational statement is signed by the athlete, acknowledging their review of the material and willingness to alert medical staff of concussion symptoms in themselves or teammates.4 Annual concussion education will be provided to all athletes via Power Point presentation and question/answer session, by athletic trainer and/or team physician.4 Sports Health Staff The sports health staff will also review the CMP annually and each member of the sports health staff will acknowledge their acceptance and understanding of the policy by signature (Appendix L).4,6 Directors of Athletics The directors of athletics will also review the CMP annually, and acknowledge their acceptance and understanding of the policy by signature (Appendix L). Page 10 Reducing Exposure to Head Trauma It is important to emphasize ways to minimize head trauma exposure. Coaches and athletes will be responsible for taking a safety first approach, and exercise proper technique during all activities. Regarding football, the UAA will incorporate the NCAA Inter-Association Consensus: Year-Round Football Practice Contact Guidelines. Administrative The NCAA Concussion Safety Protocol Committee will review the CMP annually. The plan will be submitted to the committee by May 1 of each year for review. A signed certificate of compliance from the Director of Athletics must accompany the submission to the committee.6 Availability As recommended by the NCAA4, the CMP is publicly available upon request to the UAA Communications Department, (352) 375-4683. References 1. 2. 3. 4. 5. 6. McCrory P, Meeuwisse WH, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport. Zurich. November 2012. Br J Sports Med. 2013;47(5):250-258. National Collegiate Athletic Association. Committee on Competitive Safeguards and Medical Aspects of Sports. NCAA sports medicine handbook 2014-1015. Overland Park, KS. Collins M, Lovell M, Troutman-Enseki C. Univ. of Pittsburgh Medical Center Sports Medicine Concussion Program Guidelines for Post-Concussion Rehabilitation. Presented at: Emerging Frontiers in Concussion: Advancements in Assessment, Management and Rehabilitation. 2013. Pittsburgh, PA. Concussion Diagnosis and Management. NCAA Inter-association Consensus Guidelines. July 2014. Independent Medical Care in the Collegiate Setting. NCAA Inter-association Consensus Guidelines. July 2014. Concussion Safety Protocol. NCAA Autonomy Legislation. January 2015. Page 11 Appendix A: UF Athletic Association Concussion History Form UF Athletic Association Concussion History Form Name: ______________________________ UF ID #: ________-________ How many years have you played this sport? _______ Education History – please circle Years of education completed (excluding kindergarten): 12 Received speech therapy Attended special education classes Repeated one or more years of school Diagnosed with a learning disability Problems with ADHD or hyperactivity Handedness Right Native language: English Date: ________________ Sport: ________________ 13 Yes Yes Yes Yes Yes Left Spanish 14 No No No No No Other: ____________ Ambidextrous Other: _____________ Contact Sport History How many years have you played the following sports Boxing _____ Field Hockey _____ Football – tackle _____ Ice Hockey _____ Lacrosse _____ Martial Arts _____ Soccer _____ Wrestling _____ Concussion History Number of times diagnosed with a concussion:_________________________ Dates of each concussion: __________________________________________ Number of concussions which resulted in loss of consciousness: ____________________ Number of concussions which resulted in confusion: ____________________ Number of concussions which resulted in difficulty remembering events after the injury: ___________________ Number of concussions which resulted in difficulty remembering events before the injury: ____________________ Total games missed as a result of all concussions combined: ____________________ Treatment History – please circle Treatment for headaches by a physician Treatment for migraine headaches by a physician Treatment for epilepsy/seizures History of brain surgery History of meningitis Treatment for substance/alcohol abuse Treatment for psychiatric condition (depression/anxiety) Diagnosis History Diagnosed with ADD/ADHD Diagnosed with dyslexia Diagnosed with autism Yes Yes Yes Yes Yes Yes Yes No No No No No No No Yes Yes Yes No No No Adapted from ImPACT™ demographic section Page 12 Appendix B: SCAT3 Symptom Evaluation (S3SE) Name: UFID #: Date of Injury: Time of Injury: AM / PM Date of Exam: Time of exam: AM / PM EXAM: (circle one) Baseline Post-Injury Sport: Examiner: SCAT3 Symptom Evaluation (S3SE)1 Circle appropriate number for each Symptom SYMPTOM Headache “Pressure in Head” Neck Pain Nausea or Vomiting Dizziness Blurred Vision Balance Problems Sensitivity to Light Sensitivity to Noise Feeling Slowed Down Feeling like “in a fog” “Don’t feel right” Difficulty Concentrating Difficulty Remembering Fatigue or Low Energy Confusion Drowsiness Trouble Falling Asleep More Emotional Irritability Sadness Nervous or Anxious None 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total Number of Symptoms /22 Symptom Severity Score /132 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Mild 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Do the symptoms get worse with physical activity? Do the symptoms get worse with mental activity? How hours did you sleep last night? Moderate 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Yes □ Yes □ 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Severe 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 No □ No □ (hrs) 1. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. Apr 2013;47(5):250-262 Page 13 Appendix C: Standardized Assessment of Concussion (SAC) Form A Name: Loss of Consciousness/ Witnessed Unresponsiveness Post Traumatic Amnesia? Poor recall of events after injury Retrograde Amnesia? Poor recall of events before injury UF ID: Exam: (circle) Baseline Post-Injury Date of Injury: Time: Date of Exam: Strength Right Upper Extremity Left Upper Extremity Right Lower Extremity Left Lower Extremity Time: Examiner: INTRODUCTION I am going to ask you some questions. Please listen carefully and give your best effort. ORIENTATION What Month is it? What’s the Date today? What’s the Day of the Week? What year is it? What Time is it right now? (within 1 hour) Award 1 point for each correct answer. 0 0 0 0 1 1 1 1 0 1 ORIENTATION TOTAL SCORE IMMEDIATE MEMORY I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order. LIST TRIAL 1 TRIAL 2 TRIAL 3 Elbow 0 1 0 1 0 1 Apple 0 1 0 1 0 1 Carpet 0 1 0 1 0 1 Saddle 0 1 0 1 0 1 Bubble 0 1 0 1 0 1 TOTAL Trials 2 & 3: I am going to repeat that list again. Repeat back as many words as you can remember in any order, even if you said the word before. Complete all 3 trials regardless of score on trial 1 & 2. 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the subject that delayed recall will be tested. IMMEDIATE MEMORY TOTAL SCORE EXERTIONAL MANEUVERS If subject is not displaying or reporting symptoms, conduct the following maneuvers to create conditions under which symptoms likely to be elicited and detected. These measures need not be conducted if a subject is already displaying or reporting any symptoms. If not conducted, allow 2 minutes to keep time delay constant before testing Delayed Recall. These methods should be administered for baseline testing of normal subjects. EXERTIONAL MANEUVERS 5 Jumping Jacks 5 Push-ups 5 Sit-ups 5 Knee Bends NEUROLOGIC SCREENING □ No □ Yes Length: □ No □ Yes Length: □ No □ Yes Length: Normal Abnormal □ □ □ □ □ □ □ □ Sensation- examples: Finger-to-nose/Romberg □ □ Coordination- examples Tandem Walk/ Finger-Nose□ □ Finger CONCENTRATION Digits Backward: I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7. If correct, go to next string length. If incorrect, read trial 2. 1pt. possible for each string length. Stop after incorrect on both trials. 4-9-3 3-8-1-4 6-2-9-7-1 7-1-8-4-6-2 6-2-9 3-2-7-9 1-5-2-8-6 5-3-9-1-4-8 0 1 0 1 0 1 0 1 Months in Reverse Order: Now tell me the months of the year in reverse order. Start with the last month and go backward. So you’ll say December, November… Go ahead. 1pt. for entire sequence correct. Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan CONCENTRATION TOTAL SCORE 0 1 DELAYED RECALL Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order. Circle each word correctly recalled. Total score equals number or words recalled. Elbow Apple Carpet Saddle Bubble DELAYED RECALL TOTAL SCORE SAC SCORING SUMMARY Exertional Maneuvers & Neurologic Screening are important for examination, but not incorporated into SAC Total Score. ORIENTATION /5 IMMEDIATE MEMORY / 15 CONCENTRATION /5 DELAYED RECALL /5 SAC TOTAL SCORE / 30 Page 14 Appendix C: Standardized Assessment of Concussion (SAC) Form B Name: NEUROLOGIC SCREENING UF ID: Exam: (circle) Baseline Post-Injury Date of Injury: Time: Date of Exam: Time: Examiner: INTRODUCTION I am going to ask you some questions. Please listen carefully and give your best effort. ORIENTATION What Month is it? 0 1 What’s the Date today? 0 1 What’s the Day of the Week? 0 1 What year is it? 0 1 What Time is it right now? (within 1 hour) 0 1 Award 1 point for each correct answer. ORIENTATION TOTAL SCORE IMMEDIATE MEMORY I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order. LIST TRIAL 1 TRIAL 2 TRIAL 3 Candle 0 1 0 1 0 1 Paper 0 1 0 1 0 1 Sugar 0 1 0 1 0 1 Sandwich 0 1 0 1 0 1 Wagon 0 1 0 1 0 1 TOTAL Trials 2 & 3: I am going to repeat that list again. Repeat back as many words as you can remember in any order, even if you said the word before. Complete all 3 trials regardless of score on trial 1 & 2. 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the subject that delayed recall will be tested. IMMEDIATE MEMORY TOTAL SCORE EXERTIONAL MANEUVERS If subject is not displaying or reporting symptoms, conduct the following maneuvers to create conditions under which symptoms likely to be elicited and detected. These measures need not be conducted if a subject is already displaying or reporting any symptoms. If not conducted, allow 2 minutes to keep time delay constant before testing Delayed Recall. These methods should be administered for baseline testing of normal subjects. EXERTIONAL MANEUVERS 5 Jumping Jacks 5 Push-ups 5 Sit-ups 5 Knee Bends Loss of Consciousness/ Witnessed Unresponsiveness Post Traumatic Amnesia? Poor recall of events after injury Retrograde Amnesia? Poor recall of events before injury □ No □ Yes Length: □ No □ Yes Length: □ No □ Yes Length: Normal Strength Abnormal □ □ □ □ □ □ □ □ Finger-to-nose/Romberg □ □ Tandem Walk/ Finger-Nose-Finger □ □ Right Upper Extremity Left Upper Extremity Right Lower Extremity Left Lower Extremity Sensation- examples: Coordination- examples CONCENTRATION Digits Backward: I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7. If correct, go to next string length. If incorrect, read trial 2. 1 pt. possible for each string length. Stop after incorrect on both trials. 5-2-6 1-7-9-5 4-8-5-2-7 8-3-1-9-6-4 4-1-5 4-9-6-8 6-1-8-4-3 7-2-4-8-5-6 0 0 0 0 1 1 1 1 Months in Reverse Order: Now tell me the months of the year in reverse order. Start with the last month and go backward. So you’ll say December, November… Go ahead. 1 pt. for entire sequence correct. Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan CONCENTRATION TOTAL SCORE 0 1 DELAYED RECALL Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order. Circle each word correctly recalled. Total score equals number or words recalled. Candle Paper Sugar Sandwich Wagon DELAYED RECALL TOTAL SCORE SAC SCORING SUMMARY Exertional Maneuvers & Neurologic Screening are important for examination, but not incorporated into SAC Total Score. ORIENTATION IMMEDIATE MEMORY CONCENTRATION DELAYED RECALL SAC TOTAL SCORE /5 / 15 /5 /5 / 30 Page 15 Appendix C: Standardized Assessment of Concussion (SAC) Form C Name: NEUROLOGIC SCREENING UF ID: Exam: (circle) Baseline Post-Injury Date of Injury: Time: Date of Exam: Time: Examiner: INTRODUCTION I am going to ask you some questions. Please listen carefully and give your best effort. ORIENTATION What Month is it? 0 1 What’s the Date today? 0 1 What’s the Day of the Week? 0 1 What year is it? 0 1 What Time is it right now? (within 1 hour) 0 1 Award 1 point for each correct answer. ORIENTATION TOTAL SCORE IMMEDIATE MEMORY I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order. LIST TRIAL 1 TRIAL 2 TRIAL 3 Baby 0 1 0 1 0 1 Monkey 0 1 0 1 0 1 Perfume 0 1 0 1 0 1 Sunset 0 1 0 1 0 1 Iron 0 1 0 1 0 1 TOTAL Trials 2 & 3: I am going to repeat that list again. Repeat back as many words as you can remember in any order, even if you said the word before. Complete all 3 trials regardless of score on trial 1 & 2. 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the subject that delayed recall will be tested. IMMEDIATE MEMORY TOTAL SCORE EXERTIONAL MANEUVERS If subject is not displaying or reporting symptoms, conduct the following maneuvers to create conditions under which symptoms likely to be elicited and detected. These measures need not be conducted if a subject is already displaying or reporting any symptoms. If not conducted, allow 2 minutes to keep time delay constant before testing Delayed Recall. These methods should be administered for baseline testing of normal subjects. EXERTIONAL MANEUVERS 5 Jumping Jacks 5 Push-ups 5 Sit-ups 5 Knee Bends Loss of Consciousness/ Witnessed Unresponsiveness Post Traumatic Amnesia? Poor recall of events after injury Retrograde Amnesia? Poor recall of events before injury □ No □ Yes Length: □ No □ Yes Length: □ No □ Yes Length: Normal Strength Abnormal □ □ □ □ □ □ □ □ Finger-to-nose/Romberg □ □ Tandem Walk/ Finger-Nose-Finger □ □ Right Upper Extremity Left Upper Extremity Right Lower Extremity Left Lower Extremity Sensation- examples: Coordination- examples CONCENTRATION Digits Backward: I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7. If correct, go to next string length. If incorrect, read trial 2. 1 pt. possible for each string length. Stop after incorrect on both trials. 1-4-2 6-8-3-1 4-9-1-5-3 3-7-6-5-1-9 6-5-8 3-4-8-1 6-8-2-5-1 9-2-6-5-1-4 0 0 0 0 1 1 1 1 Months in Reverse Order: Now tell me the months of the year in reverse order. Start with the last month and go backward. So you’ll say December, November… Go ahead. 1 pt. for entire sequence correct. 0 1 Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan CONCENTRATION TOTAL SCORE DELAYED RECALL Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order. Circle each word correctly recalled. Total score equals number or words recalled. Baby Monkey Perfume Sunset Iron DELAYED RECALL TOTAL SCORE SAC SCORING SUMMARY Exertional Maneuvers & Neurologic Screening are important for examination, but not incorporated into SAC Total Score. ORIENTATION IMMEDIATE MEMORY CONCENTRATION DELAYED RECALL SAC TOTAL SCORE /5 / 15 /5 /5 / 30 Page 16 Appendix D: Balance Error Scoring System (BESS) Name: UFID #: Date of Injury: Time of Injury: AM / PM Date of Exam: Time of exam: AM / PM EXAM: (circle one) Baseline Post-Injury Sport: Examiner: Balance Error Scoring System (BESS)1 Balance Error Scoring System – Types of Errors 1. 2. 3. 4. Hands lifted off iliac crest Opening eyes Step, stumble, or fall Moving hip into >30 abduction, adduction, flexion or extension 5. Lifting forefoot or heel 6. Remaining out of testing position > 5 sec. • • • • • • • NO SHOES. Barefoot or in socks 20 seconds at each position Each type of error can be counted more than once in each position Simultaneous errors count as 1 error 10 points maximum score in each position If <5 consecutive seconds of stability per stance then give max score of 10 Total possible score of 60 Total Score: Which foot was used for testing (i.e. non-dominant foot): ☐ Left ☐ Right 1 Guskiewicz KM, Perrin DH, Gansneder BM. Effect of mild head injury on postural stability in athletes. J Athl Train. 1996 Oct;31(4):300-6. Page 17 Appendix E: Brief Symptom Inventory-18 (BSI-18) Name: UFID #: Date of Injury: Time of Injury: AM / PM Date of Exam: Time of exam: AM / PM EXAM: (circle one) Baseline Post-Injury Sport: Examiner: BSI - 18 DIRECTIONS: Below is a list of problems people sometimes have. Read each one carefully and circle the number that best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Do not skip any items. If you change your mind, erase your first mark carefully and then fill in your new choice. HOW MUCH WERE YOU DISTRESSED BY: NOT AT ALL 1. Faintness or Dizziness 2. Feeling no interest in things 3. Nervousness or shakiness inside 0 0 0 A LITTLE BIT 1 1 1 4. Pains in the heart or chest 0 0 0 0 0 0 10. Trouble getting your breath 11. Feeling of worthlessness 12. Spells of terror or panic 13. Numbness or tingling in parts of your body 14. Feeling hopelessness about the future 15. Feeling so restless you can’t sit still Feeling weak in parts of your body 17. Thoughts of ending your life 18. Feeling fearful 5. 6. 7. 8. 9. Feeling lonely Feeling tense or keyed up Nausea or upset stomach Feeling blue Suddenly scared for no reason MODERATELY QUITE A BIT EXTREMELY 2 2 2 3 3 3 4 4 4 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 0 0 0 1 1 1 2 2 2 3 3 3 4 4 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 0 1 1 2 2 3 3 4 4 0 1 2 3 4 Total Number of Symptoms: ______ (maximum possible 18) Symptom Severity Score: _______ (maximum possible 72) Page 18 Appendix F: Pre/Post-Test Exhaustion Rating (PPTER) Name: UFID #: Date of Injury: Time of Injury: AM / PM Date of Exam: Time of exam: AM / PM EXAM: (circle one) Baseline Post-Injury Sport: Examiner: PRE-TEST EXHAUSTION RATING Athlete: Compared to how you normally feel and function each day, give a rating between 0 and 100 of how tired you feel right now, with 0 being extremely exhausted and 100 being completely awake and alert ____________ Examiner: Please place a number next to the following tests to indicate the order of performance (“1” indicating the first test performed, “2” indicating the second test performed and so forth). If not performed, leave blank. ____ S3SE ____ BSI-18 ____ SAC ____ BESS ____ KDT ____ ImPACT™ ____ Other: _________________________________ POST-TEST EXHAUSTION RATING Athlete: Compared to how you normally feel and function each day, give a rating between 0 and 100 of how tired you feel right now, with 0 being extremely exhausted and 100 being completely awake and alert ____________ Page 19 Appendix G: Concussion Testing Summary Name: Sport: Current Concussion Date: UFID#: Time: Dates of prior concussions: Baseline Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Date/Time Asymptomatic 0-6hrs 24-48hrs Stage 1 Stage 5 6 months S3SE BSI-18 SAC BESS KDT ImPACT™ PPTER additional test additional test Return-to-Play Protocol Stage Date/Time returned to full contact practice (Stage 5): Date/Time returned to competition (Stage 6): Page 20 Appendix H: UF Concussion Return to Play Protocol (UFCRTPP)1,3 Rehabilitation Stage Description Autonomic Recovery+ Vestibular/Ocular Recovery 1. Minimal activity Limit concentration activities including class and meetings. Exercise in quiet area, no impact activities (running, jumping). Balance and vestibular treatment by specialist (prn). Limit head movement/position change. 30-40% max exertion. HR ≈ 100-115. Stationary aerobic conditioning; bike. Static balance activities. Exercises that limit head movements (weight machines, squats/lunges with focusing). Core exercises without head movements. 2. Light activity May attend class and meetings. May exercise in gym areas. Use various exercise equipment. Allow some positional changes and head movement. 40-60% max exertion. HR ≈ 115-145. More progressive dynamic aerobic conditioning: elliptical, treadmill walking, progress to treadmill jogging. Balance activities with head movements. Resistance exercises with head movements (example: lateral squats with head movement). Low intensity sport specific activities. Core exercises with head movements (ex: side planks with arm /head turn, bicycles, Russian twists). 3. Moderate activity Any environment ok for exercise (indoor, outdoor). Integrate strength, conditioning, and balance/proprioceptive exercise. Can incorporate concentration challenges (counting exercises, visual games). 60-80% max exertion. HR ≈ 145-170. Moderately aggressive aerobic exercise (intervals, pyramids, stair running). All forms of strength exercises. Dynamic warm-ups. Impact activities (running, plyometrics). Challenging positional changes (burpees, mountain climbers). 4. Non-contact sport-specific activity Continue to avoid contact activity, but resume aggressive training in normal sport environment. 80-100% max exertion. HR ≈ 170-200. Sport-specific activities avoiding contact. 5. Full contact practice Must be back to baseline in all testing. Initiate contact activities as appropriate to sport. Full exertion. 100% max exertion. HR ≈ 200. Full physical training activities with contact. 6. Return to play Normal game play. + % Max Exertion calculated by formula {[(Max HR – Rest HR) x %)] + Rest HR} with assumption that UF athlete is 20 years old, Max HR = (220 – age), and Rest HR = 60. Page 21 Appendix I: ImPACT Instructions ImPACT™ Instructions Revised 1/25/15 Gator Gator 1. You will be asked to study and try to memorize a list of words. The list will be shown to you twice. 2. Then a word will be presented to you and you will respond by clicking “Yes” if the word was from the list you were told to memorize. Click “No” if the word was not from the original list. 3. Ex) If the word “Gator” was on the list you were asked to memorize, you would click “Yes.” If “Gator” was not on the original list, you would select “No.” Page 22 1. You will be asked to study and try to memorize a set of designs. The designs will be shown to you twice. 2. Then a design will be presented to you and you will respond by clicking “Yes” if the design was from the set you were told to memorize. Click “No” if the design was not from the original list. 3. Ex) If the design on the left was part of the original set you were asked to memorize, you would click “Yes.” If it was not from the original set, you would click “No.” Press “Q” Press “P” 1. A random assortment of X’s and O’s is displayed, and three of the X’s or O’s are illuminated in YELLOW. You have to try and remember the location of the YELLOW X’s and O’s. 2. A shape identification test is then presented. You must press “Q” when you see a red circle, and press “P” when you see a blue square. RESPOND AS QUICKLY AS POSSIBLE. 3. After the shape identification test, the X’s and O’s screen reappears and you have to remember where the yellow X’s and O’s were located. Page 23 1. You will be asked to click the number that matches the symbol shown at the bottom AS QUICKLY AS POSSIBLE. You must also try and remember which symbol goes with which number. 2. Ex) for the “≠” symbol, you would click on the number 5. 3. After a while, the symbols will disappear from the top row and you will be asked to click the number that goes with the presented symbol from memory. 1. A word of a color will be displayed on the screen. The word will either be displayed in the same color ink as the word, or a different color. 2. You must CLICK WITHIN THE BOX on the screen whenever the word presented matches the color of the ink. DO NOTHING if the word and color of the ink do not match. 3. Ex) If the word “RED” is presented in RED ink, click AS QUICKLY AS POSSIBLE within the box. If the word “RED” is presented in BLUE ink (as shown above), DO NOTHING. Page 24 1. You will first be asked to click AS QUICKLY AS POSSIBLE the numbered buttons on the screen, starting with #25 and counting backwards to #1. 2. Then you will be shown three letters that you will have to try and memorize. 3. After seeing the three letters, the numbered grid will reappear and you will repeat the counting backwards test, clicking as quickly as possible from #25 backwards to #1. 4. You will then be asked to recall the three letters shown to you before the counting test 1. You are asked to recall the words and designs that you were told to memorize at the beginning of the test. Page 25 Appendix J: Concussion Take Home Instructions Concussion Take Home Instructions University of Florida Athletic Association You have a brain injury called a concussion. A careful medical examination has been performed and no serious complications have been found. It is recommended that you have short term monitoring by a responsible adult/teammate while you are away from the athletic training facility in case new or worsening symptoms occur. Listed below are instructions and important points to follow while at home: Signs to watch for: - Changes in behavior - Worsening headache - Vomiting - Double vision Things to AVOID: - Drinking alcohol - Driving a car, scooter, or any motorized vehicle - Doing strenuous activities - Crowds Things that are “OK” or that you should do: - REST - Apply ice to injured areas - Eat nutritious meals - Dizziness Numbness and tingling anywhere in the body Excessive drowsiness Slurred speech - - Taking certain medications: o Aspirin, Aleve, Ibuprofen or other anti-inflammatories (i.e. Celebrex) o Sedating pain killers Video games, loud music, TV/movies - Take Tylenol (Acetaminophen) as directed Drink plenty of fluids (Gatorade and water) If any of the above “signs to watch for” or any other problems occur, or if you have any questions please contact your athletic trainer and/or go to the Emergency Department immediately. Additional comments: Athlete’s Name: Signature: Athletic Trainer: Date: (AT’s Signature): Phone #s: Page 26 Appendix K: NCAA Concussion Fact Sheet for Coaches CONCUSSION FDFI mH?? TII .Amultahlqury. CUM-HEEL . mammal Ian-mu nap mmumbmmummum rm hyper-Ilium:qu Ian-I11: nun: . 3mm: mm . Ht? Jilin]- Eur-nihun communth 5 b: m! Inme tbsp-:11. . cm mumh?lhE-ijl numan . mummy-mm um yup-mm: rug-mm:th l! A. I.ij mtg-111m]- bl Club]! ?int: ?u mum- mm! tug-I111:qu With: h-d. than?: u: IJ- Miami aluminum uthl Mulch. Mimi-p nun: aid.qu LEIIJII Mq?m?h-I hli. Will? A. Pill-31M mm Tulip Will I. mh?qill mm; mln-umu m1 1. .I. mun-urn: Emm-rtud?tm ll-?l Ln:qu Minimum .L Alrchu?n?lht mm mummy SHIRE AHD ll' aluminum? I I m? mu m. Illa-Final.me Page 27 All Al I. Inn-11.. @1111": m; Hun :11 I311: unlit: bun? ?ute-1 jut: dumm? Wm Mull lime-1m: Cram? Egg-11mm Inn Mum-ply: lain-Ind.me mm glut: you: :hzl?j'. [um- II-mrcu are mummy-1 : nun-cl. tum: tum: 11111 In}: Equal I11.I1 pun-11mm mun-H11 almanac-1. I'm: crummy Ind Emu-u}. mart-1mm Ell-I1 mam?mu- H?h bunt-Id]: mm syn-:1: mum-nu. - Inn-nutty: mu: ??hl H'Elul Spads?l?dm Emma mini-111cm mum Erinlqum?'?? . M1111 ain't-m1- mi. Emmet-atom! think-1119: - Emmn?un-?nlnu Funny-nu mm ?11111111: - WITH amp-Minna? an Inn-1m: alumni: Hannah: brill-11m :11! Hum-chm. EmmM-?qm??l my Inumwnm 1mm hm li?lmMW-I??m-Im Ill?ml?ll'lil upm-whumum: mm! Em" Ina-m mum-ame mutual-:11 mainland? mumm Hymn-unman- mm-1mm?hlm minimum. 5. Mll'h? I111 111 Maura-Ill: pa-mLIIhnIrII: I "plum 11 nun-1m. ADE-II- manila] Min-1d; until-tr 11 [un?t-111; Armada-?g mint-Eh: mummy-Hum 1111511111 i. Dinky I pm pm. mum?111111: Ibo-land: mun: "1:11:11.qu nun. I11.I1 nit-t mmumnay?namm 11 mm unit-tumulm Mumm-Fllf?m?mm Comma-1m I.an MISS DHE GAME 11-IE I?ll-I DOUBT, BIT 1H e. un??hh?aEr?m?f Page 28 Appendix L: Acknowledgement of Concussion Education I acknowledge that I have received concussion education in the form of concussion fact sheet and have had an opportunity to answer questions with appropriate Sports Health Staff. In addition, I have reviewed the UAA Concussion Management Plan. Team / Department: ____________________________________ Name Signature Date Page 29 Appendix M: NCAA Concussion Fact Sheet for Student Athletes CONCUSSION A FACT SHEET FOFI WHAT IS A GUN: ARE THE DF A con: Ilslol Isa brain cancuss'a?? 1-3 3 1301119 headmbadf- Toll cart't seesLIooi:LcIissi.I:ii:lI but groun'iight notice Home ofthe From contact with another player. hittinga hard slid: right Ethel. Hummus can Ehm up hours 01. days HEM?the mum as the gonad, 'Lce or?oor, or being hit by apiece ofequipnient (3mm mm?mfhde. such as ahat.I lacro?e stickor?eld hockey hall . mm. - Can diangethe war yourbrsin normally works. Cunfmn - Caursmgefrom mildto severe. Headadll - Presents itsdi'diiferently for each athlete. I 0f Emma - Can occurdiiringpractice or competition IIan sport. Balance m. - Can happen even it'lnou do Iol lose emissions-ens. . D?ume m- fume-jam. - Sensitivity tolight or noise. HDW Ch? I PH EVENT A CD HGLISSID - Nausea (feeling that you might 1.?omitll. Bade step-B you can take I: prolectyorridf Iron - Feelingsluggiah, foggy or groggy. - Do not initiate contact with {warhead or helmet. Toucan Eillget - Feeling unusually irritable. a mmssionifyou are 1is'earii'ig ahelniet. I or memoryprohlems (forgetting grueplaglrs.I fartsD - Avoid opponeutiuthe head. Undercut?nngying elbows. stepping on a head, checking anmiprotected opponent, - Slowed reaction time. deticlrs to the head allcauae concussionsFollowirour athletics departmentsrules ?or H'etyandtherules of Butte camping ?Playingva mam ?use the concusion (such as headache or lire-dues] toreappeeror - Practice good at me . Practice andperfect the skills ofthe sport. 3? WHAT SHOULD I DO IF I THINK I HAVE A team [thy-ideas. athletic trains: orhelith. cure prufmlicml nus. mnemsions cm Em damage yumwhdelife. TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. For more information and resources, and mEDCgow'Concussion agitate meg-mm uni}- on His HEM I: on Murat by he Gom?itj?emw I: predate or ?rm-er. Page 30 Appendix N: Statement of Student Athlete Responsibility What is a CONCUSSION? A concussion is a brain injury caused by a blow to the head, face or elsewhere on the body with a force transmitted to the head. Concussions can result from hitting a hard surface such as the ground or floor, from players colliding with each other or from being hit by a ball, bat or other sporting equipment. Facts about CONCUSSION 1. A concussion is a serious brain injury 2. Concussions can occur without loss of consciousness or other obvious signs 3. Concussions can occur from blows to the body as well as to the head 4. Concussions can occur in any sport 5. Athletes can still get a concussion even if they are wearing a helmet 6. Recognition and proper response to concussions when they first occur can help prevent further injury or even death Signs and Symptoms of CONCUSSION include 1. Headache or “pressure” in head 2. Nausea or vomiting 3. Balance problems or dizziness 4. Double or blurry vision 5. Sensitivity to light and /or noise 6. Feeling sluggish, hazy, foggy or groggy 7. Concentration or memory problems 8. Confusion 9. Sensation that one does not “feel right” Why knowing you have a CONCUSSION is important Most concussions resolve but some concussions can lead to chronic symptoms such as headache, decreased memory, sleeping problems or personality change. Rest, avoiding another blow to the head and following the advice of your medical staff are critical in helping you recover as fast and as safely as possible. Sustaining another concussion prior to recovery from the first increases your chance of long term symptoms. There have been reports of death with a second concussion in younger athletes. It is very important for you to report any concussion symptoms as described above to your athletic trainer or team physicians at the time of injury. This includes alerting the medical staff to symptoms in your teammates if you notice these. Statement of Student Athlete Responsibility I accept responsibility for reporting all injuries and illnesses to the University of Florida Athletic Association Medical Staff (athletic trainers and team physicians) including any signs and symptoms of CONCUSSION. I have read and understand the above information on concussion. I will inform the supervising athletic trainer or team physician immediately if I experience any of these symptoms or witness a teammate with these symptoms. Signature of Student Athlete: Printed Name: Date: NCAA. Concussion – a fact sheet for coaches. 2010. NCAA. Concussion – a fact sheet for student-athletes. 2010. UAA Concussion Management Plan. 2014. Page 31 Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan Last Updated: April, 2015 Overview 1. 2. 3. 4. 5. 6. Intended Audience Introduction Pre-Season Plan & Procedures Post-Injury Plan & Procedures References Appendices 1 2 5 9 13 Intended Audience Intended Use The Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan exists for the use of Florida State University Athletic Trainers, Student Athletic Trainers, and Team Physicians. A hard copy and electronic version of the Florida State UniversitySports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan will be provided to all Florida State University Athletic Trainers. The Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan will also be available online for Florida State University Student Athletic Trainers to access at their convenience. A hard copy or electronic version of the Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan will be made available to any member of the Florida State University Coaching Staff at their request. Any questions regarding the Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan should be directed to Jeronimo Boche, ATC Assistant Athletic Trainer (Football). This document will serve as the official concussion management plan for the Florida State University-Sports Medicine department and will be transmitted to the required/designated organizations for compliance with NCAA concussion management policies and procedures. 1 Introduction Policy This document is intended to provide a stepwise process to evaluate and manage a sports-related head injury or concussion from an athletic trainer and team physician perspective. The Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan is designated for implementation with Florida State University sanctioned intercollegiate sports. Rationale The Florida State University is committed to the identification, evaluation, management, and treatment of concussions sustained by student-athletes. All concussion management and treatment procedures will be in compliance with the NCAA Concussion Management Plan, set forth by the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports (CSMAS). Definition of Concussion The Zurich 2012 Consensus Statement provides the following definition of concussion. Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathophysiologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies (CT/MRI). 4. Concussion results in a set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged [1]. Further, a concussion results in a complex neurometabolic cascade involving ionic, metabolic and physiologic events. This results in an increased demand for glucose; and a decrease in cerebral blood flow and metabolic rate for oxygen [2]. Given the neurometabolic cascade mentioned above, it is believed a concussion occurs more on a cellular rather than structural level. During this initial period following the concussion the student-athlete may develop cerebral edema or excess accumulation of fluid in the 2 intra-cellular and extracellular spaces of the brain. However, the brain’s auto-regulatory mechanisms often compensate for the mechanical and physiological stress to protect against massive brain swelling. Second Impact Syndrome (SIS) Further injury or stress while neurons are injured may result in cell death or serious cell damage. Continued trauma after cell dysfunction has occurred may even result in Second Impact Syndrome, a serious condition in which a second traumatic event occurs while the brain is attempting to heal from the initial injury. During the second event, the brain loses its ability to auto-regulate resulting in possible cerebral edema, brain herniation, and even death. Death has been reported to occur in a matter of 2-5 minutes following the second trauma, usually without time to stabilize or transport a student-athlete from the playing field to the ED. It should be noted that this process can occur far more rapidly than the progression of a subdural hematoma or subarachnoid hemorrhage. Recognition and knowledge of the signs and symptoms of acute concussion can be helpful in identifying student-athletes who have sustained a concussion. Signs of Acute Concussion The diagnosis of acute concussion involves the assessment of multiple domains including physical signs. Common acute signs of concussion may include but are not limited to the student-athlete appearing; dazed or confused, moving clumsily, changes in behavioral or emotional functioning, difficulty remembering plays or assignments, changes in balance, vomiting, loss of memory for events before or after the trauma, seizure or “fencing” response, and loss of consciousness. Symptoms of Acute Concussion Clinical symptoms may also be present in acute concussion. Acute symptoms may be somatic, cognitive, emotional, or sleep related in nature. Student-athletes may or may not be reticent to divulge symptoms of concussion, as a result subjective symptoms based on student-athlete self-report provides a single component of a comprehensive evaluation of acute concussion. Common symptoms of acute concussion may include but are not limited to; headache, fatigue, drowsiness, visual changes (blurry, double vision), migraine symptoms (visual aura, light sensitivity, noise sensitivity, nausea), dizziness, fogginess, balance problems, difficulty with thinking (attention, concentration, memory), and feeling slowed down [3]. Post-Concussion Syndrome (PCS) Previous research regarding recovery and collegiate athletes suggests the majority of concussions (80%-90%) resolve in a short period of time (7-10 days) [4].The FSU Sports Medicine Department recognizes that recovery from concussion differs on a case by case basis. Recovery time may be longer in some cases resulting in symptoms of post-concussion syndrome (PCS). While a lack of consistency exists in the literature regarding the timeline and transition from acute concussion to PCS, it is possible student-athletes who sustain a concussion may continue to experience symptoms beyond 7-10 days. Symptoms of PCS include, but are not limited to; loss of intellectual capacity, poor recent memory, difficulty with multitasking, slowness of thought, fogginess, mood changes, personality changes, sleep changes, headache, migraine symptoms, dizziness, and irritability [5]. 3 Individual Recovery from Concussion Individual recovery following concussion can vary significantly among collegiate student-athletes. Previous studies have suggested recovery time for concussion ranges from 1-7 days for total cognitive resolution, and 3-7 days for total symptom resolution [6-8]. While previous research supports resolution in the majority of collegiate student-athletes, the FSU Sports Medicine Concussion Team recognizes some student-athletes may experience lingering symptoms beyond 710 days that may qualify as post-concussion syndrome. Concussion recovery among the FSU Sports Medicine Concussion Team staff is understood as existing on an individual basis. No two studentathletes are the same in terms of concussion recovery. Underreporting of Concussion Symptoms Previous research supports that many student-athletes often do not report symptoms of concussion. In a collegiate football sample, 47% of football players did not report their symptoms and fail to do so due to the belief that the injury doesn’t warrant reporting [9]. The FSU Sports Medicine Concussion Team recognizes student-athletes may not be likely to report symptoms of concussion and as a result must rely on objective measures to aid in concussion diagnosis. These objective measures are discussed later in relation to sideline, locker-room, and follow-up evaluations. While some student-athletes may be reticent to report symptoms of concussion due to a belief that the injury doesn’t warrant reporting, the FSU Sports Medicine Concussion Team recognizes that some student-athletes may lack a general education or context for concussion injuries. As a result, the FSU Sports Medicine Team is dedicated to expanding the education, knowledge, and awareness of concussions in collegiate athletics to all FSU student-athletes. Risk Factors for Concussion in Sports A number of risk factors exist in relation to concussion. First and foremost, a history of concussion is associated with a 2-5.8 times higher risk of sustaining another concussion [8, 10-12]. A prior history of learning disability such as ADD or ADHD has been shown to be associated with prolonged recovery and increased cognitive dysfunction [13]. A history of pre-existing migraine headaches may be a risk factor for concussion as well as being associated with prolonged recovery [14]. Previous studies of professional football players have shown specific playing styles (aggressive) may be at greater risk for concussion [15]. Other risk factors such as a history of mood disorders, gender, age, and even genetic factors (APOE G-219T) have been examined. It is possible following a concussion, student-athletes may experience an exacerbation of previous risk factors mentioned above. Similarly, these risk factors may become more pronounced during the recovery period and even contribute to prolonged recovery in some cases. Collecting a detailed medical, academic, and psychological history is critical to proper concussion management. An awareness of the risk factors mentioned above on an individual student-athlete basis can aid in the treatment of individuals who sustain a concussion. The FSU Sports Medicine Concussion Team medical history form which covers risk factors for concussion is provided in “Appendix A”. 4 Preseason Plan & Procedures Preseason Plan Overview Preparation for the care of a concussed student-athlete begins prior to any practice or competition with a pre-participation examination. The following procedures are included in The Florida State University pre-participation examination for concussion management. Pre-participation procedures for ALL Florida State University student-athletes include the following; • • • • • Preseason risk factor screening to assess risk and provide historical data as a reference in case a concussive injury is sustained by the student-athlete (Appendix A). Baseline neurocognitive testing provides comparison data for ALL student-athletes in case a concussive injury is sustained. Baseline neurocognitive data may be more important in high risk athletes and in sports with a higher incidence of concussion injuries. Baseline testing using a sideline concussion evaluation provides data for comparison, increased clarity when diagnosing concussion, and improved removal from play decisions. Baseline testing using a sideline evaluation tool may be more important in high risk athletes and in sports with a higher incidence of concussion (Appendix B). The Vestibular Ocular Motor Screening (VOMS) serves as an assessment of balance and vestibular functioning and will be administered to all student-athletes prior to any sport participation. Preseason concussion education for ALL student-athletes, coaches, and graduate assistant coaches provides documentation that ALL student-athletes, coaches, and graduate assistant coaches have been provided with concussion education in accordance with NCAA requirements. Preseason concussion education and documentation will serve as a written acknowledgement that ALL student-athletes, coaches, and graduate assistant coaches have received concussion education prior to participation in any practice or competition (Appendices C-F). Pre-season education will be made available for athletic trainers, athletic directors, team physicians and they will provide a signed acknowledgement of concussion education. Following the baseline concussion procedures a team physician will determine whether the student-athlete is medically cleared for participation. Any additional testing or consultation will be made on an as needed basis. Team physicians will re-evaluate to determine participation if additional testing or consultation is required. Preseason Risk Factor Screening Individual student-athletes vary widely with respect to medical, psychological, and academic history. A detailed history that highlights risk factors commonly associated with concussion can serve as a valuable component to proper concussion treatment and management. Risk factors for concussion in sports are provided in the previous section. A summary of common risk factors for concussion include; migraines, motion sickness, psychiatric diagnoses, academic difficulties, prior concussions, and ADD/ADHD. 5 Risk Factor Screening Procedures 1. ALL incoming student-athlete will complete the Concussion Risk Factors form provided in “Appendix A” prior to the beginning of their eligibility at Florida State University. 2. ALL current student-athletes who have not completed the Concussion Risk Factors form will be requested to complete the form prior to their participation in Florida State University sanctioned athletics. 3. All Concussion Risk Factor form results will be given to the respective athletic trainer in charge of the designated sport. Concussion Risk Factor form data will be compiled into an excel spreadsheet and scanned into Injury Zone software. 6 Baseline Neurocognitive Testing Computer-based neurocognitive assessment programs such as the ImPACT test are commonly used to document neurocognitive performance for comparison with post-concussion testing. The ImPACT test battery has been demonstrated to serve as a reliable measure of baseline neurocognitive functioning that is difficult to intentionally perform poorly without detection [16-19]. Baseline neurocognitive testing may be helpful to add useful information to the overall interpretation of neurocognitive testing. It also provides an additional educational component to discuss the significance of a concussive injury with the student-athlete. Preseason baseline neurocognitive testing requires an honest and forthright effort on the part of the athlete. Computerized neurocognitive testing requires adequate resources and a quiet environment for best results, but can be performed in large groups [20]. Baseline Neurocognitive Testing Procedures 1. ALL incoming student-athlete will undergo baseline neurocognitive testing prior to the beginning of their eligibility at Florida State University. ALL current student-athletes will have baseline measures. 2. Invalid baseline neurocognitive tests will be repeated in a reasonable timeframe (<7 days) to assure a valid baseline exists for every student-athlete prior to the beginning of their eligibility at Florida State University. 3. The tool utilized by the Florida State University-Sports Medicine Department to assess neurocognitive functioning will be the ImPACT test (ImPACT Applications, Inc. Pittsburgh, PA). 4. ALL baseline neurocognitive results will be available to the respective athletic trainer in charge of the designated sport. Baseline neurocognitive testing results are maintained online through the ImPACT website and accessible by each respective athletic trainer in charge of the designated sport. Baseline Sideline Concussion Evaluation Protocol The immediate (sideline, on-field, locker room, etc.) evaluation of concussion has been described as a challenge given the variability of concussion presentation, difficulty in making a timely diagnosis, poor specificity and sensitivity of current assessment measures, and an over-reliance on subjective symptom reporting from the student-athlete [21]. Measures such as the SCAT 3, SAC, and KingDevick test have all been utilized as an acute sideline concussion evaluation, however all three of these measures have inherent weaknesses. Given the collegiate athletic demands for a brief and accurate sideline concussion measure, The Florida State University-Sports Medicine Department have implemented a sideline concussion evaluation tool provided in Appendix B. Baseline sideline evaluation testing will provide a comparison on an individual student-athlete basis following a suspected injury. The tool will serve as brief measure to determine whether or not a student-athlete has sustained a concussion. 7 Baseline Sideline Concussion Evaluation Procedures 1. ALL incoming student-athlete will undergo baseline evaluation with the sideline concussion evaluation prior to the beginning of their eligibility at Florida State University. 2. The tool utilized by The Florida State University-Sports Medicine Department to assess for concussion will be the sideline concussion evaluation provided in Appendix B. 3. All baseline results will be given to the respective athletic trainer in charge of the designated sport. Baseline sideline concussion evaluation results are to be kept on file as well as in a travel folder for away competition. If possible, baseline data will be entered into injury tracking software. Preseason Concussion Education Team physicians, athletic director, ALL student-athletes, coaches, and graduate assistant coaches will be provided multiple options for concussion education prior to participation in any practice or competition. Decisions may be made on a team-by-team basis at the discretion of the coaching staff of the designated sports and athletic trainer responsible for the designated sport. Preseason concussion education options may include one or more of the following; attending an educational seminar conducted by a medical provider with specific knowledge of concussion (diagnosis, assessment, treatment, and management), reviewing the NCAA Concussion Fact Sheet, and/or attending a viewing of an NCAA approved film on concussion awareness. All team physicians, athletic directors, student-athletes, coaches, and graduate assistant coaches will be provided one or more of the previous options listed to satisfy the NCAA requirements for preseason concussion education. Preseason Concussion Education Procedures (Student-Athlete) 1. Each student-athlete will be provided an opportunity to attend an educational seminar on concussion or view a concussion education film. 2. Each year EVERY student athlete will be educated with the NCAA “Concussion Fact Sheet for Student Athletes” provided in Appendix C. 3. Each student-athlete will read the fact sheet and sign a statement provided in Appendix D confirming they accept the responsibility for reporting their injuries and illnesses to The Florida State University medical staff, including signs and symptoms of concussions. Preseason Concussion Education Procedures (Team Physicians, Athletic Directors, Coaches/Graduate Assistant Coaches) 1. Each year team physicians, athletic directors, and every coach and graduate assistant coach will be provided an opportunity to attend an educational seminar on concussion or view a concussion education film. 2. Each year every coach and graduate assistant coach will be educated with the NCAA “Concussion Fact Sheet for Student Athletes” provided in Appendix E. 3. Each team physician, athletic director, coach and graduate assistant coach will read the fact sheet and will sign a statement provided in Appendix F confirming that the information on concussions was presented and they understand their role in these policies and procedures. 8 Post-Injury Plan & Procedures On-Field Management On-field management related to head and cervical injuries should always be directed by a Florida State University team physician when present. Certified athletic trainers, emergency medical staff (EMTs), and other team medical designees should defer to medical management directives provided by designated Florida State University team physicians. In the case of a Florida State University team physician being absent, the certified athletic trainer responsible for the injured student-athlete should direct injury management with the assistance of emergency medical staff when present. On-Field Management Procedures 1. The initial step in the management of a collapsed student-athlete should be an assessment of the student-athlete’s airway, breathing, and heart function (circulation). 2. This should be followed by a physical examination to rule out a cervical spine injury. a. If a cervical spine injury cannot be ruled out, neck immobilization and immediate transfer to an emergency department capable of advanced neuroimaging and management of cervical trauma should occur. 3. This should be followed by a physical examination to rule out more severe brain injury. a. If more severe brain injury cannot be ruled out, emergency transfer to an emergency department should also occur. Signs of more severe brain injury include; deteriorating mental status, focal neurological findings, abnormal or unequal pupil reaction, abnormalities with extra-ocular movements (upbeat nystagmus), and/or worsening of symptoms. The Glasgow-Coma Scale <13 guidelines will be followed. 4. If a cervical spine injury and/or more severe brain injury can be ruled out with a physical examination, then an on-site evaluation may be initiated. On-Site Evaluation and Management Any student-athlete suspected of having sustained a concussion should be immediately removed from play and evaluated by a licensed medical provider trained in the diagnosis and management of concussion. It is important to utilize a standardized approach which takes into account cognition, signs of concussion, symptoms of concussion, and vestibular –ocular functioning. On-Site Evaluation and Management Procedures 1. If a student-athlete is suspected of having sustained a concussion following signs of concussion or reporting symptoms of concussion, they will be removed from practice/competition as early as feasible with safety to the student-athlete in mind. 2. The student-athlete will be escorted to a safe location (sideline, locker room, or other on-site facility) by an ATC, team physician, and/or designee for further evaluation. 9 3. The student-athlete will undergo a concussion evaluation by the ATC, team physician, and/or designee utilizing cognitive, vestibular/balance, and ocular screening measures. The Glasgow-Coma scale <13, BESS, and or King-Devick Test will be used on a case by case basis. 4. The student-athlete’s performance on evaluation measures will be compared with baseline data (if available) to provide increased accuracy in concussion diagnosis. 5. A collaborative decision will be made by the ATC, team physician, and/or designee regarding the diagnosis of concussion and whether a removal from play decision will be made. If a disagreement exists between the ATC, team physician, and/or designee, all final decisions will be made by the team physician. a. In the event that the ATC and/or designee believe that the student-athlete and has sustained a concussion and the team physician does not believe the student-athlete has sustained a concussion, an open discussion should occur with all parties reviewing concussion related data including; risk factors, immediate signs, immediate symptoms, Sideline Concussion Evaluation results, and any other pertinent information related to the suspected injury. After this discussion has occurred, the diagnosis of concussion remains a medical decision and the determination of whether a student-athlete has or has not sustained a concussion will be made by the team physician. b. In the event that the team physician believes the student-athlete has sustained a concussion and the ATC and/or designee does not believe the student-athlete has sustained a concussion, an open discussion and review of the data mentioned above should occur. After this discussion has occurred, the diagnosis of concussion remains a medical decision and the determination of whether a student-athlete has or has not sustained a concussion will be made by the team physician. i. If the ATC, team physician, and/or designee determine the student-athlete has not sustained a concussion following evaluation and a concussion has not been diagnosed by the team physician, the student-athlete will be permitted to return to play. ii. If the ATC, team physician, and/or designee determine the student-athlete has sustained a concussion following evaluation, the student-athlete will be diagnosed with a concussion and not permitted to return to play or competition on the same day that the initial injury was sustained. 6. The ATC responsible for the student-athlete will be responsible for informing the coaching staff that the student-athlete has sustained a concussion and will not be permitted to return to play as soon as possible. 7. After removal from play has occurred, the student-athlete will be monitored by the ATC, team physician, and/or designee to assess any changes in presentation or functioning and determine if further interventions are necessary. 8. The student-athlete and an individual that lives with the student-athlete will be given specific instructions in the care of the student-athlete’s injury. If the student-athlete lives alone, there will be a staff ATC, graduate assistant ATC, and/or another teammate assigned to monitor the student-athlete’s status overnight. The person responsible for the student-athlete will be given a concussion take home sheet provided in Appendix G with directions to follow. 1 Follow-Up Procedures 1. Within 72 hours following the injury, the student-athlete will undergo a clinical evaluation by the team physician and/or designee. The clinical concussion evaluation may consist of a n y o r a l l o f t h e f o l l o w i n g ; cognitive testing (ImPACT), symptom assessment, vestibular-ocular functioning, balance, and/or any other assessment measures deemed necessary by the team physician and/or designee. 2. The team physician and/or designee will provide the athlete and ATC responsible for the student-athlete with a treatment plan consisting of physical exertion tolerance, academic/cognitive tolerance, medications (if necessary), physical therapy recommendations, a future evaluation timeline, and/or any other interventions deemed necessary by the team physician and/or designee. 3. The ATC assigned responsible for the student-athlete will be responsible for contacting “Student Academic Services” and notifying them that the student-athlete may have academic difficulties following concussion. A recommendation from the team physician and/or designee to the ATC responsible for the student-athlete will be made regarding class attendance. 4. The team physician and/or designee will provide recommendations to the ATC responsible for the student-athlete regarding a physical exertion progression and allotted physical exertion that the student-athlete will be able to tolerate. The Florida State University-Sports Medicine Concussion Exertion Program is provided in Appendix H. Post-Injury General Guidelines • • • • • All of the steps provided in the Post-Injury Plan and Procedures need to be properly documented and stored into Injury Zone. All papers need to be signed by the student-athlete and the certified ATC responsible for the injured student-athlete. Guidelines and clinical experience with concussion by the ATC, team physician, and/or designee will be considered when making a concussion: o Diagnosis o Removal from play decision o Return to play decision o Clinical recommendations (medication, physical therapy, etc.) o Physical exertion progression o Academic/cognitive exertion progression The goal in managing student-athletes that have sustained a concussion is to prevent a catastrophic outcome and to return the student-athlete to competition in a manner that minimizes both, the possibility of second-impact syndrome (SIS) or more severe head injury, while minimizing the amount of time lost from competition. ALL student-athletes with a protracted (> 21 days) recovery times will undergo an evaluation with team physician. 10 Return-to-Learn 1. Jeronimo Boche, ATC Assistant Athletic Trainer (Football) is the point person when it comes to matters of the Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan. 2. The concussion multi-disciplinary team consists of but is not limited to the following individuals: Dr. Kris Stowers, MD (team physician); Dr. Scott Burkhart, PsyD (team neuropsyochologist); Jeronimo Boche, ATC (point ATC with concussions); Dr. Pamela Perrewe, PhD (faculty athletic representative); the Student-Athletic Academic Services staff; staff athletic trainers for each sport; head and assistant coaches for each sport; FSU Athletic Department psychologist consultants will also be made available when needed. 3. Upon diagnosis of a concussion a letter will provided to the student-athlete’s academic advisor in Student-Athletic Academic Services (SAAS). a. The student-athlete will be removed from ALL classroom activity on the day of mTBI onset. b. The academic advisor will provide this letter to the student-athlete to be provided to professors, counselors and tutors. c. The letter will state the name of the student-athlete, date of onset, definition of concussion, concussion education including signs and symptoms, date of follow-up appointment for student-athlete with team physicians, and any recommendations for academic accommodations. d. After each follow-up appointment a new letter will be provided to the studentathlete’s academic advisor from SAAS. The letter will provide an up-to-date individualized initial plan that outlines recommendations for academic accommodations including but not limited to: i. Class attendance recommendations ii. Gradual return to classroom/studying as tolerated by symptoms iii. Possibly extending time requirements for completion of assignments, quizzes and/or exams. iv. Accommodations will be requested for a period of up to two weeks. v. For those individuals who encounter symptom duration lasting longer than two-weeks, a follow-up with the appropriate members of the multidisciplinary team will be arranged. 4. The Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan is implemented in accordance to the Americans with Disabilities Act Amendments Act of 2008. a. Campus resources will be utilized in accordance with the ADAAA when needed. These include but are not limited to: i. Learning specialists ii. Office of disability services iii. ADAAA office 11 Return to Play: The Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan takes an active and safe approach in the return to play progression of every FSU student-athlete. A step-wise process will be followed in the Exertional Progression Protocol. 1. Upon clearance from team physician and/or his designee the process to return to play will be initiated as tolerated. 2. As symptoms allow patient will be allowed to return to begin activity in a quiet environment, non-contact, limit head/neck movement and position change, limit cognitive demand. If tolerated the next step will be: 3. Exercise in normal gym environment, allow for minor positional changes and head/neck movements, minor cognitive demand (counting exertion reps). If symptoms do not return: 4. Indoor/Outdoor training, initiate strength/conditioning, and dynamic balance exercises. Increased cognitive demand (visual demand). 5. Return to sport specific practice/training, non-contact 6. Simulated contact in practice training settings with full activity. Reducing Exposure to Head Trauma: 1. The Florida State University-Sports Medicine Concussion and Mild Traumatic Brain Injury (mTBI) Management Plan utilizes education to emphasize curtailing of gratuitous head trauma and it adheres to the following: a. Inter-Association Consensus: Year-Round Football Practice Contact Guidelines b. Inter –Association Consensus: Independent Medical Care Guidelines 2. Emphasis is placed on proper technique education to both the coach and player. a. A safety first approach to sport should be taken b. Remove the head from contact as much as possible 3. It is recommended that during athletic practices full-contact be limited. a. Improper technique criticized and corrected. b. Sound technique be encouraged and positively reinforced. Concussion and head trauma is an inherent risk to sport but every attempt should be made to decrease the number of sub-concussive forces endured by the student-athlete. Every measure should be taken to ensure that the sever-intensity head impacts endured by the participating student-athlete are limited to competition. 12 References 1. McCrory P, Meewise WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport Zurich 2012. Br J Sports Med 2013;47:250-258. 2. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train 2001;3:228235. 3. Pardini J, Lovell MR, Collins MW, Moritz K, & Fu F. The post-concussion symptom scale (PCSS): a factor analysis. Br J Sports Med 2004;38:654-664. 4. McCrory P, Johnston K, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004.Br J Sports Med 2005;39:196-204. 5. Guinto G, Guinto-Nishimura Y. Post-Concussion Syndrome: A complex and under diagnosed clinical entity. World Neurosurg 2013;13:1302-1308. 6. McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290:2556-2563. 7. McCrea M, Kelly J, Randolph C, et al. Immediate neurocognitive effects of concussion. Neurosurgery 2002;50:1032-1042. 8. Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players. JAMA 2003;290:2549-2555. 9. McCrea M, Hammeke T, Olsen G, et al. Unreported concussion in college and high school football players: implications for prevention. Clin J Sports Med 2004;14:13-17. 10. Schulz MR, Marshall SW, Mueller FO, et al. Incidence and risk factors of concussion in high school athletes. Am J Epidemiol 2004;160:937-944. 11. Bruce JM, Echemendia RJ. Concussion history predicts self-reported symptoms before and following a concussive event. Neurology 2004;63:1516-1518. 12. Iverson GL, Gaetz M, Lovell MR, et al. Cumulative effects of concussion in amateur athletes. Brain Inj 2004;18:433-443. 13. Collins MW, Grindel SH, Lovell MR, et al. Relationship between concussion and neuropsychological performance in college football players. JAMA 1999;282;964-972. 14. Kinart CM, Cuppett MM, Berg K, et al. Prevalence of migraines in Division I male and female basketball players. NCAA. Headache 2002;42:620-629. 15. Pellman EJ, Powell JW, Viano DC, et al. Concussion in professional football: epidemiological features of game injuries and review of the literature. Neurosurgery 2004;54:86-94. 16. Schatz P. Long-term test-retest reliability of baseline cognitive assessments using ImPACT. AJSM 2010;38(1):47-53. 17. Elbin RJ, Schatz P, Covassin T. One-year test-retest reliability of the online version of ImPACT in high school athletes. AJSM 2011;39(11):2319-2324. 18. Schatz P, Glatts C. “Sandbagging” baseline test performance on ImPACT, without detection, is more difficult than it appear. Arch Clin Neuropsych 2013;28(3):236-244. 19. Schatz P, Ferris CS. One-month test-retest reliability of the ImPACT test battery. Arch Clin Neuropsych 2013;28(5):499-504. 13 20. Harmon KG, Drezner JA, Gammons M, et al. American medical society for sports medicine position statement: Concussion in sport. BJSM 2013;47:15-26. 21. Putukian M, Raftery M, Guskiewicz K, Herring S, Aubry M, Cantu RC, & Molloy M. Onfield assessment of concussion in the adult athlete. BJSM 2013;47(5):285-288. 14 Appendix A Florida State University-Sports Medicine Department Concussion Risk Factors Questionnaire Demographics Name: Age: Date of Birth: Position: Relevant History Y=Yes N=No 1. Have you ever been diagnosed with a concussion? If no, skip to Question 5. 2. If yes to Question 1, how many times? 3. If yes to Question 1, how many times did you lose consciousness? 4. If yes to Question 1, how many times did you have memory problems following a concussion? 5. Do you have a history of migraine headaches? DK=Don’t Know Y N DK 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5 6 7 8 9 10+ Y N DK 6. Does anyone in your family have a history of migraine headaches? Y N DK 7. Do you have a history of car sickness or motion sickness? Y N DK 8. Does anyone in your family have a history of motion sickness? Y N DK 9. Do you have a history of seizures or epilepsy? Y N DK 10. Does anyone in your family have a history of seizures or epilepsy? Y N DK Appendix A Florida State University-Sports Medicine Department 11. Do you have a history of lazy eye or cross eye? Y N DK 12. Does anyone in your family have a history of lazy eye or cross eye? Y N DK 13. Do you have a history of ADD or ADHD/ Y N DK 14. Did you ever take medication for ADD or ADHD? Y N DK 15. Are you currently taking medication for ADD or ADHD? Y N DK 16. Does anyone in your family have a history of ADD or ADHD? Y N DK Y N DK Y N DK Y N DK 20. Did you ever take medication for a psychological condition? Y N DK 21. Are you currently taking medication for a psychological condition? Y N DK Y N DK 17. Were you ever placed on an IEP or 504 Plan in school for a diagnosed learning disability? 18. Has anyone in your family ever been placed on an IEP or 504 Plan in school for a diagnosed learning disability? 19. Have you ever been diagnosed with a psychological condition (Anxiety, etc.)? 22. Has anyone in your family ever been diagnosed with a psychological condition? Sideline Concussion Evaluation (SCE) General On-Field Management Guidelines 1. The initial step in the management of a collapsed athlete should be an assessment of the athlete’s airway, breathing, and cardiac functioning (circulation). 2. This should be followed by a physical examination to rule out any severe cervical spine injury. a. If a cervical spine injury cannot be ruled out, neck immobilization and immediate transfer to an emergency department capable of advanced neuroimaging and management of cervical trauma should occur. 3. This should be followed by a physical examination to rule out more severe brain injury. a. If more severe brain injury cannot be ruled out, emergency transfer to an emergency department should also occur. Signs of more severe brain injury include; deteriorating mental status, focal neurological findings, abnormal or unequal pupil reaction, abnormalities with extra-ocular movements (upbeat nystagmus), and/or worsening of symptoms. 4. If a cervical spine injury and/or more severe brain injury can be ruled out with a physical examination, then an on-site evaluation of concussion may be initiated. 5. Any athlete suspected of having sustained a concussion should be immediately removed from play as early as feasible with the safety of the athlete in mind, and evaluated by a licensed medical provider trained in the diagnosis and management of concussions. Definition of Concussion The Zurich 2012 Consensus Statement provides the following definition of concussion. Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathophysiologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neural-pathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies (CT/MRI). 4. Concussion results in a set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged [1]. Further, a concussion results in a complex neural-metabolic cascade involving ionic, metabolic and physiologic events. This results in an increased demand for glucose; and a decrease in cerebral blood flow and metabolic rate for oxygen [2]. This metabolic dysfunction results in an energy crisis on a cellular level rather than presenting as a structural injury often visible on standard imaging such as CT or MRI. Challenges of Sideline Concussion Assessment The immediate (sideline, on-field, locker room, etc.) evaluation of concussion has been described as a challenge given the variability of concussion presentation, difficulty in making a timely diagnosis, poor specificity and sensitivity of current assessment measures, and an over-reliance on subjective symptom reporting from the student-athlete [3]. Current Sideline Concussion Assessment Measures Available Abbreviated testing measures are intended for quick and accurate concussion screening for on-site use following a suspected concussion and are not intended to replace a comprehensive clinical evaluation. On-site measures for concussion screening should also not be used as a stand-alone tool for the continued management of sports concussion. Domains Tested Duration Administrator Recommended for Baseline NFL Signs/symptoms, Sideline neuro/cervical, Tool orientation, memory, concentration, & BESS SCAT Symptoms, GCS, orientation, memory, BESS, cervical, coordination SAC Orientation, memory, exertion maneuvers, neuro exam, & concentration KingSaccadic tracking, Devick attention, & language 10-12 minutes ATC & MD Yes Recommended for Post-Injury Management No 12-15 minutes ATC, MD, Neuropsych, & Coach Yes No 5-7 minutes ATC, MD, Neuropsych, & Coach Yes No 2 minutes Yes Yes BESS 5 minutes ATC, MD, Neuropsych Parent, & Coach ATC & MD Yes Yes Balance Limitations of Current Sideline Measures Available Orientation questions (date, place, time, etc.) have shown to be unreliable in the sports setting when compared to memory assessment [4, 5]. Balance testing and modified BESS scoring is a specific indicator of balance disturbance and possible indicator of concussion, but lacks sensitivity and interrelator reliability [6]. The King-Devick test has been utilized as a sideline evaluation of concussion to monitor changes in eye tracking from baseline functioning [7-12]. However, the King-Devick test is an assessment of eye tracking and saccadic eye movement and may not be a comprehensive assessment of concussion. Athlete symptom reporting following a concussion may not be a reliable source of information given as few as 30% of athletes report their symptoms after sustaining a concussion resulting in a large number of undiagnosed concussions [13]. Benefits of Current Sideline Measures Available Brief neuropsychological test batteries to assess cognitive domains such as; attention, concentration, and memory have been shown to be practical and effective in concussion evaluation. These tests include the SCAT 3 [14] and SAC [15-17]. Military studies have suggested the need to implement the assessment of saccadic eye tracking and eye pursuit movements with soldiers who sustain blast and non-blast related TBI [18] similar to domains assessed with the King-Devick Test. Vestibular-Ocular Dysfunction Post-Concussion Some dizziness following a concussion may be due to labrynth causes (vertigo/BPPV) and nonlabrynthe causes. Non-labrynthe causes may be the result of structural or micro structural central nervous system injury or more complicated interactions between migraine and anxiety [19]. Military studies of blast related mTBI have encouraged the assessment of; near point convergence, saccades, and eye pursuit movements [18]. When gaze stability testing, vestibular-ocular reflex testing, and convergence testing are combined, results indicate 89% accuracy of identifying patients with concussion [20]. Vestibular-ocular motor screening (VOMS) assessment may be a complimentary tool to balance testing [20]. Provocation of symptoms during VOMS assessment may represent useful cutoffs in the assessment of concussion [20]. A Case for Something New The ideal sideline concussion measure should include; attention, concentration, memory, vestibular, and ocular assessment. Further, symptom reporting associated with sideline concussion assessment may be beneficial when based on clinically significant cut-offs and specific to provocation or increase during sideline assessment. An ideal sideline concussion assessment tool should have baseline utility, acute (sideline) utility, and be clinically relevant to follow-up treatment and injury management. Sideline Concussion Evaluation (SCE) The SCE was created as a brief (under 5 minutes), comprehensive, and accurate evaluation for on-site and sideline assessment of concussion in sport. The SCE integrates cognitive, vestibular, and ocular (including saccadic eye movement) testing. More specifically, the following domains of functioning are assessed; concentration, attention, immediate memory, saccadic eye functioning, gaze stability testing, vestibular ocular reflex cancellation, convergence, and recall memory. Symptoms reported are specific to clinically significant cut-off scores that have been empirically validated. The SCE has utility as a baseline measure, acute (sideline) measure, and is based on assessment measures consistent with a comprehensive clinical concussion evaluation. The SCE utilizes vestibular and ocular motor screening measures that have been validated to differentiate from healthy controls. Further, vestibular and ocular motor screening included in the SCE is an objective clinical test and relatively devoid of athlete manipulation. The SCE has been created for the utilization of ATCs, MDs, and medical personnel affiliated with collegiate and professional sports teams who have undergone specific training on how to properly use the SCE. References 1. McCrory P, Meewise WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport Zurich 2012. Br J Sports Med 2013;47:250258. 2. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train 2001;3:228-235. 3. Putukian M, Raftery M, Guskiewicz K, Herring S, Aubry M, Cantu RC, & Molloy M. On-field assessment of concussion in the adult athlete. BJSM 2013;47(5):285-288. 4. Maddocks D, Dicker G, Saling NM. The assessment of orientation following concussion in athletes. Clin J Sports Med 1995;5:32-35. 5. McCrea M, Kelly J, Kluge J, et al. Standardized assessment of concussion in football players. Neurology 1997;48:586-588. 6. Harmon KG, Drezner JA, Gammon M, et al. American Medical Society for sports medicine position statement: concussion in sport. Br J Sports Med 2013;47(1):15-26. 7. Galetta M, Galetta K, McCrossin J, et al. Saccades and memory: baseline associations of the King-Devick and SCAT 2 SAC tests in professional ide hockey players. J Neurol Sci 2013;328(12):28-31. 8. Handmaker H, Waldorf RA. Comment: the King-Devick test and sports-related concussion: study of a rapid visual screening tool in a collegiate cohort. J Neurol Sci 2013;327(1-2):80. 9. Balcer LJ, Galetta SL. In reply: the King-Devick test and sports-related concussion: study of a rapid visual screening tool in a collegiate cohort. J Neurol Sci 2013;327(1-2):81. 10. King D, Brughelli, M, Hume P, Gissane, C. Concussions in amateur rugby union identified with the use of a rapid visual screening tool. J Neurol Sci 2013;326(1-2):59-63. 11. Galetta K, Brandes LE, Maki K, et al. The King-Devick test and sports-related concussion: study of a rapid visual screening tool in a collegiate cohort. J Neurol Sci 2011;309(1-2):34-39. 12. Galetta K, Barrett J, Allen M, et al. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology 2011;76(17):1456-1462. 13. Meehan WP, Mannix RC, O’Brien MJ, Collins MW. The prevalence of undiagnosed concussions in athletes. Clin J Sports Med 2013;23(5):339-342. 14. Maddocks D, Dicker G. An objective measure of recovery from concussion in Australian rules footballers. Sport Health 1989;7:6-7. 15. McCrea M. Standardized mental status assessment of sports concussion. Clin J Sport Med 2001;11:176-181. 16. McCrea M, Kelly J, Randolph C, et al. Standardized assessment of concussion (SAC): on site mental status evaluation of the athlete. J Head Trauma Rehab 1998;13:27-36. 17. McCrea M, Randolph C, Kelly J. The standardized Assessment of Concussion (SAC): manual for administration, scoring, and interpretation. 2nd ed. Waukesha, WI, 2000. 18. Capo-Aponte, JE, Urosevich, TG, Temme, LA et al., Visual dysfunctions and symptoms during the sub-acute state of blast-induced mild traumatic brain injury. Mil. Med. 2012 Jul;177(7):804-13. 19. Fife, T. & Giza, C. Posttraumatic vertigo and dizziness. Semin. Neurol. 2013 Jul;33(3):238-43. 20. Mucha A, Collins MW, Furman J, Troutman-Enseki C, DeWolf R, & Marchett G. Brief vestibular and ocular motor screening (VOMS) assessment: Preliminary findings in patients following sports-related concussion. In Press. Appendix B: Sideline Concussion Evaluation 1. Concentration Repeat the months of the year backwards starting with the current month. (Dec, Nov, Oct, Sep, Aug, Jul, Jun, May, Apr, Mar, Feb, Jan) 2. Attention (Say the digits, ideally one digit per second. Ask the student-athlete to wait to repeat the digits until you have completed the entire sequence of digits. Then have the student-repeat the digits back to you. All 4 trials of forwards digits, then all 4 backward digits) Forwards 2-7 3-9-4 8-1-6-2 5-9-7-4-3 Backwards 5-9 (9-5) 8-3-6 (6-3-8) 1-9-4-7 (7-4-9-1) 3. Immediate Memory (Choose one of the lists, say each of the words once, then have the student-athlete repeat the list back to you). List 1 Tractor Carrot Necklace List 2 Airplane Onion Pendant 4. Vestibular Functioning Gaze Stability [Horizontal] Eyes fixed on the thumb, move the head back Upon completion of the exercise, ask the and forth as if the student athlete is saying student-athlete if they are feeling any increase “no”, continue for 15 seconds. in dizziness or fogginess. [Rate 0-10] Gaze Stability [Vertical] Eyes fixed on the thumb, move the head up Upon completion of the exercise, ask the and down as if the student-athlete is saying student-athlete if they are feeling any increase yes, continue for 15 seconds. in dizziness or fogginess. [Rate 0-10] Vestibular Ocular Reflex Cancellation Arm extended, thumb up, rotate the upper Look for observable difficulty tracking the body 180 degrees keeping the eyes focused on thumb as the student-athlete rotates their the thumb. upper body. [Rate 0-10] 5. Ocular Functioning H-Test Fixation stick, focus on the red dot, head still. Look for provoked nystagmus or shaking of ATC moves the stick in an “H” pattern as the the eyes. The student-athlete may squint/rub student-athlete follows. eyes upon completion of the task. Saccades [Horizontal] ATC holds both index fingers laterally, Look for provoked nystagmus or shaking of shoulder width apart. Head still, studentthe eyes. The student-athlete may squint/rub athlete moves eyes back and forth for 10 eyes upon completion of the task. Count the seconds. number of times the target is hit in 10 seconds. Saccades [Vertical] ATC holds both index fingers vertically, Look for provoked nystagmus or shaking of shoulder width apart. Head still, studentthe eyes. The student-athlete may squint/rub athlete moves eyes back and forth for 10 eyes upon completion of the task. Count the seconds. number of times the target is hit in 10 seconds. Convergence Fixation stick, focus on the white dot, ask the Look for an exophoria (one eye deviating student-athlete to report when they see 2 away from the nose) or isophoria (one eye white dots. deviating towards the nose) when the studentathlete sees 2 dots. [Anything over 10cm is abnormal] 6. Delayed Memory (Ask the student-athlete to recall all words from the designated list from Immediate Memory task). ANY POSITIVE FINDINGS OR INCORRECT RESPONSE IS INDICATIVE OF CONCUSSION AND PRECLUDES RETURN TO PLAY. Appendix B: Sideline Concussion Evaluation Loss of Consciousness (LOC): LOC may be an indicator of severity of injury. LOC for a few seconds to a few minutes is likely indicative of concussion/mTBI. Prolonged LOC which occurs for several minutes to hours is likely indicative of more severe traumatic brain injury and should receive immediate emergency medical attention. Seek immediate emergency medical attention if the following signs are observed: Repeated Vomiting Severe Disorientation/Confusion Slurred Speech Combative/Unusual Behavior Clear Fluid Draining from Ears/Nose Convulsions/Seizures Common Observable Signs of Concussion: Appears Dazed/Stunned Forgets Events Before the Trauma Vomiting Eye Rubbing/Squinting/Attempts to Clear Vision Shaking of the Head to Clear Vision Common Symptoms of Concussion: Pressure Base Headache Nausea Blurry Vision Fogginess Problems Concentrating Fatigue Irritability One Large Pupil/One Small Pupil Loss of Coordination Weakness/Numbness in Fingers/Toes Confusion About Plays/Assignments Forgets Events After the Trauma Moves Clumsily Holding of the Head Following Trauma Loss of Consciousness “Fencing”/Seizure Response Loses Balance Makes Uncharacteristic Mistakes Appears Foggy/In a Haze Behavior/Personality Change Sensitivity to Light Dizziness Double Vision Feeling “Slowed Down” Problems Remembering Drowsiness Numbness or Tingling Sensitivity to Noise Visual Aura (sees different colors) Black/White Vision Not feeling “Right”/”Off” Balance Problems Feeling “More Emotional” Sadness/Nervousness General Concussion Management Guidelines: 1. 2. 3. Any positive findings during the Sideline Concussion Evaluation (SCE) are indicative of a concussion diagnosis and the student-athlete should immediately be removed from play and not return to activity until evaluated by a team physician or designated medical professional trained in concussion treatment and management. Any student-athlete diagnosed with a concussion is not to return to competition on the same day. Observable signs of concussion witnessed by a member of the Florida State University Sports Medicine Staff should be interpreted as a possible concussion and the student-athlete should be evaluated using the Sideline Concussion Evaluation (SCE) as soon as feasible. ANY POSITIVE FINDINGS OR INCORRECT RESPONSE IS INDICATIVE OF CONCUSSION AND PRECLUDES RETURN TO PLAY. CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A CONCUSSION? A concussion is a brain injury that : • Is caused by a blow to the head or body. - From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball . • Can change the way your brain normally works. • Can range from mild to severe. • Pre ents itself differently for each athlete. • Can occur during practice or competition in A NY sport. • Can happen even if you do not lo e consciousness . HOW CAN I PREVENT A CONCUSSION? Basic steps you can take to protect yourself from concu sion : • Do not initiate contact with your head or helmet. You can till get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting , flying elbows, stepping on a head , checking an unprotected opponent, and sticks to the head all cause concussions . • Follow your athletics department ' rule for afety and the rules of the sport. • Practice good sport man hip at all time . • Practice and perfect the skill of the sport. WHAT ARE THE SYMPTOMS OF A CONCUSSION? You can't see a concussion, but you might notice some of the symptom s right away. Other symptoms can show up hours or days after the inj ury. Concussion symptoms indude: • Amn esia. • Confusion . • Headache. • Los of consciousness. • Balance problems or 4 weeks) in order to consider additional diagnosis (i.e. post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression, ocular or vestibular dysfunction, etc...) and best management options.  Student-athletes that experience prolonged recoveries following concussion may be allowed to complete light, low-risk physical and cognitive activities that do not worsen symptoms at the discretion of the team physician. § 6 Month Follow-Up: If feasible, obtain a symptom checklist, balance exam, neuropsychological exam at a minimum (unless directed otherwise by physician and/or neuropsychologist). § UGAA will have on file and annually update an emergency action plan for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses. All athletics healthcare providers and coaches shall review and practice the plan annually. These sessions will be conducted prior to the start of the sport season. The UGAA sports medicine department and the compliance office will maintain a list of staff that have completed the requirement on file. Return to Learn: § Academic advisors and professors will be notified of student-athlete’s concussion (Appendix 7), with permission for release of information from the student-athlete. If necessary, appropriate academic accommodations will be made to help the studentathlete strike an optimum balance between rest and continued academic progress during recovery.18 § UGAA will utilize a return-to-learn management plan that specifies: § The sports medicine staff, in conjunction with Athlete Academic Services, will navigate return-to-learn with the student-athlete. § A multi-disciplinary team, including, but not be limited to: team physician, athletic trainer, psychologist/counselor, neuropsychologist consultant, faculty athletic representative, academic counselor, course instructor(s), college administrators, office of disability services representatives, and coaches will navigate more complex cases of prolonged return-to-learn. § Academic accommodations will be in line with the Americans with Disabilities Act Amendments Act (ADAAA) § Student-athletes will not participate in classroom activity on same day as concussion. § Each student-athlete will receive an individualized initial plan based on their clinical presentation that includes directions regarding: o Remaining at home/dorm if student-athlete cannot tolerate light cognitive activity. o Gradual return to classroom/studying as tolerated. § Student-athletes will be re-evaluated by their team physician if concussion symptoms worsen with academic challenges. § Modification of schedule/academic accommodations may be made for student-athletes for up to two weeks, as indicated, with help from specific academic advisor, under the direction of the senior associate athletic director of academic services. § Student-athletes will be re-evaluated by their team physician and members of the multi-disciplinary team, as appropriate if symptoms persist longer than two weeks following injury. § Campus resources such as UGA’s Disability Resource Center and the associate dean of student affairs will be utilized for cases that cannot be managed through schedule modification/academic accommodations. Return to Play: § When medically cleared by physician, repeat exertional testing; re-evaluation by physician for return to play decision § Final determination of return-to-play is from the team physician or medically qualified physician designee. § Each student-athlete with concussion must undergo a supervised stepwise progression management plan by a health care provider with expertise in concussion (Appendix 8) § Student-athletes will review and sign the Concussion Return to Athletic Activity Acknowledgement (Appendix 9) prior to return to play § Equipment evaluation and refitting should be considered prior to full return to contact for equipment laden sport. Reducing Exposure to Head Trauma: § Athletics staff, student-athletes and officials will continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted. § All coaches receive first aid/CPR training which includes review of the concussion and safety issues in sport. § A SEC Concussion Education poster is posted in all locker rooms. § Although “reducing” may be difficult to quantify, it is important to emphasize ways to minimize head trauma exposure. Examples of minimizing head trauma exposure include, but are not limited to: § Adherence to Inter-Association Consensus: Year-Round Football Practice Contact Guidelines § Adherence to Inter-Association Consensus: Independent Medical Care Guidelines § Reducing gratuitous contact during practice § Taking a ‘safety first’ approach to sport § Taking the head out of contact § Coaching and student-athlete education regarding safe play and proper technique Administrative: § UGAA will submit an institutional concussion management plan to the NCAA Concussion Safety Protocol Committee by May 1 of each calendar year, accompanied by a written certificate of compliance signed by the director of athletics. § UGAA sports medicine staff members and other athletics healthcare providers will practice within the standards as established for their professional practice (e.g., team physician7, certified athletic trainer8, physical therapist, nurse practitioner, physician assistant, neurologist9, neuropsychologist10). § UGAA sports medicine staff members shall have the exclusive empowerment to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. Conflicts or concerns will be forwarded to the director of sports medicine and the head team physician for remediation. § UGAA will document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion. Aggregate concussion numbers per sport will be reported to the director of athletics and deputy director annually. Approved by: ________________________ Medical Director Fred Reifsteck, M.D. Date: ________________ Approved by: Date: _______________ _______________________ Neurosurgeon Kim Walpert, M.D. Approved by: ________________________ Dir. Sports Medicine Ron Courson, ATC, PT, NREMT-I, CSCS Date: ________________ Approved by: _______________________ UGA Concussion Research Laboratory Directory Julianne Schmidt, PhD, ATC Date: ________________ Approved by: _______________________ Neuropsychologist Kate Finley, PhD Date: ________________ Approved by: ________________________Emergency Medical Director Glenn Henry, MA, EMT-P Date: ________________ Reference Documents 1. NCAA and CDC Educational Material on Concussion in Sport. Available online at www.ncaa.org/health-safety 2. NCAA Sports Medicine Handbook. 2009-2010. 3. National Athletic Trainers’ Association Position Statement: Emergency Planning in Athletics. Journal of Athletic Training, 2002; 37(1):99–104. 4. Sideline Preparedness for the Team Physician: A Consensus Statement. 2000. Publication by six sports medicine organizations: AAFP, AAOS, ACSM, AMSSM, AOSSM, and AOASM. 5. Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics. National Athletic Trainer’s Association. 2000. Revised 2003, 2007, 2010. 6. Consensus Statement on Concussion in Sport 4th International Conference on Concussion in Sport Held in Zurich, November 2012. Clinical Journal of Sport Medicine, 2013; 23(2):89-117. 7. Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement. 2006. Publication by six sports medicine organizations: AAFP, AAOS, ACSM, AMSSM, AOSSM, and AOASM. 8. National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion. Journal of Athletic Training (Allen Press). 2014;49:245-265. 9. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology, 1997; 48:581-5. 10. Neuropsychological evaluation in the diagnosis and management of sports-related concussion. National Academy of Neuropsychology position paper. Moser, Iverson, Echemendia, Lovell, Schatz, Webbe, Ruff, Barth. Archives of Clinical Neuropsychology, 2007; 22:909–916. 11. Who should conduct and interpret the neuropsychological assessment in sports-related concussion? Echemendia RJ, Herring S, Bailes J. British Journal of Sports Medicine, 2009; 43:i32-i35. 12. Test-retest reliability of computerized concussion assessment programs. Broglio SP, Ferrara MS, Macciocchi SN, Baumgartner TA, Elliott R Journal of Athletic Training, 2007; 42(4):509-514. 13. Sensitivity of the concussion assessment battery. Broglio SP, Macciocchi SN, Ferrara MS. Neurosurgery. 2007;60(6):1050-7. 14. Sensitivity and specificity of the impact test battery for concussion in athletes. Schatz P, Pardini JE, Lovell MR, Collins MW, Podell K. Arch Clin Neuropsychol. 2006;21(1):91-99. 15. The "Value added" Of neurocognitive testing after sports-related concussion. Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. Am J Sports Med. 2006;34(10):1630-1635. 16. One-year test-retest reliability of the online version of impact in high school athletes. Elbin RJ, Schatz P, Covassin T. Am J Sports Med. 2011;39(11):2319-2324. 17. Long-Term Test-Retest Reliability of Baseline Cognitive Assessments Using ImPACT. Schatz P. Am J Sports Med. 2010; 38(1): 47-53. 18. Supporting the Student-Athlete’s return to classroom after a sport-related concussion. McGrath N. Journal of Athletic Training, 2010; 45(5):492-498. 19. 2002. Publication by six sports medicine organizations: AAFP, AAOS, ACSM, AMSSM, AOSSM, and AOASM. Table of Appendices Appendix 1: Concussion Management Checklist Appendix 2: NCAA Concussion Information Fact Sheets Appendix 3: Student-Athlete Concussion Statement Appendix 4: Concussion Symptom Checklist Appendix 5: Within 6-Hour Assessment Packet Appendix 6: Concussion Patient Information Sheet Appendix 7: Concussion Academic Notification Letter Appendix 8: Exertional Testing Protocol Following Concussion Appendix 9: Concussion Return to Athletic Activity Acknowledgement Appendix 1 University of Georgia Sports Medicine Concussion Management Checklist/CQI Name: __________________________ 81____________ DOB: ________ Sport (position): ___________________ Injury Date: _________ Injury Time: ___:___ am/pm □ Game □ Practice □ Other: _____________________________ Mechanism of Injury: ________________________________________________________________________________ __________________________________________________________________________________________________ Pertinent PMH: □ History of prior concussions; if so, how many: ___ Date of most recent prior concussion: _______ □ LOC with prior concussion □ Hospitalization with prior concussion □ Prior brain imaging tests: _______________ Medications currently taking: __________________________________________________________________________ Additional Risk Factors: □ Migraines □ Learning disability/dyslexia □ ADD/ADHD □ Seizure disorder □ Depression, anxiety or other psychiatric disorder □ Family history of risk factors: __________________________ Within 6 hours PI testing: □ symptom checklist □ BESS □ SAC (Appendix 5) Diagnostic testing: □ x-ray □ CT scan □ MRI Other: ____________________________________________________ Medical Referral: □ Primary care sports medicine physician: Date: ______ Results: _________________________________________ □ Neurologist Date: ______ Results: __________________________________________________________ □ Neurosurgeon Date: ______ Results: __________________________________________________________ □ Neuropsychologist Date: ______ Results: __________________________________________________________ □ Other: __________ Date: ______ Results: __________________________________________________________ Date/Clinician: □ Athlete Education: reviewed injury, common S&S of concussion, management plan (Appendix 6) _____________ □ Concussion information sheet: provided to athlete/other responsible party(ies); signature obtained _____________ □ Establish plan for follow up communication over next 24 hour _____________ □ Tylenol provided and □ DHA Omega 3 supplementation provided (optional) _____________ □ Parents/guardians contacted: individual spoken to: ___________________________________ _____________ □ Sport coach contacted: individual spoken to: _________________________________________ _____________ □ Academic support staff contacted: individual spoken to: _______________________________ _____________ □ Concussion information letter sent to academic support staff (Appendix 7) _____________ □ 24-48 Hours PI testing: □ symptom checklist □ balance □ neuropsych: ________ □ King-Devick _____________ □ Symptom Checklist (Appendix 4): reviewed daily 1-on-1 with clinician: Date: __/__/__: Duration/Severity Scores __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ __/__/__: D:____ S:____ □ Asymptomatic on: __/__/__ _____________ Asymptomatic testing: □ symptom checklist □ balance □ Neuropsych: ________ □ King-Devick _____________ □ Cleared by physician for Exertional Testing Protocol (Appendix 8) _____________ _____________ □ Stage 1: Light exercise: ~<70% age-predicted maximal heart rate _____________ □ Stage 2: Sport-specific activities without the threat of contact from others _____________ □ Stage 3: Noncontact training involving others, resistance training _____________ □ Stage 4: Unrestricted training _____________ □ Stage 5: Non-contact or low-risk practice activities following completion of exertional protocol □ Stage 6: Limited to full contact practice _____________ □ Stage 7: Full Return to Play _____________ □ Cleared by physician for return to practice activities _____________ □ Non-contact practice activities: _________________________________________________ _____________ □ Contact practice activities: _____________________________________________________ _____________ Full RTP testing: □ symptom checklist □ balance □ neuropsych: ________ □ King-Devick _____________ □ Cleared by physician for return to competition _____________ □ Return to competition: ________________________________________________________ _____________ □ Completed return to full athletic activity acknowledgement form; signature obtained (Appendix 9) _____________ 6 Month PI testing: □ symptom checklist □ balance □ Neuropsych: ________ □ King-Devick _____________ Appendix 1 cont. Comments: _______________________________________________________________________________ __________________________________________________________________________________________   Appendix 2 CONCUSSION A fact sheet for student-athletes What is a concussion? A concussion is a brain injury that: • Is caused by a blow to the head or body. – From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. • Can change the way your brain normally works. • Can range from mild to severe. • Presents itself differently for each athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness. How can I prevent a concussion? Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport. What are the symptoms of a concussion? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. What should I do if I think I have a concussion? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. It’s better to miss one game than the whole season. When in doubt, get checked out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. Appendix 2 cont. CONCUSSION A fact sheet for Coaches The Facts • A concussion is a brain injury. • All concussions are serious. • Concussions can occur without loss of consciousness or other obvious signs. • Concussions can occur from blows to the body as well as to the head. • Concussions can occur in any sport. • Recognition and proper response to concussions when they first occur can help prevent further injury or even death. • Athletes may not report their symptoms for fear of losing playing time. • Athletes can still get a concussion even if they are wearing a helmet. • Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries, depending on the sport. What is a concussion? A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Recognizing a possible concussion To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; -AND2. Any change in the student-athlete’s behavior, thinking or physical functioning (see signs and symptoms). Signs and Symptoms Signs Observed By Coaching Staff • Appears dazed or stunned. • Is confused about assignment or position. • Forgets plays. • Is unsure of game, score or opponent. • Moves clumsily. • Answers questions slowly. • Loses consciousness (even briefly). • Shows behavior or personality changes. • Can’t recall events before hit or fall. • Can’t recall events after hit or fall. Symptoms Reported By Student-Athlete • Headache or “pressure” in head. • Nausea or vomiting. • Balance problems or dizziness. • Double or blurry vision. • Sensitivity to light. • Sensitivity to noise. • Feeling sluggish, hazy, foggy or groggy. • Concentration or memory problems. • Confusion. • Does not “feel right.” Appendix 2 cont. PREVENTION AND PREPARATION As a coach, you play a key role in preventing concussions and responding to them properly when they occur. Here are some steps you can take to ensure the best outcome for your student-athletes: • Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to-play. – Review and practice your emergency action plan for your facility. – Know when you will have sideline medical care and when you will not, both at home and away. – Emphasize that protective equipment should fit properly, be well maintained, and be worn consistently and correctly. – Review the Concussion Fact Sheet for Student-Athletes with your team to help them recognize the signs of a concussion. – Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete. • Insist that safety comes first. – Teach student-athletes safe-play techniques and encourage them to follow the rules of play. – Encourage student-athletes to practice good sportsmanship at all times. – Encourage student-athletes to immediately report symptoms of concussion. • Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death. IF YOU THINK YOUR STUDENT-ATHLETE HAS SUSTAINED A CONCUSSION: IF A CONCUSSION IS SUSPECTED: Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion. 1. Remove the student-athlete from play. Look for the signs and symptoms of concussion if your student-athlete has experienced a blow to the head. Do not allow the student-athlete to just “shake it off.” Each individual athlete will respond to concussions differently. An athlete who exhibits signs, symptoms or behaviors consistent with a concussion, either at rest or during exertion, should be removed immediately from practice or competition and should not return to play until cleared by an appropriate health care professional. Sports have injury timeouts and player substitutions so that student-athletes can get checked out. 2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the studentathlete to the appropriate athletics medical staff, such as a certified athletic trainer, team physician or health care professional experienced in concussion evaluation and management. 3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return-to-play progression should occur in an individualized, step-wise fashion with gradual increments in physical exertion and risk of contact. 4. Develop a game plan. Student-athletes should not return to play until all symptoms have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact, as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change. It’s better they miss one game than the whole season. When in doubt, sit them out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. Appendix 3 University  of  Georgia  Sports  Medicine     Student-­‐Athlete  Concussion  Statement   *If  there  is  anything  on  this  sheet  that  you  do  not  understand,  please  ask  your  athletic  trainer  or  team   physician  to  explain  it  to  you.       Student-­‐Athlete  Name  (printed):_______________________________________________________________     I  have  read  and  understand  the  NCAA-­‐CDC  Concussion  Fact  Sheet  for  Student-­‐Athletes.                  If  true,  please  check  box.   I  am  over  18  years  old.                  If  true,  please  check  box.  If  you  are  not  yet  18  years  old,  please  consult  your  team  physician  or  athletic  trainer.       Student-­‐ Athlete   Initials                           By  initialing,  you  confirm  that  you  understand  the  following  information  that  has   been  provided  to  you  about  concussions:     A  concussion  is  a  brain  injury  caused  by  a  blow  to  the  head  or  body.   A  concussion  can  change  the  way  your  brain  normally  works,  such  as  the  ability  to   think,  balance,  and  perform  classwork.     A  concussion  can  range  from  mild  to  severe.   A  concussion  can  present  itself  differently  for  each  athlete.   A  concussion  can  occur  during  practice  or  competition  in  any  sport.  A  concussion   can  also  occur  outside  of  sport.   A  concussion  can  occur  even  if  you  do  not  lose  consciousness.   You  can’t  see  a  concussion,  but  you  might  notice  some  symptoms  right  away  or   hours/days  after  the  injury.   Exercise  or  activities  that  involve  a  lot  of  concentration  may  cause  concussion   symptoms  to  reappear  or  get  worse.   I  will  tell  my  sports  medicine  staff  if  I  think  I  may  have  sustained  a  concussion.   I  will  tell  my  sports  medicine  staff  if  I  think  one  of  my  teammates  may  have   sustained  a  concussion.   I  will  not  return  to  participation  in  a  game,  practice  or  other  activity  with  symptoms.   After  a  concussion,  the  brain  needs  time  to  heal.  I  understand  that  I  am  much  more   likely  to  have  a  repeat  concussion  if  I  return  to  play  or  practice  before  concussion   symptoms  go  away.  In  rare  cases,  repeat  concussions  can  cause  permanent  brain   damage,  and  even  death.  Severe  brain  injury  can  change  my  whole  life.     __________________________________       Signature  of  Student-­‐Athlete         _____________   Date     Appendix 4 University of Georgia Sports Medicine Concussion Symptom Checklist   Name______________________________ Day of Testing: ___/___/___ Baseline: ___/___/___ Symptom Response: Symptomatic (SRS): Day 1 2 3 4 5 6 7 ____ Symptom Response: Asymptomatic (SRA): Day 1 2 3 4 5 6 7 ____ Administration Mode: Patient Administered Clinician Administered by: ______________________________ DURATION SEVERITY You should score yourself on the following symptoms, based on how you feel now. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à Sometimes Always Mild Moderate Severe 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 3. Neck Pain 1 2 3 4 5 6 1 2 3 4 5 6 4. Nausea or Vomiting 1 2 3 4 5 6 1 2 3 4 5 6 5. Dizziness 1 2 3 4 5 6 1 2 3 4 5 6 6. Blurred Vision 1 2 3 4 5 6 1 2 3 4 5 6 7. Balance Problems 1 2 3 4 5 6 1 2 3 4 5 6 8. Sensitivity to Light 1 2 3 4 5 6 1 2 3 4 5 6 9. Sensitivity to Noise 1 2 3 4 5 6 1 2 3 4 5 6 10. Feeling Slowed Down 1 2 3 4 5 6 1 2 3 4 5 6 11. Feeling like “in a fog” 1 2 3 4 5 6 1 2 3 4 5 6 12. “Don’t feel right” 1 2 3 4 5 6 1 2 3 4 5 6 13. Difficulty concentrating 1 2 3 4 5 6 1 2 3 4 5 6 14. Difficulty remembering 1 2 3 4 5 6 1 2 3 4 5 6 15. Fatigue or Low Energy 1 2 3 4 5 6 1 2 3 4 5 6 16. Confusion 1 2 3 4 5 6 1 2 3 4 5 6 17. Drowsiness 1 2 3 4 5 6 1 2 3 4 5 6 18. Trouble Falling Asleep 1 2 3 4 5 6 1 2 3 4 5 6 19. More Emotional 1 2 3 4 5 6 1 2 3 4 5 6 20. Irritability 1 2 3 4 5 6 1 2 3 4 5 6 21. Sadness 1 2 3 4 5 6 1 2 3 4 5 6 22. Nervous or Anxious TOTAL DURATION SCORE: TOTAL SEVERITY SCORE: Do the symptoms get worse with physical activity? Yes No NA Do the symptoms get worse with mental activity? Yes No NA How many hours did you sleep last night?________(hrs) Comments:__________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ 1. Headache 2. “Pressure in Head” No No No No No No No No No No No No No No No No No No No No No No Briefly Appendix 5 University  of  Georgia   Concussion  Evaluation  Program  Details  &  “Within  6  Hour”  Assessment  Packet     Baseline  Testing:  All  athletes  should  complete  baseline  testing  every  year.     Incoming  Athletes  from  Higher  Risk  Sports:  Contact:  Emily  Miller   All  incoming  athletes  from  the  sports/events  listed  below  will  report  to  the  Butts-­‐Mehre  Concussion  Research   Laboratory  (Butts-­‐Mehre)  to  complete  baseline  testing  prior  to  their  season  of  play:   • Baseball   • Football   • Soccer   • Basketball   • Gymnastics   • Softball   Returning  Athletes  from  Higher  Risk  Sports  &  All  Athletes  from  Lower  Risk  Sports:  Contact:  Emily  Miller   All  returning  athletes  (incoming  baseline  established)  and  athletes  from  the  sports  listed  below  will  report  to  a   location  decided  on  by  the  staff  Athletic  Trainer  and  the  Concussion  Research  Laboratory  Team  during  their  off   season:   • Cross  Country     • Tennis   • Equestrian   • Golf   • Track  &  Field   • Cheerleading • Swimming  &  Diving     • Volleyball     Post-­‐Concussion:  Contact:  Emily  Miller  (ugaconcussion@uga.edu)   Within  6  hours  Assessment  *Complete  the  following  measures  within  6  hours  of  injury  (assessments  attached)*:   Injury  information  sheet   Symptom  Checklist   Standardized  Assessment  of  Concussion  (SAC)   Balance  Error  Scoring  System  (BESS)   Daily  Administration  of  Symptom  Checklist   Within  48  hours  Appointment:     Schedule  appointment  with  team  physician  to  occur  within  48  hours  of  injury.  The  appointment  time   should  be  include  the  appointment  time  plus  40  minutes  to  complete  CNS  Vital  Signs,  SAC,  BESS,  &   Graded  Symptom  Checklist  (total  time:  1  hour).   Inform  Concussion  Research  Laboratory  Team  of  the  injury  &  appointment  time.  We  will  dispatch   someone  to  meet  the  athlete  at  their  appointment  and  complete  all  measures  before  their  appointment.     Asymptomatic  Appointment  (Once  symptoms  fully  resolve):     Schedule  an  appointment  with  the  Concussion  Research  Laboratory  to  complete  concussion  evaluation  at   Butts-­‐Mehre.     Prior  to  Full  Return  to  Play  Appointment:     Schedule  a  follow-­‐up  appointment  with  the  Concussion  Research  Laboratory  to  complete  concussion   evaluation  at  Butts-­‐Mehre.     6  Month  post-­‐Injury  Appointment:       Schedule  a  follow-­‐up  appointment  with  the  Concussion  Research  Laboratory  to  complete  concussion   evaluation  (location  can  vary).       Contact  Information:   Julianne  Schmidt   Michelle  Weber   Concussion  Research  Laboratory  Director   Graduate  Student   Cell:  (919)  699-­‐0055   Cell:  (541)  974-­‐3396   Email:  schmidtj@uga.edu   Email:  michelle.weber25@uga.edu     Emily  Miller     Nicole  Hoffman   Project  Coordinator   Graduate  Student   Cell:  (678)  643-­‐3085   Cell:  (302)  540-­‐3032   Email:  emmolee@uga.edu  or   Email:  nhoffman25@uga.edu   ugaconcussion@uga.edu       CONCUSSION ASSESSMENT, RESEARCH AND EDUCATION (CARE) CONSORTIUM LONGITUDINAL CLINICAL STUDY CORE Appendix 5 cont. POST-INJURY PACKET ***Completed post-injury regardless of first assessment point*** INTERNAL USE ONLY Internal School ID:__________________________ Today's Date (mm/dd/yyyy)_____________________ Institution/School Name_____________________ Examiner's name______________________________ Quesgen ID_______________________________ Examination Time (hh:mm)______________ AM PM GUID ____________________________________ INJURY DESCRIPTION (completed by the clinician) Injury Date _____/_____/_______ (mm/dd/yyyy) Injury time ___________________ AM PM The injury occurred during: ☐ Practice/Training ☐ Competition ☐Outside organized sport If injured during sport, at what venue did it occur: ☐Home ☐Away ☐Neutral Site Athlete is a US Military Academy Cadet/Midshipman ☐ Yes ☐No For athletes at a College/University (ie nonmilitary academy), the concussion occurred during which of the following (check one)? Was the injury captured on film? ☐Yes ☐No When during the event did the injury occur? Football Ice Hockey ______Quarter or ☐ OT _____ Period or ☐ OT ☐ Baseball ☐ Basketball ☐ Bowling ☐ CC / Track ☐ Diving ☐ Fencing ☐ Field Event ☐ Field Hockey ☐ Football ☐ Golf ☐ Gymnastics ☐ Ice Hockey ☐ Lacrosse ☐ Rifle ☐ Rowing / Crew ☐ Skiing ☐ Soccer ☐ Softball ☐ Swimming ☐ Tennis ☐ Volleyball ☐ Water polo ☐ Wrestling ☐ Other__________ If yes, was Hudl filming software used? ☐Yes ☐No Lacrosse ____ ☐Quarter ☐Half or ☐ OT Soccer ____Half or ☐ OT All other sports ____________minutes into training/playing/competing when injury occurred ☐N/A Mechanism of Injury ☐Tackled by opponent ☐Tackling an opponent ☐Blocking ☐Collision with opponent ☐Collision with teammate ☐Header with physical contact ☐Header without physical contact ☐Being checked ☐Checking ☐Contact with ball/puck/stick ☐Other__________________________ Injured athlete collided with: ☐ Other player's head/helmet ☐Other player's body (elbow, knee, etc) ☐Turf/Ground/Floor/Ice ☐ Field equipment (eg goal post) ☐Sideline equipment (eg bench) ☐Other______________________________ Impact location resulting in Injury: ☐ Head - Front ☐ Head - Left ☐ Head - Right ☐Head - Back ☐Head - Top ☐Trunk/Torso ☐Unknown ☐Other_________________________ Did the athlete immediately report the injury ☐Yes ☐No If no, what was the date of reporting_____/_____/_______ (mm/dd/yyyy) Was the athlete immediately removed from play ☐Yes ☐No ☐N/A If not immediately identified / removed, how long did the athlete continue to play?______________ (min) *****ALL INFORMATION WILL REMAIN CONFIDENTIAL***** © NCAA-DoD Grand Alliance Post-Concussion Packet v.3 Page - 1 - Appendix 5 cont. Examiners Name: Quesgen ID _______________________ Was there a delayed onset of symptoms after injury (ie initially normal, later symptomatic) ☐Yes ☐No If yes, how long was the symptom onset after injury __________(min) Once identified, was the athlete declared normal 15min after the injury? ☐Yes ☐No Did the athlete return to activity on the same day? ☐Yes ☐No Did the athlete have an alteration in mental status at the time of injury (eg dazed, stunned, confused, saw stars)? ☐Yes ☐No Did the athlete experience post-traumatic amnesia? (Loss of memory after the injury) Did the athlete lose consciousness? ☐Yes ☐No If yes, for how long? ________________(sec) If yes, was a LOC witnessed or self-reported? ☐Witness ☐Self-report Did the athlete experience retro-grade amnesia? (Loss of memory before the injury) ☐Yes ☐No ☐Yes ☐No If yes, for what duration_________________(min) If yes, for what duration________________(min) Was the athlete taken to the hospital? ☐Yes ☐No Was imaging completed? ☐None ☐MRI ☐CT If yes, were there positive findings? ☐Yes ☐No If positive findings, please describe: ________________________________________________________________ PLAYING SURFACE Playing Surface: ☐ Grass – consistent surface ☐ Grass – irregular surface ☐ Field-Turf ☐ Astro-Turf ☐ Dirt ☐ Wood ☐ Asphalt/Concrete/Pool Deck ☐ Pool ☐ Ice ☐ Gymnastics/Wrestling mat ☐ Other_____________________ COMMENTS / ADDITIONAL INJURY INFORMATION *****ALL INFORMATION WILL REMAIN CONFIDENTIAL***** © NCAA-DoD Grand Alliance Post-Concussion Packet v.3 Page - 2 - Appendix 5 cont. University of Georgia Sports Medicine Concussion Symptom Checklist **Completed within 0-6 hours post Injury** Name______________________________ Day of Testing: ___/___/___ Baseline: ___/___/___ Time: ___:___ AM PM Symptom Response: Symptomatic (SRS): Day 1 2 3 4 5 6 7 ____ Symptom Response: Asymptomatic (SRA): Day 1 2 3 4 5 6 7 ____ Administration Mode: Patient Administered Clinician Administered by: ______________________________ DURATION SEVERITY   You should score yourself on the following symptoms, based on how you feel now. 1. Headache 2. “Pressure in Head” 3. Neck Pain 4. Nausea or Vomiting 5. Dizziness 6. Blurred Vision 7. Balance Problems 8. Sensitivity to Light 9. Sensitivity to Noise 10. Feeling Slowed Down 11. Feeling like “in a fog” 12. “Don’t feel right” 13. Difficulty concentrating 14. Difficulty remembering 15. Fatigue or Low Energy 16. Confusion 17. Drowsiness 18. Trouble Falling Asleep 19. More Emotional 20. Irritability 21. Sadness 22. Nervous or Anxious Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No Briefly If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à If yes à Sometimes Always Mild Moderate 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 3 TOTAL DURATION SCORE: TOTAL SEVERITY SCORE: Yes No Do the symptoms get worse with mental activity? Yes No 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Severe 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Do the symptoms get worse with physical activity? How many hours did you sleep last night?________(hrs) Comments:__________________________________________________________________________________________________________________________________ 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Appendix 5 cont. STANDARDIZED ASSESSMENT OF CONCUSSION - SAC NAME: TEAM: EXAMINER: DATE OF EXAM: TIME: EXAM (Circle One): BLINE INJURY DAY1 FORM C NEUROLOGIC SCREENING POST-GAME DAY2 DAY3 DAY5 DAY7 DAY90 No Length: No Length: No Length: NORMAL LOSS OF CONSCIOUSNESS/ WITNESSED UNRESPONSIVENESS POST-TRAUMATIC AMNESIA? Poor recall of events after injury RETROGRADE AMNESIA? Poor recall of events before injury INTRODUCTION: I am going to ask you some questions. Please listen carefully and give your best effort. Yes Yes ABNORM AL STRENGTH - ORIENTATION What Month is it? What’s the Date today? What’s the Day of Week? What Year is it? What Time is it right now? (within 1 hr.) 0 0 0 0 0 1 1 1 1 1 Award 1 point for each correct answer. ORIENTATION TOTAL SCORE Š I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order. TRIAL 1 0 1 0 1 0 1 0 1 0 1 TRIAL 2 0 1 0 1 0 1 0 1 0 1 Right Upper Extremity Left Upper Extremity Right Lower Extremity Left Lower Extremity SENSATION - examples: FINGER-TO-NOSE/ROMBERG COORDINATION - examples: TANDEM WALK/ FINGER-NOSE-FINGER IMMEDIATE MEMORY LIST BABY MONKEY PERFUME SUNSET IRON TOTAL Yes TRIAL 3 0 1 0 1 0 1 0 1 0 1 Trials 2 & 3: I am going to repeat that list again. Repeat back as many words as you can remember in any order, even if you said the word before. CONCENTRATION Digits Backward: I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7. If correct, go to next string length. If incorrect, read trial 2. 1 pt. possible for each string length. Stop after incorrect on both trials. 1-4-2 6-8-3-1 4-9-1-5-3 3-7-6-5-1-9 6-5-8 3-4-8-1 6-8-2-5-1 9-2-6-5-1-4 Do not inform the subject that delayed recall will be tested. DELAYED RECALL If subject is not displaying or reporting symptoms, conduct the following maneuvers to create conditions under which symptoms likely to be elicited and detected. These measures need not be conducted if a subject is already displaying or reporting any symptoms. If not conducted, allow 2 minutes to keep time delay constant before testing Delayed Recall. These methods should be administered for baseline testing of normal subjects. EXERTIONAL MANEUVERS 5 Jumping Jacks 5 Push-Ups 5 Sit-ups 5 Knee Bends 0 1 Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan CONCENTRATION TOTAL SCORE EXERTIONAL MANEUVERS: 1 1 1 1 Months in Reverse Order: Now tell me the months of the year in reverse order. Start with the last month and go backward. So you’ll say December, November...Go ahead. 1 pt. for entire sequence correct. Complete all 3 trials regardless of score on trial 1 & 2. 1 pt. for each correct response. Total score equals sum across all 3 trials. IMMEDIATE MEMORY TOTAL SCORE Š 0 0 0 0 Š Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order. Circle each word correctly recalled. Total score equals number of words recalled. BABY MONKEY PERFUME SUNSET DELAYED RECALL TOTAL SCORE IRON Š SAC SCORING SUMMARY Exertional Maneuvers & Neurologic Screening are important for examination, but not incorporated into SAC Total Score. ORIENTATION IMMEDIATE MEMORY CONCENTRATION DELAYED RECALL © 1998 MCCREA, KELLY & RANDOLPH SAC TOTAL SCORE /5 / 15 /5 /5 Š /30 Appendix 5 cont. Start Time (hh:mm) ______________ AM PM Date (mm/dd/yy): ______________________ Internal School ID_______________________ Assessment: <6hr post-injury Balance Error Scoring System (BESS) Which foot was tested (i.e. non-dominant foot): ☐ Left ☐ Right Error Types 1. Hands lifted off iliac crest 2. Opening eyes 3. Step, stumble, or fall 4. Moving hip into > 30 degrees abduction 5. Lifting forefoot or heel Athlete wore: ☐ Socks ☐No Socks SCORE CARD:(# errors) FIRM Surface FOAM Surface Double Leg Stance (feet together) Single Leg Stance (non-dominant foot) 6. Remaining out of test position >5 sec Tandem Stance (non-dominant foot in back) The BESS is calculated by adding one error point for each error during the six 20-second tests. Total Scores: BESS TOTAL: Assessment End Time (hh:mm) ______________ AM PM Assessment not performed because: ☐ Athlete unavailable ☐ Athlete physical inability ☐ Athlete refused to complete ☐ Time point was not completed ☐ Symptoms worsened during assessment ☐ Other____________________ FATIGUE RATING - Following all assessments, please ask the athlete Compared to how you normally feel and function each day, give a rating between 0 and 100 of how tired you feel right now, with 0 being extremely exhausted and 100 being completely awake and alert)____________________________ *****ALL INFORMATION WILL REMAIN CONFIDENTIAL***** © NCAA-DoD Grand Alliance Post-Concussion Packet v.3 Page - 5 - Appendix 6       University  of  Georgia  Sports  Medicine   Concussion  Patient  Information  Sheet   Name:  _______________________________________________:    You  have  had  a  concussion  and  need  to  be  watched  closely  for   the  next  several  days  until  you  have  completely  recovered.    The  following  information  is  regarding  your  treatment  and  recovery.     What  is  a  concussion?    A  concussion  is  a  brain  injury  that  is  caused  by  a  blow  to  the  head  or  body.  It  may  occur  from  contact  with   another  player,  hitting  a  hard  surface  such  as  the  ground,  floor,  being  hit  by  a  piece  of  equipment  such  as  a  bat  or  ball,  or  a  motor   vehicle  accident.      A  concussion  can  change  the  way  your  brain  normally  works.    It  can  range  from  mild  to  severe  and  presents  itself   differently  for  each  athlete.    A  concussion  can  happen  even  if  you  do  not  lose  consciousness.     What  are  the  symptoms  of  a  concussion?    You  can’t  see  a  concussion,  but  you  may  notice  some  of  the  symptoms  right  away.  Other   symptoms  can  show  up  hours  or  days  after  the  injury.    Concussion  symptoms  may  include:   •  Amnesia   •  Confusion   •  Headache   •  Loss  of  consciousness   •  Balance  problems  or  dizziness   •  Double  or  fuzzy  vision   •  Sensitivity  to  light  or  noise   •  Nausea  (feeling  that  you  might  vomit)   •  Feeling  sluggish,  foggy  or  groggy   •  Feeling  unusually  irritable   •  Difficulty  getting  to  sleep  or  disrupted  sleep   •  Slowed  reaction  time   •  Concentration  or  memory  problems          (forgetting  game  plays,  facts,  meeting  times)       How  do  you  recover  from  a  concussion?    Your  brain  needs  time  to  heal.  Until  you  completely  recover  from  your  concussion,  you   will  be  held  from  all  athletic  activity.    Exercise  or  activities  that  involve  a  lot  of  concentration,  such  as  studying,  working  on  the   computer,  or  playing  video  games  may  cause  concussion  symptoms  (such  as  headache  or  tiredness)  to  reappear  or  get  worse.    While   your  brain  is  still  healing,  you  are  much  more  likely  to  have  a  repeat  concussion.  In  rare  cases,  repeat  concussions  can  cause   permanent  brain  damage,  and  even  death.  Severe  brain  injury  can  change  your  whole  life.      You  will  be  evaluated  by  your  physician   initially  and  undergo  some  testing  to  determine  how  the  concussion  is  affecting  your  ability  to  balance  (e.g.  Neurocom  test)  and   process  information  (e.g.  computer  neuropsychological  test).    You  will  be  followed  daily  by  your  athletic  trainer  to  monitor  your   symptoms.    When  your  symptoms  are  completely  gone  and  your  concussion  testing  results  have  returned  to  a  normal  level,  you  will   perform  some  exertional  tests  under  the  supervision  of  your  athletic  trainer.      Before  returning  to  your  sport,  you  must  be  re-­‐ evaluated  by  your  physician  and  medically  cleared  for  return.         What  to  watch  for?  If  you  develop  any  new  symptoms  or  increases  in  current  symptoms,  contact  your  athletic  trainer  or  physician   immediately  at:  (_________)_________________________.     Medications:  You  have  been  given  two  medications  to  take  as  follows:   • Acetaminophen  (Tylenol):  take  2  tablets  every  6  hours  as  needed  for  headache  (no  more  than  3  grams  per  day).   • Martek  DHA  Omega  3:  take  3  capsules  three  times  a  day     Additional  Instructions:    DO  NOT  drive  a  car  or  motor  scooter,  drink  alcohol,  eat  greasy  or  spicy  foods,  or  take  aspirin,  Aleve,  Advil   or  other  anti-­‐inflammatory  medications!     Follow-­‐up:  You  will  be  seen  for  follow-­‐up  examination  by  ________________________  on  _______________  at  ________________.   Recommendations  provided  to  ______________________________  by  ______________________________  on                        /                    /                    .   I  acknowledge  that  I  have  received  and  understand  the  concussion  information  above  and  that  I  will  notify  a  healthcare  provider   immediately  with  any  changes  in  my  signs  and  symptoms.     ________________________________________________________________________________________     Student-­‐Athlete  Name  (print)               Student-­‐Athlete  Signature       Date   ________________________________________________________________________________________     Witness  Name  (print)                Witness  Signature         Date   Appendix 7 Sample Academic Notification Letter Concussion Notification for ____________________ Student ID #____________ Date: / / The University of Georgia Sports Medicine and Student Services/Academic Counseling Departments would like to inform you that Name sustained a concussion on Date / / while provide brief concussion details (i.e. practice/competition, motor vehicle accident, etc…). He/She was evaluated by Name of Physician, MD. Name will undergo additional concussion testing in our sports concussion laboratory under the direction of Julianne Schmidt, PhD, ATC. Name is currently being held from all athletic activities while symptomatic. He/she will be followed daily by our sports medicine staff. When his/her symptoms completely clear, follow-up concussion testing will be performed to determine return to activity. Name will not return to any athletic activity until he/she is completely symptom free and has been cleared by a physician. A concussion is a type of traumatic brain injury (TBI) that results from a force to the head or body that causes the head and brain to bounce around or twist in the skull, stretching and damaging brain cells and creating chemical changes in the brain. These changes can lead to a set of symptoms affecting the student’s cognitive, physical, emotional, and sleep functions. Concussions affect each individual differently. Most students will have symptoms that last for a few days or a week. A more serious concussion can last for weeks, months or even longer. Educators may be challenged with helping return a student to school still experiencing concussion symptoms as learning problems and poor academic performance can occur. Name may require some academic accommodations during the recovery time from his/her concussion, which may include excused absence from classes, rest periods during the school day, the extension of assignment deadlines, postponement or staggering of tests, excuse from specific tests and assignments, extended testing time, accommodation for oversensitivity to light and/or noise, excuse from physical exertion activities, use of a reader for assignments and testing, use of a note taker or scribe, and use of a smaller, quieter examination room to reduce stimulation and distraction. You may find additional information related to return to the classroom following a concussion at the web links below. Any academic accommodations you may provide for name during this time would be greatly appreciated. Should you have any questions or require further information, please do not hesitate to contact me at rcourson@sports.uga.edu or 706-542-9060 (work) and/or name’s sport athletic trainer. Thank you in advance for your time and understanding with this circumstance. Sincerely yours, Ron Courson, ATC, PT, NREMT-I, CSCS Sport Athletic Trainer Senior Associate Athletic Director - Sports Medicine cc: David Shipley, JD Fred Reifsteck, MD Alan Campbell, PhD Julianne Schmidt, PhD Greg McGarity S-A Name Carla Williams, PhD Head Sport Coach Ted White CDC link: http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf NCAA link: http://www.ncaa.org/health-and-safety/medical-conditions/concussion-return-learn-guidelines NATA link: http://www.nata.org/sites/default/files/attr-45-05-pg-492-498.pdf Appendix 8 Exertional Testing Protocol Following Concussion The following stages are not ALL to be performed on the same day. In some cases, stages 1 through 4 (or even 5) may be completed on the same day, but typically will occur over multiple days. Stages 6 and 7 will each be performed on separate and subsequent days. Student-athletes that present with symptoms at any stage should rest for 24 hours, be re-evaluated by the physician, and return to the previous stage at the physician’s discretion. No Activity Once asymptomatic for 24 hours and cleared by medical staff Symptom checklist, balance exam, and neuropsychological exam, and brief visual exam WNL Exertional Testing Protocol Stage 1: Light exercise: ~<70% age-predicted maximal heart rate Stage 2: Sport-specific activities without the threat of contact from others Stage 3: Noncontact training involving others, resistance training Stage 4: Unrestricted training If no change or increase in symptoms, move to next stage. Stage 5: Non-contact or low-risk practice activities following completion of exertional protocol If no change or increase in symptoms, move to next stage. Stage 6: Limited to full contact practice If no change or increase in symptoms, final return to play decision made by medical staff. Stage 7: Full Return to Play Athlete will be monitored by the medical staff for return of symptoms. Appendix 9 University  of  Georgia  Sports  Medicine     Concussion  Return  to  Athletic  Activity  Acknowledgement     □      I  acknowledge  that  I  have  sustained  a  concussion.    I  understand  that  a  concussion  is  a  brain  injury  that  is   caused  by  a  blow  to  the  head  or  body.  It  may  occur  from  contact  with  another  player,  hitting  a  hard  surface   such  as  the  ground,  floor,  being  hit  by  a  piece  of  equipment  such  as  a  bat  or  ball,  or  a  motor  vehicle  accident.       A  concussion  can  change  the  way  your  brain  normally  works.    It  can  range  from  mild  to  severe  and  presents   itself  differently  for  each  athlete.    A  concussion  can  happen  even  if  you  do  not  lose  consciousness.     □      I  acknowledge  that  I  have  experienced  signs  and  symptoms  of  concussion  following  my  injury;  however,   all  of  my  symptoms  have  fully  resolved.  I  understand  that  concussion  symptoms  may  include:   •  Amnesia   •  Confusion   •  Headache   •  Loss  of  consciousness   •  Balance  problems  or  dizziness   •  Double  or  fuzzy  vision   •  Sensitivity  to  light  or  noise   •  Nausea  (feeling  that  you  might  vomit)   •  Feeling  sluggish,  foggy  or  groggy   •  Feeling  unusually  irritable   •  Difficulty  getting  to  sleep  or  disrupted  sleep   •  Slowed  reaction  time   •  Concentration  or  memory  problems          (forgetting  game  plays,  facts,  meeting  times)     □      I  acknowledge  that  I  have  recovered  from  my  concussion.    I  understand  that  my  brain  needs  time  to  heal   following  injury.    I  was  held  from  athletic  activity  until  I  completely  recovered.  I  understand  that  exercise  or   activities  that  involve  a  lot  of  concentration,  such  as  studying,  working  on  the  computer,  or  playing  video   games  may  cause  concussion  symptoms  (such  as  headache  or  tiredness)  to  reappear  or  get  worse.    I   understand  that  while  your  brain  is  still  healing,  you  are  much  more  likely  to  have  a  repeat  concussion.  In  rare   cases,  repeat  concussions  can  cause  permanent  brain  damage,  and  even  death.       □      I  acknowledge  that  I  have  been  evaluated  by  a  physician,  undergone  concussion  testing,  performed   exertional  tests,  and  have  been  medically  cleared  for  return  to  athletic  activity.       □      I  acknowledge  that  if  I  experience  any  concussion  signs  and  symptoms,  I  will  immediately  report  to  a   healthcare  provider.         I  acknowledge  that  I  fully  understand  the  concussion  information  above,  that  the  acknowledgements  above   are  true  and  correct  to  the  best  of  my  knowledge,  and  that  I  will  notify  a  healthcare  provider  and  my  coach   immediately  with  any  changes  in  my  signs  and  symptoms.   ____________________________________________________________     Student-­‐Athlete  Name  (print)          Student-­‐Athlete  Signature     Date                                   ____________________________________________________________     Witness  Name  (print)            Witness  Signature       Date   Georgia Tech Athletics Concussion Program and Protocol Estimates of greater than 300,000 concussions occur per year in athletic events and many concussions go unreported for many reasons. Reasons for not reporting possible concussions include fear of being pulled from competition and lack of education of the symptoms of concussion. Concussions also remain one of the more difficult injuries to assess and treat. Objective testing tools are not always the most practical method to assess the severity of the injury. There are also no real definitive treatment options available except physical and cognitive rest for the athlete. With this background, the Georgia Tech Concussion Program strives to combine all areas of concussion evaluation and management into a comprehensive team based approach to the care of the student-athlete. The main areas of the program include education, evaluation, and management. The recent 3rd Edition Zurich Concussion consensus statement has much of what is discussed here in greater detail. NCAA guidelines as well as the Concussion Safety Protocol Checklist will also be followed and polices will be adjusted accordingly in the management of concussions as the guidelines continue to evolve. Education Education is an important aspect of the program as studies have shown that both coaches and student-athletes are not always aware of the symptoms as well as seriousness of concussions. Pre-season education will consist of an educational presentation and/or handout for later referral for the athlete and coach. Student-athletes who sustain a concussion will also be reminded of the symptoms, usual duration, and return to play criteria for concussions. The importance of self-reporting will be stressed in this educational component. Student-athletes will also be reminded of the critical nature of this selfassessment and that it be honest and thorough. Education will also include information on the potential progression of post-concussion syndrome if they return too soon. Prevention of concussion will also be discussed including appropriate equipment, strength training, and utilization of safer techniques in their sport. Additionally, all team physicians, athletic trainers and designated academic support staff will receive yearly educational updates on concussion evaluation and management. The director of sports medicine will brief the director of athletics annually on current concepts in concussion management. All will sign letters acknowledging receiving such training. Revised June 2015 Evaluation and Management Evaluation and management will consist of pre-participation baseline testing, on-field management, acute management, and return to play progression. Chronic and multiple concussion management will be addressed in conjunction with our referral program to neurology. Pre-Participation Assessment Each student-athlete will be asked to provide a detailed history of all past brain injury or concussions on their medical history form to be completed prior to obtaining their preparticipation physical. Pre-participation testing will consist of baseline SCAT 3/SAC, ImPACT testing, and IsoSport balance testing. Baseline testing will occur upon a student-athlete’s entry into the program and may be repeated if player sustained a concussion during the previous year. On-Field Management of Acute Concussions When a student-athlete sustains a suspected concussion or head injury, or exhibits signs/symptoms consistent with a concussion, they will be evaluated first by an athletic trainer and if present, a physician. The student-athlete will be removed from practice or competition during the evaluation. The initial evaluation will include a brief history of signs and symptoms as well as some form of SCAT3/SAC evaluation. A physical exam including, but not limited to, cervical spine assessment and evaluation for skull fracture or intracranial hemorrhage will be conducted as well. If a concussion is diagnosed at the time of initial exam, the student-athlete will not return to play, symptoms will be monitored and serial examinations performed to evaluate progression of the injury. If an alternate diagnosis is confirmed, the student-athlete may return to play if determined to be appropriate medically. The student-athlete will be re-evaluated after the game or practice to assess whether or not symptoms have returned, increased, or decreased. The student-athlete will also receive instruction on the need for re-evaluation should symptoms worsen during that evening. Whenever possible, the student-athlete should be evaluated by a team physician the next day. Revised June 2015 Abnormal neurologic findings or worsening symptoms will warrant emergency care and immediate referral to the nearest hospital. Acute Management If warranted by presenting circumstances the emergency action plan for the specific venue will be activated to effectively manage the injury. The emergency action plan, including transportation for appropriate medical care, will be initiated for any of the following: Glasgow Coma Scale < 13; prolonged loss of consciousness; focal neurological deficit suggesting intracranial trauma; repetitive emesis; persistently diminished/worsening mental status or other neurological signs/symptoms; spine injury. All student-athletes with a diagnosed concussion will receive written Concussion Take Home Instructions for their home care. A copy of these instructions will be given to a responsible adult who can assist the student-athlete with care. This information will also be placed in the student-athlete’s medical file. In addition, cognitive instructions will be provided that will specify, as appropriate: • Cognitive rest. • Homework, reading or studying restrictions. • An excusal from classes authorized by the team physician or director of sports medicine. Upon diagnosis, the Associate Athletic Director for Academic Services or the Director of Academic Services will be notified. Student-athletes determined to have a concussion will be evaluated daily by the athletic trainer and at multiple intervals by the team physician during the course of symptoms. SCAT3/SAC and/or ImPACT testing will be done about 24 hours after injury. No pain medication will be used for the first 24 hours to determine severity of injury. If symptoms are improving, acetaminophen may be considered appropriate for pain control. The athlete will also utilize as much cognitive rest as possible while physical rest is employed during symptomatic phase. The team physician will continue to monitor and evaluate the student-athlete throughout their recovery and take appropriate action as needed. If symptoms are worsening, or if there is prolonged recovery, CT or MRI imaging will also be considered along with neurologic referral. Return to Play Progression Once the student-athlete is asymptomatic, SCAT3/SAC and/or ImPACT testing will be performed again and re-evaluation with a team physician done. If the student-athlete performs satisfactorily on testing and physical exam is normal, they will be considered to start the return to play progression. The return to play sequence will follow a daily progression from cardiopulmonary exercise, to weight lifting, to non-contact drills, then contact drills and finally return to game activity and will be supervised by the team Revised June 2015 physician or an athletic trainer with experience in concussion diagnosis and treatment. If the student-athlete becomes symptomatic during the progression, they will rest and be re-evaluated the next day. If they are asymptomatic upon the re-evaluation then the progression will resume. Final determination of return to play rests with the team physician. Return to Learn The sports medicine staff will coordinate with the academic staff person recommended by the Associate AD for Student-Athlete Academic Services or Director of Academic Services and assigned to the injured student-athlete’s sport. In collaboration, they will develop a reasonable and realistic return to learn management plan for student-athletes who have sustained concussions that require missed class or study time. This plan will be ADAAA compliant, and will include the following: • The point person for return-to-learn will be the Associate AD for Student-Athlete Academic Services. • A multi-disciplinary team will help those student-athletes who have more complex or prolonged return-to-learn scenarios. This team includes: team physician, athletic trainer, sport-specific academic staff person, Dean of Students (Request Assistance process), and Office of Disability Services(http://www.adapts.gatech.edu/, for temporary accommodations related to recovery from injury). • Student-athletes may participate in no classroom activity on the same day as a concussion, and may remain at home/dorm if they cannot tolerate light cognitive activity. • All return-to-learn plans will be individualized, with gradual return to academic activity as tolerated. • The academic schedule will be modified for up to 2 weeks, as indicated, with help from the point person. • The point person, Dean of Students and Office of Disability Services will remain in communication with faculty and closely monitor academic performance and any issues with cognitive ability. • If the student-athlete remains symptomatic for more than 2 weeks, he/she will be re-evaluated by the team physician or a member of the multi-disciplinary team. • For cases that cannot be managed by schedule modification, campus resources will be utilized, including: Registrar, Faculty Athletics Representative, Athletic Compliance Office, and Office of Disability Services. Revised June 2015 Complex Concussions and Post-Concussion Syndrome Student-athletes who cannot return to play or return to learn in a timely fashion or athletes with a history of multiple concussions and/or post-concussion syndrome will be considered for referral to neurology for further testing, evaluation, and recommendations. These cases will be managed by the team physician, athletic trainer, and other departmental staff as needed. Reducing Exposure to Head Trauma The sports medicine staff will continually monitor best practices and regularly educate coaches and student-athletes on strategies and practices intended to reduce the incidence of head injuries in all sports. Emphasis will be placed on using proper technique and equipment to reduce the likelihood of injury. Revised June 2015 University of Illinois Division of intercollegiate Athletics Sports Medicine Department Concussion Management Protocol Pre?Season Education 1. All student-athletes will receive the NCAA concussion fact sheet for student-athletes and brief education about concussion and risks from an ATC during their annual pre- season team meeting. Student-athletes will then complete the acknowledgement form stating they accept responsibility for reporting their injuries and illnesses to the sports medicine staff, including signs and of concussion. a. See ?Concussion: A Fact Sheet for Student Athletes? Appendix A b. See ?Big Ten Injury and Illness Reporting Acknowledgment Form? Appendix 2. A11 coaches and athletic directors will receive the NCAA concussion fact sheet for coaches and brief education about concussion and risks from an ATC annually. Coaches and athletic directors will then complete the acknowledgement form stating they accept responsibility for reporting any signs and of a concussion to the sports medicine staff. a. See ?Concussion: A Fact Sheet for Coaches? Appendix A b. See ?Big Ten Coaches Concussion Acknowledgement Form? Appendix 3. All sports medicine staff members (physicians and athletic trainers) will receive a copy of the current University of Illinois Concussion Management Protocol and review the protocol. Sports Medicine staff members will then complete the acknowledgement form stating they understand the protocol and will follow it. a. See ?University of Illinois Sports Medicine Acknowledgement Form? Appendix Baseline Testing 1. A11 in?coming student?athletes will complete Incoming Athlete Pre-Participation Physical Examination. a. Student-athlete is asked to specify any history of head injury or concussion. b. Cranial nerves are assessed as part of evaluation c. Team physician will review all medical information provided and determines pre- participation clearance. 2. Prior to on??eld or on-court team activities, all student-athletes who participate in intercollegiate athletics and the cheerleading team at the University of Illinois will complete baseline assessment. The baseline assessment will consist of an Baseline Test and Balance Error Scoring System (BESS) administered by a Certi?ed Athletic Trainer (ATC). Instructions for completing the and BESS can be found in Appendix respectfully. a. A new baseline concussion assessment will be completed six months or beyond for any student-athlete with a documented concussion. Revised July, 2015 Response to Signs and of a Concussion Any student-athlete with consistent with concussion: l. 2. Must be removed from practice or competition Must be evaluated by ATC or team physician student-athlete who is diagnosed with a concussion shall not return activity for at least the remainder of that calendar day. Any student-athlete diagnosed with a concussion will complete the following: mewwr Initial Evaluation (See steps below) Physician evaluation Follow up and BESS testing. (Follow BESS protocol) Follow up with physician regularly or if increase until all resolve. Return to Play Follow ?Return to Play Progression? listed below. Initial Evaluation 1. L11 7. Primary Survey: Evaluation of (care for any life threatening problems ?rst) and cervical spine trauma. The University of Illinois Emergency Action Plan, including transportation for further medical care, for any of the following: Glasgow Coma Scale 13; prolonged loss of consciousness; focal neurological de?cit suggesting intracranial trauma; repetitive emesis; persistently diminished/worsening mental status or other neurological si gns/ spine injury. Signs and Signs Headache Loss of consciousness Nausea Poor balance Vomiting Slowed or slurred speech Balance problems/dizziness Sensitivity to light/noise Ringing in ears (tinnitus) Tiredness Irritability Confusion, disorientation Poor concentration Delayed response to questions Appears to be dazed or stunned Forgets plays Unusual emotions, personality change and/or inappropriate behavior Complete the SCAT3, see Appendix F. If not improving or increasing, consult with a physician to determine if student-athlete needs to see a physician for further evaluation. Send written instructions home with a parent or roommate. a. See ?Head Injury Instructions? Appendix Follow-up the next day with physician and/or athletic trainer. Continuing Care through Recovery 1. Follow-up with physician regularly until all resolve. a. Discuss class attendance and academic recommendations with physician at each visit. Revised July, 2015 i. Obtain written documentation from the physician for missing class or extra time allowance for completion of academic assignments. 2. Notify academic counselor of injury and provide with any required documentation for academic exceptions (see ?Return to Leam?). 3. Complete ?Post?Concussion Scale? daily. Appendix a. Best practice is to complete before attending class or completing daily tasks. 4. Instruct athlete on importance of rest. a. Sleep at night. b. No video games, TV, electronics, etc. c. Limit computer usage to academic necessity. 5. Complete Post-Injury test once all resolved note hours of sleep, caffeine use, and external distractions per recommendations for accurate testing. a. Evaluate ImPact Post-Injury results with physician. i. If within normal limits, follow retum-to-play protocol. ii. If outside of normal limits, repeat in 48 hours if Graduated Return to Play Protocol Step 1: No Activity - Complete physical and cognitive rest. Step 2: Light Aerobic Activity walking, swimming or stationary cycling, keeping intensity to <70% of maximum predicted heart rate; no resistance training. Step 3: Sport Speci?c Exercise skating drills in ice hockey, running drills in soccer; no head impact activities. Step 4: Non-Contact Training progression to more complex training drills, e. g. passing drills in football and ice hockey; may start progressive resistance training. Follow-up with physician for ?nal evaluation to return to full contact activity. Step 5: Full-contact practice participate in normal training activities. Step 6: Return to play normal game/competition play. Note: The student-athlete should progress to the next step only if completely at the current step. If any post-concussion occur while in the stepwise program, the athlete should stop all activity and follow-up with a physician. After for 24-hours, the athlete should drop back to the previous step and try to progress.2 Revised July, 2015 Return to Learn Plan A team consisting of the team physician, certi?ed athletic trainer and academic counselor will work together to identify resources available and necessary accommodations for any student-athlete who a . Follow the Sports Medicine Department Concussion Management Protocol for appropriate referral to team physician for assessment. If a S-A suffers a concussion, the team athletic trainer (AT) will contact the academic counselor by phone to notify him/her of the concussion a student-athlete who is diagnosed with a concussion shall not participate in classroom activity for at least the remainder of that calendar day. a. i. Note: No speci?c information regarding the health should be left in a voicemail as voicemails are sent as electronic messages. The academic counselor will contact the learning specialist to notify him/her of the concussion. If the team physician recommends accommodations should be made for class attendance or coursework beyond the initial calendar day of the occurrence of the concussion, the team physician will complete the form letter on letterhead noting the date the concussion occurred. may complete letter(s) but MD must 1. ii. iv. The team athletic trainer will provide the initial letter(s) to the academic counselor. The academic counselor will notify the learning specialist of the recommendations. 0 The learning specialist will work with the S-A to facilitate short-term accommodations or academic schedule modi?cation (up to 2 weeks). The learning specialist will work with the S-A to set-up an evaluation with Disability Resources and Education Services (DRES). DRES will facilitate any accommodations needed in accordance with A student?athlete will follow-up with a physician immediately if: 0 worsen with academic challenges 0 last longer than 2 weeks Follow-up documentation, i.e. physician of?ce visit notes, will be provided to the academic counselor/learning specialist upon request. Revised July, 2015 Appendix A NCAA Facts Sheets Revised July, 2015 CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A A concussion is a brain injury that: - ls caused by a blow to the head or body. From contact with another player, hitting a hard surface as the ground. ice or ?oor, or being hit by a piece of equipment such as a bat, lacrosse stick or ?eld hockey ball. - Can change the way your brain normally works. - Can range from mild to severe. - Presents itself differently for each athlete. - Can occur during practice or competition in ANY sport. - Can happen even if you do not lose consciousness. HOW CAN I PREVENT A Basic steps you can take to protect yourself from concussion: - Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. - Avoid striking an opponent in the head. Undercutting, ?ying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. - Follow your athletics department's rules for safety and the rules of the sport. - Practice good sportsmanship at all times. - Practice and perfect the skills of the sport. WHAT ARE THE OF A You can?t see a concussion, but you might notice some of the right away. Other can show up hours or days after the injury. Concussion include: - Amnesia. - Confusion. Headache. - Loss of consciousness. - Balance problems or dizziness. - Double or fuzzy vision. Sensitivity to light or noise. - Nausea (feeling that you might vomit). - Feeling sluggish, foggy or groggy. Feeling unusually irritable. - Concentration or memory problems (forgetting game plays, facts, meeting times). - Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion (such as headache or tiredness) to reappear or get worse. WHAT SHOULD I DO IF I THINK I HAVE A Don't hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. For more information and resources, visit and Reference to any tonmrertml entity or product or on this page should not be Lonstrued as an endorsement by the Government of the company or its products or services. CONCUSSION A FACT SHEET FOR COACHES THE FACTS - A concussion is a brain injury. a All concussions are serious. - Concussions can occur without loss of consciousness or other obvious signs. - Concussions can occur from blows to the body as well as to the head. - Concussions can occur in any sport. - Recognition and proper response to concussions when they ?rst occur can help prevent further injury or even death. - Athletes may not report their for fear of losing playing time. - Athletes can still get a concussion even if they are wearing a helmet. - Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries. depending on the sport. SIGNS AND Signs Observed By Coaching Staff - Appears dazed or stunned. - Is confused about assignment or position. - Forgets plays. 0 Is unsure of game, score or opponent. - Moves clumsily. 0 Answers questions slowly. - Loses consciousness (even briefly). - Shows behavior or personality changes. - Can't recall events before hit or fall. - Can't recall events after hit or fall. WHAT IS A A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an ?impulsive? force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or ?oor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick or ?eld hockey ball. RECOGNIZING A POSSIBLE CONCUSSION To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; -AND- 2. Any change in the student-athlete's behavior, thinking or physical functioning (see signs and Reported By Student-Athlete - Headache or ?pressure? in head. - Nausea or vomiting. 0 Balance problems or dizziness. 0 Double or blurry vision. 0 Sensitivity to light. - Sensitivity to noise. - Feeling sluggish, hazy, foggy or groggy. - Concentration or memory problems. - Confusion. - Does not ?feel right. PREVENTION AND PREPARATION As a coach, you play a key role in preventing concussions and responding to them properly when they occur. Here are some steps you can take to ensure the best outcome for your student-athletes: - Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to- play. Review and practice your emergency action plan for your facility. - Know when you will have sideline medical care and when you will not, both at home and away. Emphasize that protective equipment should ?t properly, be well maintained, and be worn consistently and correctly. Review the Concussion Fact Sheet for Student?Athletes with your team to help them recognize the signs of a concussion. Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury in the Athlete. - Insist that safety comes ?rst. Teach student-athletes safe?play techniques and encourage them to follow the rules of play. Encourage student-athletes to practice good sportsmanship at all times. Encourage student?athletes to immediately report of concussion. - Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long?term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death. IF YOU THINK YOUR STUDENT-ATHLETE HAS SUSTAINED A CONCUSSION: Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion. An athlete who exhibits signs, or behaviors consistent with a concussion, either at rest or during exertion, should be removed immediately from practice or competition and should not return to play until cleared by an appropriate health care professional. Sports have injury timeouts and player substitutions so that student-athletes can get checked out. IF A CONCUSSION IS SUSPECTED: 1. Remove the student-athlete from play. Look for the signs and of concussion if your student-athlete has experienced a blow to the head. Do not allow the student-athlete to just ?shake it off." Each individual athlete will respond to concussions differently. 2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the student? athlete to the appropriate athletics medical staff, such as a certi?ed athletic trainer, team physician or health care professional experienced in concussion evaluation and management. 3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return-to-play progression should occur in an individualized. step-wise fashion with gradual increments in physical exertion and risk of contact. 4. Develop a game plan. Student?athletes should not return to play until all have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact. as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change. BETTER THEY MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, SIT THEM OUT. For more information and resources, visit and Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services Appendix Big Ten Acknowledgement Form Revised July, 2015 Blli?ll CONFERENGE Big Ten Injury and Illness Reporting Acknowledgement Form I, acknowledge that have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the sports medicine staff of my institution team physician, athletic training staff). I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any complaints, prior injuries and/or disabilities experienced. I hereby af?rm that have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at my institution. I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. have been provided with education on head injuries and understand the importance of immediately reporting of a head injury/concussion to my sports medicine staff. By signing below, I acknowledge that my institution has provided me with speci?c educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. I, have read the above and agree that the statements are accurate. Student-athlete?s name Signature of student-athlete Date Name of person obtaining consent Signature of person consenting 5/2010 BlliTEll GDHFEREHGE Big Ten Coaches Concussion Acknowledgement Form I. acknowledge that as a member of the athletic department at. . I accept responsibility for supporting our sports medicine department's policy on concussion management. i understand that my student-athletes may have a risk of head injury and/or concussion. I also understand the importance ofthem reporting any such of a head injury/concussion to the sports medicine staff team physician, head athletic trainer). I also accept responsibility for reporting to the sports medicine staff any signs or that i may witness. By signing below, I acknowledge that my institution has provided me with educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. I, have read the above and agree that the statements are accurate. Signature of coach Date Name of person obtaining acknowledgement Signature of such person 5/2010 Appendix University of Illinois Sports Medicine Department Acknowledgement Form Revised July, 2015 University of Illinois Division of Intercollegiate Athletics Sports Medicine Department Athletic Trainer Team Physician Concussion Policy Acknowledgement Form 1, acknowledge as a member of the DIA Sports Medicine Staff/Team Physician, have received a copy of the Concussion Management Protocol and have been able to review and ask questions relating to the protocol. By signing below, I acknowledge that the DIA Sports Medicine Department has provided me with educational materials on concussion management. I understand that is my primary responsibility, as a member of the DIA Sports Medicine staff, is the health and wellness of our student-athletes. Signature of Athletic Trainer/Team Physician Date Print Name of Athletic Trainer/Team Physician Appendix User Instructions Revised July, 2015 Sports Medicine Department User Instructions Lo -In go Request to be added as University of Illinois user by Director of Sports Medicine 0 You will receive an email with log-in instructions once you are added. 0 Go to: - Enter user name and password: 0 User name is Illinois.edu email address. 0 Password will be provided in the email and you will be prompted to create your own password after initial log-in. Baseline Testing of Athlete 0 Go to: 0 Select ?Illinois? in the drop-down box. 0 Click on ?Launch Baseline Test? button. 0 Enter Customer ID Code: GBR68PE7TR If you forget the code, you can obtain it by logging into the customer center (see above instructions) and clicking on ?Custome ID Code? button. 0 Click on ?Launch Baseline Test? button. 0 Have athlete proceed with taking baseline test. 0 Use an external mouse not a touch pad. 0 Ensure testing area is quiet and limit outside distractions during the test. Post-Concussion Testing of Athlete 0 Log-in to Customer Center (see above instructions) 0 Click on ?Start New Test? button. 0 If athlete has NOT previously taken an test 0 Select ?University of Illinois (Athletics)? from the drop-down box. 0 Click on ?Launch Post Injury 1? button. 0 A pop-up will ask: ?Should a second set of questions occur at the end of this Post- Injury test?? Select ?Yes? 0 Click on ?Launch Test? button at bottom of pop-up box. Have athlete proceed with taking post-injury test. Revised Jan?14 I Use an external mouse not a touch pad. I Ensure testing area is quiet and limit outside distractions during the test. I If athlete has previously taken an test 0 0 Reports Type in test taker?s name Select athlete from drop?down box. Click on ?Launch Post Injury 1? button (or other post injury version if athlete has previously taken version 1) A pop-up will ask: I ?Should a second set of questions occur at the end of this Post? Injury test?? Select ?Yes? I ?Would you like to skip the demographics section of the test?? Select ?No? Click on ?Launch Test? button at bottom of pop-up box. Have athlete proceed with taking post-injury test. I Use an external mouse not a touch pad. I Ensure testing area is quiet and limit outside distractions during the test. 0 Test Lookup/Clinical Reports 0000 0 Click on ?Test Lookup/Clinical Report? in right hand menu. Type in the ?rst two letters of the last name of the test taker. Select athlete from drop-down box. A grid of all the tests taken by that test taker will appear. Select the tests you would like to include in the report. I To select multiple tests, hold down the key as you click (MAC users hold the command key). Click ?Generate Report w/ Norms? button. A pop-up will tell you your report has been created. Click button. Print or save the report. 0 Organizational Reports (generates a report to track tests taken) 0 0 Click on ?Organization Report? in right hand menu Select ?University of Illinois (Athletics)? from drop-down box. Enter start and end dates note all tests completed before July 24, 2012 are not available through the on-line version. Select report ?elds to include. Click on ?Search? button. Revised Jan-14 Appendix Balance Error Scoring System (BESS) User Instructions Revised July, 2015 Balance Error Scoring Svstem (BESS) Developed by researchers and clinicians at the University of North Carolina?s Sports Medicine Research Laboratory, Chapel Hill, NC 27599-8700 The Balance Error Scoring System provides a portable, cost-effective, and objective method of assessing static postural stability. In the absence of expensive, sophisticated postural stability assessment tools, the BESS can be used to assess the effects of mild head injury on static postural stability. Information obtained from this clinical balance tool can be used to assist clinicians in making return to play decisions following mild head injury. The BESS can be performed in nearly any environment and takes approximately 10 minutes to conduct. Materials 1) Testing surfaces -two testing surfaces are need to complete the BESS test: floor/ground and foam pad. 1a) Floor/Ground: Any level surface is appropriate. 1b) Foam Pad (Power Systems Airex Balance Pad 81000) Address PO Box 31709 Knoxville, TN 37930 tel 1-800-321-6975 Web Address Dimensions: Length: 10? Width: 10? Height: 2.5? The purpose of the foam pad is to create an unstable surface and a more challenging balance task, which varies by body weight. It has been hypothesized that as body weight increases the foam will deform to a greater degree around the foot. The heavier the person the more the foam will deform. As the foam deforms around the foot, there is an increase in support on the lateral surfaces of the foot. The increased contact area between the foot and foam has also been theorized to increase the tactile sense of the foot, also helping to increase postural stability. The increase in tactile sense will cause additional sensory information to be sent to the CNS. As the brain processes this information it can make better decisions when responding to the unstable foam surface. 2) Stop watch -necessary for timing the subjects during the 6, twenty second trials 3) An assistant to act as a spotter -the spotter is necessary to assist the subject should they become unstable and begin to fall. The spotter?s attention is especially important during the foam surface. 4) BESS Testing Protocol -these instructions should be read to the subject during administration of the BESS 5) BESS Score Card (See end of document) BESS Test Administration 1) Before administering the BESS, the following materials should be present: ?foam pad -stop watch -spotter -BESS Testing Protocol -BESS Score Card 2) Before testing, instruct the individual to remove shoes and any ankle taping if necessary. Socks may be worn if desired. 3) Read the instructions to the subject as they are written in the BESS Testing Protocol. 4) Record errors on the BESS Score Card as they are described below. Scoring the BESS Each of the twenty-second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the subject. The examiner will begin counting errors only after the individual has assumed the proper testing position. Errors: An error is credited to the subject when any of the following occur: 0 moving the hands off of the iliac crests 9 opening the eyes 0 step stumble or fall 0 abduction or flexion of the hip beyond 30? 0 lifting the forefoot or heel off of the testing surface 0 remaining out of the proper testing position for greater than 5 seconds -The maximum total number of errors for any single condition is 10. Normal Scores for Each Possible Testing Surface Firm Surface Foam Surface Double Leg Stance .009 i .12 .33 i- .90 Single Leg Stance 2.45 i 2.33 5.06 i 2.80 Tandem Stance .91-1- 1.36 3.26i2.62 Surface Total 3.37 i 3.10 8.65 i 5.13 BESS Total Score 12.03 i 7.34 Maxim um Number of Errors Possible for Each Testing Surface Firm Surface Foam Surface Double Leg Stance 10 10 Single Leg Stance 10 10 Tandem Stance 10 10 Surface Total 30 30 -if a subject commits multiple errors simultaneously, only one error is recorded. For example, if an individual steps or stumbles, opens their eyes, and removes their hands from their hips simultaneously, then they are credited with only one error. -subjects that are unable to maintain the testing procedure for a minimum of five seconds are assigned the highest possible score, ten, for that testing condition. Double leg stance: Standing on a firm surface with feet side by side (touching), hands on the hips and eyes closed Single leg stance: Standing on a firm surface on the non-dominant foot (defined below), the hip is flexed to approximately 30? and knee flexed to approximately 45?. Hands are on the hips and eyes closed. *Non-Daminant Leg: The non-dominant leg is defined as the opposite leg of the preferred kicking leg Tandem Stance: Standing heel to toe on a firm surface with the non-dominate foot (defined above) in the back. Heel of the dominant foot should be touching the toe of the non-dominant foot. Hands are on the hips and their eyes are closed. Script for the BESS Testing Protocol Direction to the subject: I am now going to test your balance. Please take your shoes off, roll up your pant legs above ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of 6 - twenty second tests with three different stances on two different surfaces. I will describe the stances as we go along. DOUBLE LEG STANCE: Direction to the subiect: The ?rst stance is standing with your feet together like this [administrator demonstrates two-legged stance] You will be standing with your hands on your hips with your eyes closed. You should try to maintain stability in that position for entire 20 seconds. I will be counting the number of times you move out of this position. For example: if you take your hands off your hips, open your eyes, take a step, lift your toes or your heels. If you do move out of the testing stance, simply open your eyes, regain your balance, get back into the testing position as quickly as possible, and close your eyes again. There will be a person positioned by you to help you get into the testing stance and to help if you lose your balance. Direction to the spotter: You are to assist the subject it they fall during the test and to help them get back into the position. Direction to the subject: Put your feet together, put your hands on your hips and when you close your eyes the testing time will begin [Start timer when subject closes their eyes] SINGLE LEG STANCE: Direction to subiect: If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now stand on your non-dominant foot. [Before continuing the test assess the position of the dominant leg as such: the dominant leg should be held in approximately 30 degrees of hip ?exion and 45 degrees of knee ?exion] Again, you should try to maintain stability for 20 seconds with your eyes closed. I will be counting the number of times you move out of this position. Place your hands on your hips. When you close your eyes the testing time will begin. [Start timer when subject closes their eyes] Direction to the spotter: You are to assist the subject if they fall during the test and to help them get back into the position. TANDEM STANCE: Directions to the subject: Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly distributed across both feet. Again, you should try to maintain stability for 20 seconds with your eyes closed. I will be counting the number of times you move out of this position. Place your hands on your hips. When you close your eyes the testing time will begin. [Start timer when subject closes their eyes] Qirection to the spotter: You are to assist the subject if they fall during the test and to help them get back into the position. Repeat each set of instructions for the foam pad Score Card Balance Error Scoring System (BESS) (Guskiewicz) SCORE CARD: FIRM FOAM Balance Error Scoring System errors) Surface Surface Types Of Errors Double Leg Stance 1. Hands lifted off iliac crest (feet together) 2. Opening eyes Single Leg Stance 3. Step, stumble, or fall (non-dominant foot) 4. Moving hip into 30 degrees abduction Tandem Stance 5. Lifting forefoot or heel (non-dom foot in back) 6. Remaining out of test position >5 sec Total Scores: The BESS is calculated by adding one BESS TOTAL: error point for each error during the 6 20-second tests. Which foot was tested: El Left El Right which is the non-dominant foot) Appendix Sport Concussion Assessment Tool -3 (SCAT3) Revised July, 2015 Downloaded from bjsm.bmj.com on February 5, 2014 - Published by group.bmj.com For use by medical professmnals only Name Date/Time of Iniury Date of Assessment What is the The SCAT3 is a standardized tool for evaluating athletes for concussrcin and can be used in athletes aged from 13 years and rider It supersedes the orig- inal SCAT and the SCAT2 published in 2005 and 2009, respectively? For younger persons, ages 12 and under, please use the Child SC AT3 The IS de5igned for use by medical professionals. If you are not qualified, please use the Sport Concussmn Recognition Tool? Preseason baseline testing With the SCAT3 can be helpful for interpreting post-injury test scores SpeCI?c Instructions for use of the are prowded on page 3. If you are not familiar With the SCATB, please read through these instructions carefully This tool may be freely copied '1 its current form ford stribution to ndividuals. teams, groups and organizations Any revrsion or any reproduction in a digita form re- qurres approval by the Concussmn in Sport Group NOTE: The diagnosn of a concussron is a clinical Judgment, ideally made by a medical professwnal The SCAT3 should not be used solely to make, or exclude, the diagnons of concussmn in the absence of clinical Judgement An athlete may have a concusnon even if their SC AT3 is "norma." What is a concussion? A concussmn is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-speCIfic Signs and/or (some examples listed below) and most often does not invo ve loss of consoousness Concussmn should be suspected in the presence of any one or more of the followrng - headache), or - Physical Signs unsteadiness), or - Impaired brain funct on (eg. confusion) or - Abnormal behaviour le.g., change in personality' SIDELINE ASSESSMENT Indications for Emergency Management NOTE: A hit to the head can sometimes be assocrated With a more serious brain injury Any of the followmg warrants conSIderation of activating emergency pro- cedures and urgent transportation to the nearest hospital - Glasgow Coma score less than 15 - Deteriorating mental status - Potential spinal injury - Progressive, worsening or new neurolog Signs Potential signs of concussion? If any of the fo"ow ng Signs are observed after a direct or rid rert ow to the head the ath ete should stop partiopation, be evaluated by a medical profes- 5iona and should not be permitted to return to sport the same day if a concussron 's suspected Any loss of consoousness7 ?lf so, long?" Balance or motor Incoordlnation (stumbles. slow.' laboured movements, etc )7 Disorientation or confusion (inability to respond appropriately to questions)7 Loss of memory "If so, how long? 2 "Before or after the injury? Blank or vacant look Vi5ible facial injury in combination With any of the above SCAT3 SPORT CONCUSSION ASSESMENT TOOL 3 PAGE 1 ii Sport Concussion Assessment Tool - 3rd Edition Examiner Glasgow coma scale (GCS) Best response (E) No opening opening in response to pain opening to speech Eyes opening spontaneously hWN?i Best verbal response (V) No verbal response sounds Inappropriate Words Confused Oriented whwwa Best motor response (M) No motor response Extension to pain Abnormal fleXIon to pain Flex Orr/Withdrawal to pain Localizes to pain Obeys commands Glasgow Coma score (E M) GCS should be recorded for all athletes in case 01 subsequent deterioration Maddocks Score? 'Iam going to ask you a few questions. please t-sten carefully and give your best effort Modified Maddocks questions (1 paint for each correct answer) What venue are we at today? 0 1 Which half is it now? 0 1 Who scored last in th 5 match? 0 1 What team did you play last week/game? 1 Did your team Win the last game? 0 1 Maddocks score of Maddotks score is validated lor sideline diagnose oi concussion only and is nut used lor serial testing Notes: Mechanism of Injury ('tel me whathappened'ii Any athlete with a suspected concussion should be REMOVED FROM PLAY, medically assessed. monitored for deterioration should not be left alone) and should not drive a motor vehicle until cleared to do so by a medical professional. No athlete diag? nosed with concussion should be returned to sports participation on the day of Iniury. 2013 Contussmn tn Sport Group 259 Downloaded from bjsm.bmj.com on February 5, 2014 - Published by group.bmj.com BACKGROUND Name Date Examiner Sport/team/school Datelt me of ll'iJUfy Age Gender Years of education completed Dominant hand right left neither How many concussrons do you think you have had in the past? When was the most recent concussron? How long was your recovery from the most recent concussion7 Have you ever been hospitalized or had medical Imaging done for a head injury? Have you ever been diagnosed With headaches or migraines? Do you have a learning disability, dysleXia, Have you ever been diagnosed With depressron, anxrety or other disorder? Has anyone in your family ever been diagnosed With any of these problems? Are you on any medications? if yes, please list SCAT3 to be done in resting state. Best done 10 or more minutes past excercise. EVALUATION How do you feel? You should score yourself on the fo.'.'cw.ng based on how you feel now mild moderate severe Headache "Pressure in head" Neck Pain Nausea or vomiting Dizzmess Blurred viSion Balance problems Sen5itivrty to light Sensrtivity to norse Feeling slowed down Feeling like "in a fog" ?Don't feel right" Difficulty concentrating Difficulty remember ng Fatigue or low energy Confusion Drowsrness Trouble falling asleep More emotional Irritability Sadness Nervous or Amtious Total number of (Maximum possible 22) L. i severity score (Maximum possible 132) Do the get worse With physical activrty7 00 the get worse With mental self rated self rated and clinioan monitored clinician interwew self rated With parent input Overall rating: If you know the athlete well prior to the injury, how different is the athlete act.ng compared to his/her usual self? PIEBSE leC 8 one no different very different unsure Scoring on the SCAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete's readiness to return to competition after concussion. Since signs and may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion. HE SCAT3 SPORT CONCUSSION ASSESMENT TOOL 3 PAGE 2 COGNITIVE 8: PHYSICAL EVALUATION Cognitive assessment Standardized Assessment of Concussion Orientation (l point for each correct answer) What month is it? 0 1 What is the date today? 0 '1 What is the day of the week? 0 ?i What year is it? 0 i What time is it right now? (wrihin I hour) 0 1 Orientation score of 5 Immediate memory List Trial 1 Trial 2 Tr:al 3 Alternative viiord I:st elbow 0 1 1 0 i candle baby ?nger apple 0 1 0 i 0 1 paper monkey penny carpet 0 i 1 1 sugar perfume blanket saddle 0 i 0 1 0 i sandwich sunset lemon bubble i i 0 1 wagon iron insect Total Immediate memory score total of ?6 Concentration Digits Backward List Trial 1 Alternative digit list 4-9-3 0 1 6-2?9 5?2.5 4-1-5 3~8-i-4 0 i 3 9 i-7-9-S 4-9?6-8 5-2-9-7-1 1 15-2-86 3-3-5-2-7 6-1-8-4-3 7-1-8-4-6-2 1 5-3-9-1-4-8 8-3-1-9-6-4 7-2-4-8-5-6 Total of4 Concentration' Month in Reverse Order (1 or for entiresequente correct) CI 1 Concentration score of 5 Neck Examination: Range of motion Tenderness Upper and lower limb sensationaistrength Findings: Balance examination Do one or both of the following tests. Footwear (shoes, barefoot, braces, tape, etc i Modified Balance Error Scoring System (BESS) testingI Which foot Was tested which sthe non-dominant fooii Left Right Testing surface (hard floor, field, etc.i Condition Double leg stance Errors Single leg stance (non-dominant foot) Errors Tandem stance (non-dominant foot at back) Errors And/Or Tandem gait" Time (best or a trials) seconds Coordination examination Upper limb coordination Which arm was tested Left Right Coordination score - SAC Delayed Recall? Delayed recall score of 5 2013 Concussion in Sport Group DOWnloaded from bjsm.bmj.com on February 5, 2014 - Published by group.bmj.com INSTRUCTIONS Words in italics throughout the SCAT3 are the instructions given to the ath ete by the tester Scale ?You should scare yourself on the following based on haw you feel noiiv To be competed by the athlete In situations where the scale is being completed after exercrse, it should still be done in a rest ng state, at least 10 minutes post exercrse For total number of maximum possih'e is 22 For severity score, add all scores In table. maxrmum is 22 x6 . 13;i Immediate Memory 1' am gorng to test your memory I will read you a list of words and when I am done. repeat back as many words as you can remember in any order Trials 2&3: ?t am gorng to repeat the same listagain Repeat back as many words as you can remember in any order, even if you said the word befcre Complete all 3 trials regardless of score on trial 1&2. Read the words at a rate of one per second Score 1 pt. for each correct response. Total score equals sum across all 3 trials Do not inlorm the athlete that delayed recall Will be tested Concentration Digits backward "i am gorng to read you a string of numbers and when lam done you repeat them back to me backwards, in reverse order of how read them to you For example if I say 7-1-9 you would say9 1-7 11 correct, go to next string length If incorrect, read trial 2. One point possible for each string length Stop alter incorrect on both tr als The digits should be read at the rate of one per secarto Months in reverse order ?Now tell me the months of the year in reverse order Start With the last month and go backward So you'll say December, Noyember Go ahead" 1 pt. for entire sequence correct Delayed Recall The delayed recall should be performed after completion of the Balance and Coor? dinat on Examination "Do you remember that list of words tread a few times earlier? Tell me as many Words from th 9 list as you can remember in any order Score 1 pt. for each correct response Balance Examination Modified Balance Error Scoring System (BESS) testing5 This balance testing is based on a modified versron of the Balance Error Scoring System A stopwatch or watch With a second hand is reqwred for this testing "i am now gorng to rat your balance Please take your shoes off roll up your pant legs above ankle (ifapplicab-'e) and remove any ankle taping (if applicablel This test WiliI consist of three twenty second tests with different stances Double leg stance: "The ?rst stance is standing w.th your feet together With your hands on your hip; and with your eyes closed You should try to maintain stability in that posrtion for 20 seconds leri be counting the number of times you move out of this position i start timing when you are set and have closed your eyes Single leg stance: you were to kick a ball, which foot would you use? [This Will be the dominant foot] Now stand on your non-dominant foot The dominant leg should be held in approxrmately 30 de- grees ofh.p flexion and 45 degrees of knee flexron Again you should try to maintain stability for 20 seconds With your hands on your hips and your eyes closed Will be counting the number of times you move out of this pasrtron If you stumble out of this position open your eyes and return to the start posmon and continue balancing start timing when you are set and have closed your eyes Tandem stance: Now stand heel-to toe With your non dominant foot in back Your weight should be evenly distributed across both feet Again you should try to maintain stability for 20 seconds With your hands on your hips and your eyes closed I Will be counting the number of times you move out of this posrtion If you stumble out of this posrtion, open your eyes and return to the start position and continue start timing when you are set and have closed your eyes SCAT3 SPORT CONCUSS ON ASSESMENT TOOL 3 PAGE 3 Balance testing types of errors 1 Hands lifted off iliac crest 2 Opening eyes 3. Step, stumble, or fall 4 Moving hip into 30 degrees abduction Lifting forefoot or heel 6 Remaining out of test posrtion 5 sec Each of the 20-second tr als is scored by counting the errors, or devrations from the proper stance, accumulated by the athlete The examiner begin counting errors only after the indiv dual has assumed the proper start posrtion The modified BESS is calculated by adding one error point for each error during the three 20-second tests. The maximum total number of errors for any single Con+ dition is 10. if a athlete commits multiple errors simultaneously, only one error is recorded but the athlete should return to the testing posrtion, and counting should resume once l5 set Subjects that are unable to maintain the testing procedure for a nimum of five seconds at the start are assigned the highest possible score, ten, for that testing condition OPTION: For further assessment, the same 3 stances can be performed on a Surface of medium density foam le 9.. approx mater 50 cm x40 cm 6 cm]. Tandem Gait? Particrpants are instructed to stand w-th their feet together behind a starting line (the test is best done With footwear removed] Then they walk in a forward direction as qurcki'y and as accurately as possible along a 38mm Wide i'sports tape), 3 meter 'ine with an alternate foot heel-to-roe gait ensuring that they approXimate their heel and toe on each step Once they cross the end of the 3m line, they turn 180 degrees and return to the starting pornt using the same gait A total of 4 tools are done and the best time is retained Athletes should complete the testin l4 seconds Athletes fail the testif they step off the line, have a separation between their heel and toe or if they touch or grab the examiner or an object In this case the time not recorded and the trial repeated if appropriate Coordination Examination Upper limb coordination Finger-to-nose (FTN) task 'l am gorng to test your coordination now Please sit comfortably on the chair With your eyes open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow and ?ngers extended) painting in front of you When lgive a start Signal, lwould like you to perform ?ve successwe ?nger to nose repetitions using your index finger to touch the rip of the nose. and then return to the starting posi tron, as quickly and as accurately as Scoring: 5 correct repetitions in 4 seconds :1 Note for testers: Athletes fall the test if they do not touch their nose, do not lul'y extend their elbow or do not perform live IEPELUOHS. Failure should be scored as 0. References Footnotes 1 This tool has been developed by a group of international experts at the 4th In ternational Consensus meeting on Concu55ion in Sport held in Zurich, in November 2012 The full details of the conference outcomes and the authors of the tool are published in The BJSM Injury Prevention and Health Protection, 2013, Volume 47, Issue 5 The outcome paper Will also be Simultaneously co-published in other leading biomedical Journals the copyright held by the Concussron in Sport Group, to allow unrestricted d-stribution, provrd ng no alterations are made 2 McCrory et al Consensus Statement on Concussron in Sport the 3rd Inter- national Conference on Concuss on .n Sport held in Zurich, November 2008. British Journal of Sports Med one 2009, 43 i76-89 3 Maddocks, DL, Dicker, GD, Sa'lng, MM The assessment of orientation followrng concussion in athletes Clinical Journal of Sport Medicine. 1995, 5(1) 32?3. 4 McCrea Standardized mental status test-ng of acute concu55ion Clinical Jour- nal of SponMedicrne 2001, 11 176?181 5 Guskiewrcz KM Assessment of postural stability iollowrng sport-related conCUs- sron Current Sports Medicme Reports 2003, 2: 24?30. 6 Schneiders, AG, Sui van, 51, Gray, A, Hammond-Tooke, &McCrory, Normative values for 16-37 year old subjects for three clin cal measures of motor performance used in the assessment of sports concussrons Journal of Scrence and Medicrne in Sport. 2010, 13(2) 196?201. 7 Schneiders, A.G . Sull van, J, Olsson, Yden SiMarshal, SW. The effect of footwear and sports-surface on dynamic neurological screen- ing in sport-re ated concussion Journal of Science and Medrcme in Sport 2010, 13(4) 382-386 CI 2013 Concussron in Sport Group 261 Downloaded from on February 5. 2014 - Published by group.bmj.com ATHLETE INFORMATION Any athlete suspected of having a concussion should be removed Scoring Summary: Test Domain Score from play, and then seek medical evaluation. Date Date Date Signs to watCh for Number of of 22 Problems could arise over the first 24?48 hours. The athlete should not be left alone Seventy Score of 132 and must go to a hospital at once if they Orientation of 5 - Have a headache that gets worse . Immediate Memory of 15 - Are very drowsy or can be awakened - Can't recognize people or places Concentrat'on 0f 5 - Have repeated vomiting Delayed Recall of 5 I - - Behave unusually or seem confused; are very irritable SAC Total - Have seizures (arms and legs Jerk uncontrollably) - Have weak or numb arms or legs - Are unsteady on their feet; have slurred speech Remember, it is better to be safe. Consult your doctor after a suspected concussion. BESS (total errors) Tandem Gait (seconds'i Coordination of 1 Return to play Notes: Ath etes should not be returned to play the same day of ll'lJUry When returning athletes to play, they should be medically cleared and then follow a stepwise supervised program, With stages of progressron For example: Rehabilitation stage Functional exercise at each stage Dbiecirve of each stage 0' rehabilitation No act vtty Physica and cognitive rest Re 'overy Light aerobic exercise Walking or stationary cycling ln ease "aalt rate keep rig intensity, 70 maximum predicted heart rate No resistance training Sport-specific exercise Skai ng drills in ice hockey, running drills in Add mi. .err- int soccer No head impact activities Hon-contact Frogressmn to more complex training drills E-ercise coordinat on and training drills eg passing In football and ice hociiey cognit ve load May start progressive esmance training Full contact practice Following medical clearance partictpate in Restore - nlidence and assess normal training actmties functionai Ski'lS by coaching stafl Return to play Normal game play There should be at least 24 hours (or longer) for each stage and if recur the athlete should rest until they resolve once again and then resume the program at the previous stage Re5istance training should only be added in the later stages If the athlete is for more than 10 days. then consultation by a medical practitioner who IS expert in the management of concu55ion, 15 recommended Medical clearance should be given before return to play. Pat ent's name (To be given to the person monitoring the concussed athlete) Date/time of injury This patient has received an injury to the head A careful medical examination has been carried out and no sign of any serious complications has been found Recovery time IS variable across indiwduals and the patient Will need monitoring for a further period by a responSible adult Your treating physician Will provide gwdance as to this timeframe Date/time of medical rev ew If you notice any change in behaviour, vomiting. dizziness. worsening head- ache, double vision or excessive drowsiness, please contact your doctor or the nearest hospital emergency department immediately Other important points: - Rest (physically and mentally), including training or playing sports untii resolve and you are medically cleared - No alcohol - No prescription or non-prescription drugs without medical I Specn?ically - No sleeping tablets Do not u5e aspirin, anti-inflammatO'y medication er sedating pain killers - Do not drive until medically cleared - Do not train or play sport until med ca 'y cleared Clinic phone number SCAT3 SPORT CONCUSSION ASSESMENT TOOL 3 PAGE 4 262 Contact deta Is or stamp 2013 Concussron ll'I Sport Group Downloaded from bjsm.bmj.com on February 5. 2014 - Published by group.bmj.com SCAT3 Sports Med 2013 47: 259 Updated information and services can be found at: References Email alerting These include: Article cited in: Receive free email alerts when new articles cite this article. Sign up in service the box at the top right corner of the online article. Topic Articles on similar topics can be found in the following collections Collections Injury (806 articles) Trauma (728 articles) Trauma CNS PN8 (111 articles) Notes To request permissions go to: To order reprints go to: To subscribe to BMJ go to: Appendix Head Injury Take Home Instructions Revised July, 2015 University of Illinois Division of Intercollegiate Athletics Sports Medicine Department HEAD INJURY INSTRUCTIONS Athletes with suspected head injuries will follow the instructions listed below: This sheet should be read by yourself and given to your roommate or family member who will be with you for the next 24 hours. A. Do NOT take any aspirin, ibuprofen or any other pain medication or any anti- B. C. in?ammatory medication unless directed by the team physician. You are out of ALL activity; including no contact sports and no weight lifting, until cleared by the Sports Medicine Staff. If you experience any of the following conditions: Persistent, intense headache or headache that worsens in intensity Nausea and/or Vomiting Ringing in the ears Slurring of Speech Blurred or double vision Dif?culty breathing Memory loss Confusion or irritability Convulsions Lack of coordination, dif?culty walking Unconsciousness or unresponsiveness Please contact one of the athletic trainers or the physician at the phone numbers listed below, regarding any of the listed above or if any questions arise concerning your condition. was 19-9 If there is a true medical emergency, call for an ambulance by dialing 9-911 (campus) or 911 (off campus). Your normal follow-up care will include: Report to the Training Room On: At: Phone numbers: Athletic Trainer: Training Room: Emergency/Ambulance 9-911 (campus) 911 (off campus) Revised June ?15 Appendix Daily Post Concussion Scale Revised July, 2015 University of Illinois Division of Intercollegiate Athletics Sports Medicine Department Daily Post Concussion Scale This is a list of that are commonly reported by individuals who have sustained a concussion. On the chart below, please indicate the extent that you have each of these today. If you do not have the your score would be 0, if the is severe your score would be 6. Athlete?s Name: Sport: Today?s Date: Concussion Date: Rating None Mild Moderate Severe Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble Falling Asleep Sleeping More than Usual Sleeping Less Than Usual Drowsiness Sensitivity To Light Sensitivity to Noise Irritability Sadness Nervousness Feeling More Emotional Numbness or Tingling Feeling Slowed Down Feeling Mentally ?Foggy? Dif?culty Concentrating Dif?culty Remembering Visual Problems Total Score Total hours of. Sleep Indiana University Athletics Concussion Management Policy The Indiana University Department of intercollegiate Athletics Concussion Management Policy follows the direction and guidance of the Concussion Safety Protocol Committee (Committee) and is compliant with a concussion management plan recommended by the Committee. It is a dynamic policy that wili be reviewed and edited as necessary to remain consistent with the most recent best practices of concussion management as set forth by the Committee. introduction: Concussion management is challenging due to the fact that concussion risk is highly individualized. A blow to the head with the exact same forces will yield different of differing severity depending on the individual concussed. Additionally, the brain is dynamic, especially in the developmental years of youth and adolescence, and is influenced by a multitude of other factors sleep deprivation, dehydration, fatigue, depression, headache disorders, drugs and supplements etc.). International experts have convened at conferences on four occasions, most recently in Zurich in 2012, in attempts to form consensus statements on the management of sports?related concussion. What has resulted is a recommendation to abandon the concept of categorizing concussions by ?grades or labeling them as ?simple? or ?complex? based on signs, and severity at presentation for the purpose of making return-to?play decisions. This supports the realization that sports concussion diagnosis and management needs to be individualized, and does not lend itself to a ?cookbook? approach. Noting this premise, some fundamental principles apply to concussion management. )1 Definition: Concussion is a complex pathophysiological process affecting brain function and induced by traumatic biomechanical forces. Concussion may or may not result in a loss of consciousness. it is most commonly characterized by the rapid onset of a constellation of physical, cognitive, emotional and sleep?related may last from several minutes to days, weeks, months or even longer in some cases. A working diagnosis of concussion includes two criteria: 1.) A mechanism of injury to the head or an ?event? which can involve direct or indirect forces and 2.) That event results in one or more of the common associated with concussion and/or any sign of a concussion. Pre -Season Education: Treatment of concussion in sports is a team endeavor. Education of the student-athletes, coaches, team physicians, athletic trainers, Director of Athletics and other administrators and academic personnel about concussion and the potential for chronic or permanent injury is essential to their understanding and cooperation with treatment. Time will be allotted in a preseason team meeting for education of the coaches and student-athletes about concussive injuries and the procedural guidelines for treatment of concussion are received by each player and coach. Each student?athlete and coach has the responsibility to report events or behaviors that might indicate that a concussion has occurred. Student?athletes will sign a statement in which they accept the responsibility for reporting all of their injuries and illnesses to the medical staff, including signs and of concussions. All Indiana University student?athletes, coaches, team physicians, athletic trainers and the Director of Athletics will annually be provided by the institution NCAA concussion fact sheets (or other applicable material) and will annually sign a statement to acknowledge they understand those fact sheets (and/or other concussion material provided), the concussion management policy, their role within the policy and that they have received education about concussions and have had an opportunity to ask questions. Each student-athlete and coach will receive a copy of the sequence of events that will occur at practice or on game day if a concussion is suspected or diagnosed (Appendix A). Recent guidelines from the Big Ten Conference and NCAA have emphasized that protocols are moving from best practices to regulatory standards by the conference, taking what were once recommendations by the NCAA and making them official policy with consequences for violation. Under the new standards the Big Ten Conference will issue penalties for failure to comply with reporting requirements, rules on removing players from the field and other aspect of the association?s concussion guidelines. Pre-Participation Assessment: Every student-athlete will receive at least one pre?participation baseline concussion assessment that addresses brain injury and concussion history, evaluation, cognitive assessment and balance evaluation. The team physician will determine pre?participation clearance and/orthe need for additional consultation or testing. Any student?athlete with a documented concussion, especially those with complicated or multiple concussion history, a new baseline concussion assessment will be considered six months or beyond the initial baseline concussion assessment. Additionally, any history of migraine/headache disorders, or other learning disabilities, or sleep disorder and drug or alcohol abuse will be recorded and considered in the assessment. The baseline concussion assessment will be stored electronically and will be accessible at practices or competition. This comparison allows for a more accurate assessment ofthe injury (Appendix B). The pre-participation assessment will also include a more detailed baseline computerized neurocognitive testing of the student?athlete?s speed and memory function test). Such testing aims to serve as an objective technique to assess neurocognitive function in an uninjured state. Recognition and Diagnosis of Concussion: If a student-athlete is diagnosed with or suspected of having experienced a concussion based on consistent with a concussion, they will be immediately removed from the activity practice, competition and/or conditioning) and not allowed to return to activity that day if a concussion is confirmed. They will be evaluated by the Certified Athletic Trainer (ATC) and/or Team Physician with concussion experience. If the injury occurs in the sport of football, the student athlete is taken to the training room for evaluation. If the injury occurs at a venue without an official designated training room, the evaluation will be made in the most appropriate setting as determined by the medical staff. As part of the evaluation, a history will be taken from the patient about their injury. A standardized ?sideline? evaluation for concussion will be performed and compared to their baseline SCAT This evaluation will be part of an initial suspected concussion evaluation management plan which will also include a assessment, physical and neurological exam, cognitive assessment, balance exam and clinical assessment or cervical spine trauma, skull fracture and intracranial bleed. Additionally, observation of the injury event by the medical staff, coaching staff and game officials can also provide valuable information in determining if a concussion injury has occurred. If it is determined that a concussion has occurred the student athlete will remain in the training room (in football and in other sports if possible) and not return to practice, competition or conditioning. in the sport of football, a trained, unaffiliated certified athletic trainer with previous sideline experience will be stationed in the replay booth as an ?eye in the sky? to observe players that might have sustained a concussive injury not witnessed by on-field personnel. This person will have the capability of communicating with the sideline medical staff of each team to alert them of a potentially injured player as well as having access to video replay to further evaluate the play where the player might have been concussed. Additionally, IU Athletics will have a neurosurgeon on the lU sideline at each home and away football game to assist in the diagnosis and evaluation of potential concussed players. Post-Concussion Management: The immediate evaluation of the head-injured athlete will include an assessment of airway, breathing and circulation cervical spine, skull fracture as well as any signs of a more serious head injury to determine if a controlled, stabilized removal from the field and tran5portation to the nearest hospital is necessary. Conditions that would require transport to a designated hospital for further medical care are for any of the following: Glasgow Coma Scale score of <13, a prolonged loss of consciousness, focal neurological deficit suggesting intracranial trauma, repetitive vomiting, persistently diminishing/worsening mental status or other neurological or a Spine injury. One of the medical personnel will observe/monitor the concussed student-athlete for any deterioration in their neurological status which might require further evaluation at a designated hospital. Prior to leaving the practice or competition venue, the athlete will be re-examined and if medically stable, will be discharged with a responsible adult (typically a roommate, friend or family member) and both are given oral and written care instructions to follow until they are seen for a follow- up medical appointment (Appendix C). The student?athlete is treated with both physical and cognitive rest at the direction of the team physician. As part of the treatment process, the team physician will evaluate a student-athlete with a prolonged recovery in order to consider best management options and additional diagnosis, such as post-concussion sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression, and ocular or vestibular dysfunction. Research has shown that determining the functional integrity of the concussed athlete?s brain also requires neurocognitive testing and this modality is being used as part of the standard of care for the diagnosis and treatment of concussion. All student?athletes receive a baseline computerized neurocognitive test prior to starting their collegiate athletics career. Following a concussion, a repeat test will be performed and test performance must return to the baseline level prior to being fully cleared for return-to-play participation. Physical rest precludes exertional activity including sport specific drills, practices, games, weight lifting and conditioning. Return?to-Play: The final determination of return?to-piay of a concussed student-athlete is from the team physician or medically qualified physician designee. In a concussed student-athlete with a complicated or prolonged course the team physician will make the final return-to-play decision after consultation with a concussion management team which may include one or more of the following: a neurosurgeon or other neurospecialist, a a vestibular/ocular motor therapist. The duration it takes to return to activity is completely individualized to the particular student?athlete and is not based on an arbitrary timeframe. Any student-athlete with a concussion must undergo a supervised stepwise progression management plan by a health care provider with expertise in concussions that specifies that the concussed student-athlete will have limited physical and cognitive activity until he/she has returned to baseline, then progresses with each of the following steps without worsening or new (1) Progression starts with light aerobic exercise without resistance training (such as biking orjogging for 15?20 minutes), with gradual and steady increases in exertion if the athlete remains without (2) Sport?specific exercise and activities are then introduced without contact or head impact. (3) Non- contact practice with progressive resistance training. (4) Unrestricted training. (5) Full, unrestricted return-to?competition. This progression can take anywhere from days to weeks and the speed with which the athlete moves through this progression and returns?to-play is dependent on multiple factors and is guided by the medical team. Some of these factors include the clinical signs and prior concussion history (number, remoteness, and severity), history of learning disability, history, sleep disorder, history of migraine headaches, age, sport, position, and the athlete?s lack of hesitancy to return. it is essential that the athlete is completely before any final clearance to return-to-play. Return-to?Learn: In addition to physical concussed student-athletes often experience cognitive and have difficulty performing at their normal academic level. Cognitive rest may necessitate not being able to attend classes and having to observe academic accommodations which reduce the workload on the brain. The timeframe and nature ofthe classes and assignments missed will be determined by the team physician. The team academic advisor will serve as the point person within IU Athletics to navigate return?to-Iearn with the student-athlete. Student-athletes may fall behind in their studies and may not be able to take tests until their brain recovers. Formal guidelines in the form of Academic Accommodations (Appendix D) and Return-to-Learn Guidelines (Appendix E) are expressly a part ofthis concussion management policy. The student-athlete?s concussion should guide the academic workload and weaning and eventual discontinuance of accommodations and restrictions. When the have resolved with activities of daily living including cognitive activities, the athlete must undergo a sport-specific activity progression program without recurrence of as outlined in the Return?to-Learn Guidelines. Potential Complications or Sequelae of Concussions: and signs of concussion in a small percentage of cases may be prolonged and a diagnosis of Post-Concussion may be made requiring specialty consultation with a or Other or signs which inciude sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression and ocular motor/vestibular dysfunction may be persistent and have to be individuain addressed by a specialist or specific therapy. Those specialists have been identified and are part of the medicai team. Role of Imaging: The role of imaging (CT scans and MRI) is very limited in the management of concussion and for most cases, not necessary. For most concussions, these studies are usually normal. These imaging studies do, however, have a role in evaiuating the concussed athlete when a concern exists for associated injuries, such as skull or orbital fractures, intracranial bleeds and seizures, or if the athlete?s persist or neurological status deteriorates. Reducing Exposure to Head Trauma: The recognition and management of concussion will continue to evolve as the knowledge base of concussive brain injury is advanced. Emphasis must continue to be placed on ways to prevent this injury. Prevention is potentially the highest-yield Opportunity in the iexicon of concussion risk reduction. Changes in the rules of collision sports wili be a significant key to the prevention of concussions. Launching one?s body and using one?s helmet as a weapon must be eliminated. Rule changes and enforcement are beginning to reflect these priorities. Sources for safety procedures are found on the websites or organizations committed to athlete safety such as USA Football and the CDC. Coaches and athletes must aiso favor an atmosphere of competitive, but non-combative, competition. Collegiate players, their teams and their institutions set the example for young pe0p e who are beginning to play athletics and brain immaturity puts them at greater risk to sustain injuries. Safe play in all sports should become the example. Consistent with the foregoing, a reducing head trauma exposure management plan has been established, which includes the foilowing: Adherence to inter?Association Consensus: Year-Round Football Practice ContactGuidelines, adherence to inter-Association Consensus: Independent Medical Care Guidelines, reducing gratuitous contact during practice, taking a ?safety first? approach to sport, taking the head out of contact, and coaching and student-athlete education regarding safe play and proper technique. Table 1: Signs and of Concussion SIGNS Amnesia prior to or after injury Headache Loss of consciousness (LOC) Nausea and/or vomiting Slurred/incoherent speech Excessive drowsiness Disoriented to time, place, person Una bie to focus, concentrate Delayed verbal motor responses Feeling hazy, foggy, groggy Vacant sta re Dizziness Light sensitivity Blurry/double vision Loss of balance, feeling unsteady Sensitivity to light/noise Crying unexpectedly or inappropriate behavior Confusion Behavior or personality change Slow to get up Rubbing, squinting or blinking one?s eyes Grabbing or shaking the head Asking for ammonia capsule Atypical response to initial questioning Not ?feeling right? Feeling slowed down .N Appendix A Guidelines for Suspected or Diagnosed Concussion During Practice or Game The student-athlete will be immediately removed from the practice or game. An initial brief assessment for concussion will be made. If a concussion is suspected the student-athlete will be taken to the training room (in football and other sports if possible) and the SCAT Ill will be repeated and compared to the baseline. If a concussion is diagnosed the student-athlete will remain in the training room (if possible) and not return to the field. The concussed student?athlete will be monitored by one of the medical personnel for any deterioration of his neurological exam. If necessary the student-athlete will be ta ken to the emergency department for further diagnosis and treatment. Before returning to their residence, the student-athlete will receive detailed instructions for him and his roommate or family to recognize if the situation is deteriorating. An test will be done at the appropriate time and compared to the baseline (or normative data). Test performance must return to normal (as determined by the team physician) for return to play consideration. Return to play is determined when all have resolved at rest, the neurologic examination is no rmai, the test has returned to baseline (or compares favorably to normative data) and the student?athlete has successfully passed a graded activity progression program without recurrence of concussion Documentation from the team doctor in consultation with other neurological specialists when applicable must be obtained. Apgendix (See next 2 pages) Sport Concussion Assessment Tool 3rd Edition For use by medical professionals only DatelTime of Injury: Date of Assessment: Name What is the The SCAT3 is a standardized tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older. It supersedes the orig- inal SCAT and the SCATZ published in 2005 and 2009, respectively? For younger persons. ages 12 and under, please use the Child SCAT3. The SCAT3 is designed for use by medical professionals. if you are not qualified, please use the Sport Concussion Recognition Tool?. Preseason baseline testing with the SCAT3 can be helpful for interpreting post-injury test scores. Specific instructions for use of the SCAT3 are provided on page 3. If you are not familiar with the SCAT3, please read through these instructions carefully. This tool may be freely copied in its current form for distribution to individuals. teams, groups and organizations. Any revision or any reproduction in a digital form re? quires approval by the Concussion in Sport Group. NOTE: The diagnosis of a concussion is a clinical judgment. ideally made by a medical professional. The SCAT3 should not be used solely to make, or exclude, the diagnosis of concussion in the absence of clinical judgement. An athlete may have a concussion even if their SCAT3 is "normal". What is a concussion? A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specific signs andfor (some examples listed below) and most often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following: - headache), or - Physical signs unsteadiness), or - Impaired brain function confusion) or - Abnormal behaviour change in personality). SIDELINE ASSESSMENT Indications for Emergency Management NOTE: A bit to the head can sometimes be associated with a more serious brain injury. Any of the following warrants consideration of activating emergency pro? cedures and urgent transportation to the nearest hospital: - Glasgow Coma score less than 15 Deteriorating mental status - Potential spinal injury Progressive, worsening or new neurologic signs Potential signs of concussion? If any of the following signs are observed after a direct or indirect blow to the head, the athlete should stop participation, be evaluated by a medical profes? sional and should not be permitted to return to sport the same day if a concussion is suspected. Any loss of consciousness? "lfso, how long?" Balance or motor incoordination (stumbles. slowllaboured movements, etc)? Disorientation or confusion (inability to respond appropriatelyto questions)? Loss of memory; ?if so, how long?" "Before or after the injury?" Blank or vacant look: Visible facial injury in combination with any of the above: SCATB SPORT CONCUSSION ASSESMENT TOOL 3 I PAGE1 .. FMaddocks Score3 Examiner: Glasgow coma scale (GCS) Best response (E) No opening opening in response to pain opening to speech Eyes opening spontaneously norm?- Best verbal response (V) No verbal response Incomprehensible sounds Inappropriate words Confused Oriented thN?i Best motor response (M) No motor response Extension to pain Abnormal flexion to pain Flexioanithdrawal to pain Localizes to pain Obeys commands mun-thde Glasgow Coma score (E M) of IS GCS should be recorded for all athletes in case of subsequent deterioration. "i am going to ask you a few questions, please listen carefully and give your best effort. Modified Haddocks questions (I point for each correct answer) What venue are we at today? 1 Which half is it now? Who scored last in this match? What team did you play last week/game? Did your team win the last game? 00000 1 1 i Maddocks score of 5 Maddocks score is val'dated for sidel'ne diagnosis ofconcussion only and is not used for serial testing. Notes: Mechanism of Injury (?tell mewhat Any athlete with a suspected concussion should be REMOVED FROM PLAY, medically assessed, monitored for deterioration should not be left alone) and should not drive a motor vehicle until cleared to do so by a medical professional. No athlete diag- nosed with concussion should be returned to sports participation on the day of Injury. 2013 Concussion in Sport Group I ,U'ul. I nun? an. an BACKGROUND Name: Date: Examiner: Sportiteamr?school: Date/time of injury: Age: Gender: Years of education completed: Dominant hand: right left neither How many concussions do you think you have had in the past? When was the most recent concussion? How long was your recovery from the most recent concussion? Have you ever been hospitalized or had medical imaging done for a head injury? Have you ever been diagnosed with headaches or migraines? Do you have a learning disability, dyslexia, Have you ever been diagnosed with depression, anxiety or other disorder? Has anyone in your family ever been diagnosed with any of these problems? Are you on any medications? If yes, please list: SCAT3 to be done in resting state. Best done 10 or more minutes post excercise. EVALUATION How do you feel? ?You shorrld score yourself on the rot-owing based on how you feel now". none mild moderate severe .b Headache "Pressure in head" Neck Pain Nausea or vomiting Dizziness Blurred vision Balance problems Sensitivity to light Sensitivity to noise Feeling slowed down Feeling like "in a fog" ?DOn?t feel right" Difficulty concentrating Difficulty remembering Fatigue or low energy Confusion Drowsiness Trouble falling asleep More emotional Irritability Sadness Nervous or Anxious Total number of (Maximum possible 22) severity score (iriaximum possible 132) Do the get worse with physical activity? Do the get worse with mental activity? self rated and clinician monitored self rated with parent input self rated clinician interview Overall rating: If you know the athlete well prior to the injury, how different is the athlete acting compared to his/her usual self? Please circle one response: no different very different unsure NIA Scoring on the SCAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete's readiness to return to competition after concussion. Since signs and may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion. SCAT3 SPORT CONCUSSION ASSESMENT TOOL 3 PAGE 2 u, COGNITIVE 8: PHYSICAL EVALUATION Cognitive assessment Standardized Assessment of Concussion Orientation ll point for each correct answer) What month is it? 0 1 What is the date today? 0 1 What is the day of the week? 0 1 Whatyear is it? 0 1 What time is it right now? {within 1 hour} 0 'l Orientation score of 5 Immediate memory List Trial 1 Trial 2 Trial 3 Alternative ward list elbow 0 1 1 1 candle baby finger apple 0 1 0 1 0 1 paper monkey penny carpet 0 1 0 1 0 1 sugar perfume blanket saddle 0 1 0 1 1 sandwich sunset lemon bubble 0 1 0 1 0 1 wagon iron insect Total Immediate memory score total of 15 Concentration: Digits Backward List Trial 1 Alternative digit list 4-9-3 0 1 6-2-9 5?2?6 4-1-5 3?8?1?4 1 3-2-7-9 1-7-9-5 43-6-8 6-2-9-7?1 0 1 1-5-2-8-6 3-8-5-2-7 6?1?8~4~3 74-84-62 0 1 5-3-9-1-4-8 8-3-1-9-6-4 7 2?4?8?5?6 Total of 4 Concentration: Month in Reverse Order it pt. for entire sequence correct) 0 1 Concentration score of 5 Neck Examination: Range of motion Tenderness Upper and lower limb sensation &strength Findings: Balance examination Do one or both of the following tests. Footwear (shoes, barefoot, braces, tape, etc.) Modified Baiance Error Scoring System (BESS) testings Which foot was tested which is the non-dominant foot) Left Right Testing surface (hard floon field, etc.) Condition Double leg stance: Errors Single leg stance (non-dominant foot): Errors Tandem Stance (non-dominant foot at back}: Errors Anler Tandem gait?-7 Time [best of4 trials): seconds K. Coordination examination Upper limb coordination Which arm was tested: Left Right Coordination score oft SAC Delayed Recall? Delayed recall score of 5 2013 Concussion in Sport Group Apgendix INDIANA HUDSIERS Concussion Information for Home You have been diagnosed with a concussion. The following are signs and to watch out for: Stiff neck Severe headache Unusual sleepiness Repeated vomiting Confusion that gets worse Difficulty walking, speaking or using your arms Convulsions Do not take any medication unless directed by your athletic trainer or team physician. If you demonstrate any of the above after leaving the sports medicine facility, please contact your athletic trainer or team physician immediately. If you plan to take nap or sleep, have a roommate, friend or family member present who can wake you up every 3 hours for the first 24 period after your concussion. Appendix Academic Accommodations for Concussions Patient Name: Date of Birth: Student-athletes recovering from concussions often exhibit cognitive that make attending school and learning difficult. They may not be able to attend classes or only partial classes. They often have iight and noise sensitivity, headache, trouble focusing, concentrating and remembering. The accommodations below often help to lessen the and allow full participation sooner. Compliance with these accommodations allows the brain to recovery more quickly. These students often do not appear but are. Attendance May not be abie to attend class or may have to leave early Visual Stimulus Allow student to wear sunglasses/hat in class Pre?printed class notes to limit bright screen or PowerPoint use Limited computer, TV screen, bright screen use Reduce brightness on monitors/screens Change classroom seating as necessary Workload/Multi-Tasking Reduce workload when possible Prorate workioad when possible Reduce amount of homework as possible More time to complete assignments Clear desktop Audio texts, listening only, no note taking Current List {student is noting these today) Headache Visuai problems Nausea Balance problems Dizziness Sensitivity to light Student is reporting most difficulty with/in All subjects Reading/La nguage arts Science Music Focusing Listening Other: Breaks Ailow the student take short breaks Allow student to sit outside classroom during movies or videos then return for discussion Testing Additionai time to complete test No more than one test a day Allow for scribe, orai response, and oral delivery of questions Postpone finals or major tests until brain has recovered Physical Exertion No physicai exertion/athietics Sensitivity to noise Memory issues Feeling foggy Fatigue Dif?culty concentrating irritability Foreign ianguage Math History Using computers Thank you for your assistance in helping these concussed students return to schooi and recover more quickly. Indiana University Sports Medicine Appendix Guidelines for Return-to-Learn 1. Academic accommodations guidelines are given to the concussed student?athlete and a copy is given to their athletic department team academic advisor. No classroom activity will occur on the same day of the concussion. 2. The team academic advisor will serve as the point person to navigate academic adjustments/accommodations and return?to?learn aspects of the student?athlete. 3. Letter from head team physician documenting the injury and the recommendation of academic accommodations will be provided to course professors and instructors when necessary. 4. An individualized initiai pian will be based on the student-athlete?s toierance of cognitive activity and will inciude: remaining at home/dorm if student-athlete cannot toierate light cognitive activity and a gradual return to classroom/studying as tolerated, modification of schedule/academic accommodations for up to two weeks, as indicated, with heip from the identified point person, re-evaluation by team physician and member of the multi?disciplinary team, as appropriate, for student?athletes with greater than two weeks, engaging campus resources for cases that cannot be managed through schedule modification/academic accommodations. Such campus resources must be consistent with and inciude at ieast one of the following: learning specialists, office of services or office. 5. Continued medical foilow up until complete recovery, including a re-evaluation by the team physician if concussion worsen with academic challenges. 6. involvement of a multi-disciplinary team when necessary for more complex or prolonged cases. The muiti-discipiinary team may include, but is not limited to: Team physician Athletic trainer and/or other mental health professionals Faculty athletic representative, appropriate campus administrators Academic course professors, counselors and instructors College administrators Services for Students (in Office of Student Affairs) representative . Coaches 7. Compiiance with the a. Engagement of compliant campus resources when typicai academic accommodations do not suffice. 8. Notification of the team academic advisor when accommodations are weaned or discontinued. Concussion Acknowledgement Form I, acknowledge that as a member of the Indiana University Department of Intercollegiate Athletics, I accept responsibility for supporting our Sports Medicine Department?s policy on concussion management. I understand that student?athletes may have a risk of head injury and/or concussion. I also understand the importance of reporting any such of a head injury/concussion to the sports medicine staff team physician, athletic trainer). I also accept responsibility for reporting to the sports medicine staff any signs or that I may witness. By signing below, I acknowledge that my institution has provided me with educational materials on concussion and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. i have read the above and agree that the statements are accurate. Signature Date UNIVERSITY OF IOWA SPORT CONCUSSION POLICY (Updated 7/26/15 – Andy Peterson, MD) Definition/Recognition: A concussion is defined as a traumatically induced transient disturbance of brain function and is caused by a complex pathophysiological process (concussion is a change in function, following a force to the head, which may be accompanied by temporary loss of consciousness, but is identified in awake individuals, with measures of neurological and cognitive dysfunction,( NCAA p3)). It can result from either direct or indirect head trauma. Concussions have also been referred to as mild traumatic brain injuries (MTBI). While all concussions are MTBIs, not all MTBIs are concussions. Concussions are a subset of MTBIs, on the less-severe end of the brain injury spectrum, and are generally self-limited in duration and resolution. MTBI’s and concussions can be recognized by several common signs and symptoms: Physical -Headache -Nausea -Vomiting -Balance problems -Dizziness -Visual problems -Fatigue -Sensitivity to light -Sensitivity to noise -Numbness/tingling -Dazed -Stunned Cognitive -Feeling mentally ‘foggy’ -Feeling slowed down -Difficulty concentrating -Difficulty remembering -Forgetful of recent information and conversations -Confused about recent events -Answers questions slowly -Repeats questions Emotional -Irritable -Sadness -More emotional -Nervousness Sleep -Drowsiness -Sleep more than usual -Sleep less than usual -Difficulty falling asleep Most sport related concussions do not result in loss of consciousness, so any impact to the head and face should be evaluated carefully for signs and symptoms of concussion. Often a concussed athlete is unaware of his or her injury and in some instances may attempt to hide the injury. Coaches and teammates should assist in identifying athletes who sustain a concussion and report any significant head impacts and/or unusual behavior to the medical staff. Modifying factors and co-morbidities including but not limited to hyperactivity disorder, migraine and other headache disorders, learning disabilities, and mood disorders should be considered when diagnosing and returning to play. Any SA withthe signs,/symptoms/behaviours consistent withconcussion is suspected, the University of Iowa Sports Medicine Staff will follow a three-point approach to initial evaluation. 1. Immediate removal from practice or competition. If other injuries are present, or suspected, first aid will be administered. 2. An initial sideline assessment consisting of a symptom score, cognitive assessment, coordination assessment and balance assessment will be performed using the Sideline Concussion Assessment Tool version 3 (SCAT3). 3. If the medical staff determines that the student athlete has not sustained a concussion, the student athlete may return to practice or competition. No student athlete who has sustained a concussion will return to practice or competition until they are asymptomatic, have returned to baseline on their SCAT3 and/or ImPACT assessments and have successfully completed the graduated return to play protocol. The University of Iowa Sports Medicine Staff (physicians employed by UIHC & athletic trainers employed by athletic department) has adopted a comprehensive approach to managing sport related concussions that entails an educational component, a baseline procedure and a treatment protocol for all designated teams and other individuals so designated at the University of Iowa. UI Concussion Policy 1. Prior to full participation in intercollegiate athletics at the University Iowa, SAs complete a PPE with a designated University of Iowa Team Physician. During this time review of the SAs medical history including head trauma occurs. Participation in intercollegiate athletics is determined by the Team Physician and takes into account previous and current medical conditions including head trauma and concussion. 2. All University of Iowa student-athletes will read the NCAA concussion fact sheet as well as the Big 10 Injury and Illness Reporting Acknowledgement Form at designated times annually. The student-athlete must sign an attached sheet indicating they have read the two documents and accept responsibility for reporting their injuries and illness to the medical staff. The concussion information will be presented by a staff ATC and they will be available to answer questions. The University of Iowa Sports Medicine staff will be responsible to assist the compliance staff in answering any questions student-athletes might have regarding the concussion fact sheet and the injury reporting form. 3. All University of Iowa coaches (including assistant coaches and strength and conditioning coaches) must read the NCAA concussion fact sheet as well as the Big 10 Injury and Illness Reporting Acknowledgement Form. They will then sign a sheet annually indicating they understand the form and they will report any suspected injuries or illness to the University of Iowa Medial Staff, including any signs or symptoms of a concussion. The UI Athletics Compliance Department will be responsible for coordinating the signing of all necessary documents by coaches. 4. The University of Iowa Sports Medicine staff, physicians, athletic trainers, graduate assistants, and athletic training students must have access to the NCAA concussion fact sheet and the Big 10 Injury and Illness Reporting Acknowledgement. The staff or student must sign a sheet indicating they have read the forms and agree to encourage their student-athletes to report any suspected illness or injury to the sports medicine staff, including signs and symptoms of concussions. 5. The Director of Sports Medicine and Director of Athletic Training Services, or their designee, will coordinate the signing of all necessary documents on an annual basis for physicians and athletic trainers. 6. The Athletic Training Department, and UI Compliance will keep the signed documents, along with the established UI Concussion Policy, on file. 7. The UI Concussion Policy will be reviewed and updated annually by the Director of Athletic Training Services, Director of Sports Medicine, or their designee, and made readily accessible to all coaches and service staff. UI Concussion Management Protocol In order to provide consistent management of this sports-related injury, the University of Iowa Sports Medicine team has developed the following management protocol. Every new student-athlete will undergo a pre-season baseline assessment for concussion. Any athlete in any sport who sustains a concussion will undergo baseline testing prior to the beginning of their next season and this baseline will be used for subsequent comparisons. The baseline assessment will consist of: Brain injury/concussion history Symptom evaluation Balance Assessment Computerized Neuropsychological Test (ImPACT) The athletic trainer for each team will conduct the balance assessment and ImPACT test for all new student-athletes on their team. A copy of these test results will be kept on file for access during practice and competitions at all home and away venues. If a student-athlete (SA) is diagnosed with a concussion, the team physician (TP) and athletic trainer (AT) will coordinate to provide an individualized treatment plan and sport-specific return to play protocol in accordance with the latest International Consensus Concussion Guidelines. The following steps apply: 1. The AT assigned to work the event will evaluate the injured student-athlete with the SCAT3. A complete SCAT3 is not required if the athlete is severely impaired and obviously concussed. a. Emergency action plan, including transportation for further medical care, for any of the following: i. Glasgow Coma Scale < 13. ii. Prolonged loss of consciousness (>1 minute). iii. Focal neurological deficit suggesting intracranial trauma. iv. Repetitive emesis. v. Persistently diminished/worsening mental status or other neurological signs/symptoms. vi. Cervical spine. If the cervical spine is injured physical and neurological assessment of the cervical spine will be completed b. Activate Emergency Action Plan i. Call (911) activate EMS. ii. Stabilize and monitor patient. iii. Transport patient by EMS. iv. Notify designated team physicians and administrators. 2. The AT will notify a TP to discuss test results and enact the evaluation plan. If the TP is present, they will be responsible for directing the evaluation process and approving a treatment plan. Provide the SA and/or responsible adult with the post-concussion plan/information document. 3. No same day return to play will be permitted for any SA who sustains a concussion. 4. The SA will be withheld from all sport related activities (practice, competition, conditioning, or other training) and encouraged to maximize physical and cognitive rest. The TP may encourage the SA to refrain from going to class and from participating in any other physically or cognitively demanding activity. 5. Routine neuroimaging is not recommended for evaluation of a concussion. However, in cases of prolonged or worsening disturbance of consciousness, progressive symptoms or physical signs or in the presence of focal neurologic deficits, the TP may order neuroimaging. 6. The SCAT3 Symptom Evaluation will be checked every 24-48 hours until the SA is asymptomatic or returns to baseline and prior to advancing to each stage in the return to play protocol. 7. Once asymptomatic for 24 hours or as designated by the TP, ImPACT computer-based Neuropsychological testing will be completed by the SA under the supervision of the AT. Note that ImPACT will not be used to “diagnose a 8. 9. 10. 11. 12. 13. 14. concussion.” Concussion is a clinical diagnosis and no diagnostic testing will be used to confirm or refute the professional opinion of the medical staff. The TP will review ImPACT and evaluate the SA. If the athlete has not returned to his or her neurocognitive or clinical baseline, cognitive and physical rest will be continued. ImPACT and/or clinical evaluation will be repeated on an individual basis, typically every 24 to 48 hours Through each stage of the graduated return to play protocol, the AT will evaluate the SA for any recurrence of symptoms using the SCAT3 Symptom Evaluation. If symptoms recur, the SA will not progress to the next stage of the graduated RTP protocol. The TP and AT will encourage cognitive rest, oral hydration, proper nutrition and good sleep hygiene throughout the management protocol. The SA must complete the entire graduated RTP protocol prior to returning to any competition. The SA will not to return to physical activity, practice or competition before returning to a regular academic schedule. The AT and TP will document results in the SAs medical record. A new baseline concussion assessment will be established for SAs that have sustained a concussion in the previous competitive season before the next competitive season. Graduated Return to Play Protocol (RTP) Once symptom-free for 24 hours and ImPACT scores are acceptable to the TP, the SA is allowed to engage in the following AT-supervised sport-specific graded return to play protocol. The SA must remain symptom free for approximately 24 hours before advancing to the next step. If, at any point in the RTP protocol, the SA experiences return of their concussion symptoms, the activity will be stopped, the athlete will be rested for at least 24 hours or until symptoms resolve (whichever is longer). When the SA is again asymptomatic, he or she may resume the RTP protocol at their previous highest symptom-free level. Final determination of return-to-play is from the team physician or medically qualified physician designee. 1.Complete physical and cognitive rest until asymptomatic, normalized SCAT3 (if applicable) and return to ImPACT baseline (if applicable). 2.Light aerobic exercise (e.g. walking, swimming, stationary bike, etc.). First easy, then harder. 3.Sport-specific exercise (e.g. mode, duration, & intensity ). First easy, then harder (no head impacts during this phase). 4.Non-contact training drills (e.g. passing drills in football or hockey) and strength training (if applicable). 5.Full contact practice 6.Normal game play Return to Learn (RT) Upon assessment of a SA suspected of having a concussion Associate Athletics Director for Student-Athlete Academic Services (Liz Tovar, PhD) should be notified. Athletics Academic Services should be kept informed of the SAs progress in relation to return to learn activities in an ADAAA-compliant manner. A multi-disciplinary team will navigate more complex cases of prolonged return to learn. This team may include, but is not limited to, the TP, AT, faculty athletic representative and neuropsychologist consultant. 1. Academic modifications up to 2 weeks will be determined by the TP or AT. The SA will have no classroom activity on the same day as a concussion, and may remain at home/dorm if light cognitive activities are not tolerated. 2. Once the SA can tolerate cognitive activity the SA should return to the classroom, often in graduated increments. 3. Prior to the SA being cleared for full participation, feedback from the Associate Athletics Director for StudentAthlete Academic Services should provide verification that the SA is participating in normal academic activities. 4. The Associate Athletics Director for Student-Athlete Academic Services will engage campus resources for prolonged cases. Such resources may include learning specialists and will be consistent with ADAAA. The TP will re-evaluate the SA if concussion symptoms worsen with academic challenges, or if symptoms last greater than 2 weeks, at which point a multi-disciplinary evaluation may also be utilized. Post-Concussion Syndrome Post-concussion syndrome, or persistent concussive symptoms, is a rare complication of concussion. There are medical and rehabilitative techniques that may be useful in the treatment of a student athlete with persistent symptoms. Any student athlete who has been symptomatic for over one month will be evaluated in the IOSMR concussion clinic. While most athletes who have been symptomatic for less than one month will not need to be evaluated in the IOSMR concussion clinic, any athlete with a concussion or history of concussion may be seen at the request of the athlete, coaches, team physician or athletic training staff. Pharmacologic treatment of concussion symptoms is controversial. Initiation of pharmacologic treatment of concussion symptoms by any team physician will require the approval of a second member of the Primary Care Sports Medicine Staff. Any SA who experiences multiple concussions, demonstrates a low threshold to concussive injury or experiences progressively severe injuries with subsequent concussions will discuss the possibility of retiring from athletics with the team physician. The team physician, in consultation with the Director of Sports Medicine and Director of Athletic Training Services, reserves the right to permanently disqualify any student athlete with persistent signs or symptoms of concussion, multiple concussions, low concussion threshold and/or progressively severe episodes of concussion. Reducing Head Trauma Exposure Management Plan 1. Adherence to Inter-Association Consensus: Independent Medical Care Guidelines. 2. Taking a ‘safety first’ approach to sport. 3. Coaching and student-athlete education regarding safe play and proper technique. Reference 1. McCrory P et al. Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport Held in Zurich, November 2012. Br J Sports Med May 2013;47:250-258. 2. The University of North Carolina at Chapel Hill Sport Concussion Policy, developed by the Matthew Gfeller SportRelated Traumatic Brain Injury Research Center and Division of Sports. August 1, 2010. 3. Harmon KG, et al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Br J Sports Med. Jan 2013;47:15-26. 4. NCAA: Concussion guidelines. http://www.ncaa.org/health-and-safety/sport-science-institute/introduction-mindbody-and-sport. 5. NCAA Concussion: Return-to-Learn Guidelines: NCAA: Independent medical care guidelines. http://www.ncaa.org/health-and-safety/independent-medical-care-guidelines. 6. NCAA Concussion: Return-to-Learn Guidelines: http://www.ncaa.org/health-and-safety/medicalconditions/concussion-return-learn-guidelinesNCAA Concussion: Return-to-Learn Guidelines. 7. National Athletic Trainers’ Association Position Statement: Management of Sport Concussion. Journal of Athletic Training, 2014; 49(2): 245-265. IOWA STATE UNIVERSITY SPORTS MEDICINE STANDARD OPERATING PROCEDURES FOR THE ATHLETIC TRAINER MEDICAL EMERGENCIES Cerebral Concussions This plan is intended to meet all policy requirements set forth by the NCAA Executive Committee and the Big 12 Conference on the prevention, identification, evaluation, and follow-up management of concussions. This plan is endorsed by the university employed team physician and fully supported by the Director of Athletics. It is understood that according to this plan, “a student-athlete who exhibits signs, symptoms, or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by Sports Medicine personnel (either athletic trainer or physician) with experience in the evaluation and management of concussion.” Based on results of the clinical evaluation and comparison to baseline testing, any student-athlete diagnosed with a concussion shall not return to activity for the remainder of that calendar day and will enter a concussion follow-up management program. Details of identification, evaluation, management, return-to-learn, and return-to-play procedures are contained in this document. A bibliography of all resources used to develop this program is listed at the end of the document. Definition of Concussion (as per the Consensus Statement on Concussion in Sport 4th International Conference on Concussion in Sport Held in Zurich, November 2012) Concussion is defined as a subset of mild traumatic brain injury (MTBI) and is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathological and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged. Pre-Season Education of Student-Athletes, Coaches, and Medical Staff Education on concussions will be performed annually for all student-athletes, coaches, and medical staff during which a concussion fact sheet made available by the NCAA will be presented. Each person will review the concussion fact sheet and individually sign a concussion education acknowledgement statement confirming their awareness and responsibilities of reporting signs and symptoms of concussion to the medical staff for evaluation (see accompanying sheets). Student-athlete acknowledgment forms will be placed in their permanent athletic health care record. Coaches, sports medicine staff, and Athletic Director acknowledgement forms will be kept on file by the Associate Athletics Director for Sports Medicine. Pre-Participation Baseline Measurements No student-athlete will be allowed to participate in any Athletics Department activities until cleared by the team physician in the pre-participation physical examination process. Student-athletes in all sports will have baseline testing performed prior to their participation in any officially sanctioned team activity. Baseline testing will include the following: 1. History of brain injury and concussion in the pre-participation physical examination and during C3 Logix and ImPact testing. 2. Current symptom evaluation (during C3 Logix and/or ImPACT tests) 3. Cognitive assessment (during C3 Logix and ImPACT tests, and/or King-Devick for selected sports who employ rapid sideline assessment due to sport rules constraints). 4. Balance assessment (during C3 Logix and/or BESS tests). 5. Vestibular-oculomotor function (C3 Logix) 6. Reaction times (C3 Logix, simple and choice) Updated: April, 2014 Testing will be done in accordance with the appropriate testing protocol as established by the developers of each of these tests. For any athlete diagnosed with a concussion, particularly student-athletes with complicated or multiple concussions in their history, re-baseline testing will be performed at six months or beyond complete resolution of concussion to establish new baseline values. Scores from all objective baseline testing will be used as comparisons to established baseline values to assist in the clinical evaluation following a suspected concussion. There is no current standard set for a symptom score that indicates concussion. Symptoms reported should be taken into consideration when determining a possible concussion and scores can be used to track symptom severity over time. Immediate Assessment Techniques for Potential Concussion Injuries As per NCAA rules, a student-athlete who exhibits signs, symptoms, or behaviors consistent with a concussion will be removed from practice or competition and evaluated by a member of the ISU Sports Medicine Staff (licensed/certified athletic trainer or physician). Athletes may be identified as exhibiting signs and symptoms of a concussion either through self-reporting or identified by others, and an immediate evaluation of the suspected concussion will be performed with the following steps: 1. On-field assessment ruling out need for initiation of the emergency action plan and transportation to emergency medical facility. -Glascow Coma Scale <13 -Prolonged loss of consciousness -Focal neurological deficit suggesting intracranial trauma -Signs/Symptoms associated with spine injury 2. If no emergency transport is needed, assist athlete from court/field. 3. Allow the athlete time to calm down 4. Move the athlete to an area where they will not be interrupted and can concentrate if at all possible (i.e. Locker Room) 5. Perform a thorough evaluation of a suspected concussion which may include, but is not limited to: -Symptom Scoring -Standardized Assessment of Concussion Test (SAC Test on C3 Logix) -Evaluation of balance (BESS Test on C3 Logix) -Reaction Time (simple (C3 Logix) -Visual tracking/testing (manual) *There may be instances where alternate orientation questioning and cognitive assessment may be utilized due to sport and rules including the King-Devick Test. King-Devick test may be utilized to determine if there has been a suspected concussive episode in a short time frame with high reliability and utilized in sports with limited injury time such as wrestling and gymnastics. Injury event information will be recorded in the C3 Logix system for tracking details of all concussions. This information will be transferred to the student-athletes electronic medical record. The determination of a concussion will be based on the collective interpretation of all test results. •Interpretation of comparison of test results and baseline scores. Symptom Scoring Scale Student-athletes symptoms will be assessed using the concussion symptom list on the C3 Logix system or other suitable alternative. It should be noted that much of the same symptom scale is utilized in post-concussion evaluation during the ImPACT Test. Total score of their symptoms can be used to compare to baseline scoring as well as immediate post-injury and follow-up testing for an infinite amount of time. Reporting of symptoms should be correlated to injury mechanism and other testing results in determining whether an athlete has suffered a concussion. SAC TEST – A drop of 3 points or greater is indicative of some alteration in cerebral function and the student-athlete is considered to have sustained a concussion and should be withheld from activity, and monitored. Updated: April, 2014 Balance Testing The preferred balance testing system will be the C3 Logix system. Following a suspected head injury, C3 Logix scores significantly lower than baseline average measurement will be indicative of possible head injury related balance problems. BESS test will be utilized in conjunction with C3 Logix as a back-up to computerized balance testing. Errors will be scored on the C3 Logix system during the test. The double leg, single leg, and tandem stances (heel to toe with the non-dominant foot in back) balanced error scoring system (BESS) tests will be utilized on both ground and on unstable surface (AirEx pad). Eyes will be closed and hands on hips for 20 seconds. More than 7 errors above baseline in balance may suggest that there may be a concussion. More than one simultaneous error will be scored as one error (i.e. eyes open while stumbling). Fatigue can compound scores and must be considered during the evaluation. Errors include: 1. hands come off of hips 2. eyes open 3. lifting of the forefoot or heel 4. step, stumble, or fall 5. remain out of the starting position for more than 5 seconds 6. exceed 30 degrees of hip abduction to either side Reaction Times – Simple reaction time testing on the C3 Logix system will be evaluated. Visual Tracking/Testing -Examine pupils: note symmetry, reaction, size, visual tracking changes, or painful areas in ROM -Visual Clarity. Abnormalities in any of these areas are cause for suspected concussion Same Day Return To Play Guidelines Following a suspected concussion, any student-athlete with abnormal testing results indicating a concussion will be removed from the game and/or practice. Final determination of diagnosis of concussion and possibility of return-to-play is left solely to the team physician or medically qualified physician designee (i.e licensed/certified athletic trainer). If the player is diagnosed with a concussion, they will be removed from participation for the remainder of the calendar day. If all testing falls within normal limits and exhibits no significant symptoms during or following the examination, the student-athlete will not be considered to have suffered a concussion, and will be allowed to return to play and continue to be monitored closely. Initial Management of the Diagnosed Concussion Once diagnosed with a concussion, the athlete will be monitored at frequent intervals for deterioration of symptoms for the remainder of the day. Should symptoms deteriorate; the student-athlete will be taken to an appropriate medical care facility for follow-up care, monitoring, and possible diagnostic imaging as dictated by physicians. These symptoms would include: -Repetitive emesis -Persistently diminished/worsening mental status -Other deteriorating neurological signs/symptoms. Should symptoms remain steady or improve, the student-athlete will be provided with written home care instructions upon release, preferably with a roommate, guardian, or other adult who can follow instructions (see example). These instructions will be reviewed with the responsible party before sending them home with the student-athlete. A follow-up appointment time for recheck evaluation will be established with the student-athlete prior to being released for home care. Should the injury occur on the day of academic classes, the student-athlete will not attend any classroom activity for the remainder of the day. Follow-Up Management of the Diagnosed Concussion Following a diagnosed concussion, the student-athlete will be re-evaluated and additional testing will be performed to track progress. This testing will include, but not be limited to: 1. Monitoring of symptom scoring (until symptoms resolve, tracked on C3 Logix) Updated: April, 2014 2. 3. 4. 5. Computerized Neuropsychological Testing (ImPACT Testing – Immediate Post-Concussion Assessment and Cognitive Testing) will be performed and compared to baseline values at a minimum of 24 hours post-injury and again at 72 hours and 1 week post-injury if necessary. ImPACT Testing will cease once there are no score drops in any of the testing areas of statistical significance as determined by ImPACT research numbers. Interpretation of ongoing abnormalities will be made by the team physician or designated neuropsychologist. Balance Testing – C3 Logix Balance Testing and/ Balance Error Scoring System (BESS) testing will be performed on the C3 Logix System. A Vestibular/Oculomotor screening examination will be performed utilizing the C3 Logix Visual Acuity test and will be compared to baseline norms. Visual and/or vestibular exercises may be prescribed if indicated by test results. Vision/Neurological Evaluation/Oculomotor Examination Evaluation will include identification of any abnormalities including, but not limited to: -pupils: note symmetry, reaction, size, visual tracking changes, or painful areas in ROM. *It should be noted that student-athletes with diagnosed ADD/ADHD or learning disabilities, migraines, or other chronic headache conditions may complicate recovery and may require other special considerations. The licensed athletic trainer will communicate all testing results and progress changes to the team physician. The team physician will have access to all concussion management developments with access to all testing results on the C3 Logix and ImPACT testing systems. Once the student-athlete’s symptoms are resolving and scores are within normal limits on ImPACT and C3 Logix testing, graduated return to play guidelines will be initiated Prolonged Recovery Guidelines It is recognized a majority of student-athletes who are concussed fully recovery occurs in 7-10 days and can be managed daily based on resolution of symptoms. Any student-athlete who has a prolonged recovery and symptoms lasting longer than two weeks will return for a full evaluation by the team physician in order to consider additional compounding factors and additional diagnoses including, but not limited to: -Post-concussion syndrome -Sleep dysfunction -Migraine or other headache disorders -Mood disorders such as anxiety and depression -Ocular or vestibular dysfunction. For student-athletes with prolonged recovery of greater than one month, secondary opinions may be sought through the University of Pittsburgh Medical Center concussion experts for diagnosis and/or suggested additional management methods. Results of all testing will be forwarded to them as requested to assist in their evaluation. Graduated Return-to-Learn Return-to-Learn is a parallel concept to return-to-play and follows a stepwise progression as such. The hallmark of return-to-learn is cognitive rest immediately following concussion just as the hallmark of returnto-play is physical rest. The majority of student-athletes who are concussed do not need a detailed returnto-learn program because full recovery occurs in 7-10 days and can be managed daily based on resolution of symptoms. However, Return-To-Learn becomes more difficult when the student-athlete has ongoing symptoms for greater than two weeks. Return-to-Learn Concepts 1. 2. 3. 4. Return-to learn will be managed in a stepwise program which fits the needs of the individual student-athlete. Return-to-learn guidelines assume that both physical and cognitive activities require brain energy utilization, and they similarly assume that for such brain injury to recover, energy is not available for physical and cognitive exertion due to the concussion-induced brain energy crisis. Return-to-learn recommendations are based on consensus statements, with a paucity of evidence-based data to correlate with such consensus recommendations. Return-to-learn recommendations will be made within the context of a multi-disciplinary team which could include, but is not limited to the team physician, athletic trainers, Updated: April, 2014 5. psychologists/counselors, the Faculty Athletic Representative, academic counselors, and administrators. Like return-to-play, it is difficult to provide prescriptive recommendations for return-to-learn because the student-athlete may appear physically normal, but is unable to perform at his/her expected normal due to concussive symptomology and effects. Return-to-Learn Administrative Procedures 1. 2. 3. 4. Following the diagnosis of concussion, the athletic trainer for the sport with notify the Assistant Athletics Director of Student Athlete Development and forward them a letter of notification to be sent to the Dean of Students and any/all instructors notifying them of the student-athletes diagnosis and possible difficulties and potential accommodations needed during recovery. The Assistant AD for Student Athlete Development will serve as the point of contact between academics and athletics in regards to return-to-learn accommodations. The student-athlete will begin the stepwise return-to learn program listed below. If the student-athlete has not had a resolution of symptoms in 7-10 days, the Student-Athlete Well-Being Group (Senior Associate AD for Student Services, Senior Associate AD SWA, Assistant AD for Student-Athlete Development, Associate AD for Compliance, Associate AD for Sports Medicine) will meet to discuss the status of the student-athlete and potential need for further accommodations and specialty care or evaluation. This meeting may also involve other parties including the team physician, sports psychologist/counselor, faculty athletic representative, and coach. The group will discuss the need for special accommodations and further course of action within academics based on medical progress and evaluation. -Accommodation request and recommendations will be communicated with the Dean of Students Office and the ISU Student Disability Resource Center by the Asst. AD for Student-Athlete Development (see example recommendations for accommodations for common ongoing post-concussive symptoms chart) -The Assoc. AD for Sports Medicine will contact the Faculty Athletic Representative to make them aware of the recommendations for accommodations and any followup progress as needed. Communication regarding the progress of the student-athlete will be communicated to the Dean of Students and ISU Student Disability Resource Center by the Asst. AD for StudentAthlete development as needed until condition is resolved. Required documentation will be supplied as needed to comply with section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities act and Amendments Act of 2008. Concussion Return-to-Learn Recommendations Stage 1 Stage Description Cannot tolerate cognitive activity, symptoms at rest 2 Ability to perform cognitive activities for up to 1 hour with no increase in symptoms. Allow for cognitive rest periods and reduce rest periods as tolerated. 3 Return to all activities Updated: April, 2014 Procedures/Activities -Remain at home and avoid classroom work for at least one day, avoid school work, video games, reading, texting, and watching television, no team meetings. -Letter sent to academic services notifying relevant parties of concussion and accommodation considerations. -As symptoms resolve, move into Stage 2 as tolerated. -If symptoms exceed two weeks initiate meeting with Student-Athlete Well-Being Group, campus officials, and specialists as needed for potential further formal Accommodations. Additional examinations with team physician and/or Specialists will be arranged. -Monitor symptoms and make appropriate adjustments to exposure to cognitive activities. May return to team meetings as part of cognitive activities as tolerated. -If athlete cannot attend class due to symptoms, they also cannot attend team meetings. -Likely will start return to play progression once cognitive activities are tolerated for multiple hour time periods. -Return to all cognitive activities including classes and team meeting activities. Report any reoccurrence of symptoms. Symptoms Examples of Potential Accommodations/Recommendations Based on Symptom Type Potential Accommodations Headaches Sensitivity to Noise (phonophobia) Sensitivity to Light (photophobia) Other Visual Problems (i.e. blurred or double vision, eye tracking problems, near-point convergence Concentration or Memory (Cognitive) Problem Sleep Difficulties -Allow frequent breaks -Identify triggers which cause headaches to worsen and avoid them -No physical activity in or around loud areas -Avoid lunch room; eat in quiet settings -Avoid attending athletic events, gymnasiums -Refrain from using headphones/earbuds -Allow to wear sunglasses -Move to area with low-lighting, dimly lit room -Avoid seating with direct sunlight from windows -Avoid or minimize bright projector or computer screens, film screens -Limit computer use -Reduce/shorten reading assignments -Record lectures, use auditory learning apps if possible/as needed -Allow for more listening discussions vs. reading -Increase font size on computer screens -Desktop work only -Refrain from texting, video gaming -Refrain from watching TV close-up or from a distance -Place main focus on essential academic content/concepts -Postpone major tests or participation in standardized testing -Allow extra time for assignments, quizzes -Allow extra time to complete tests, projects -Reduce class assignments, homework -Allow frequent breaks Graduated Return-to-Play Guidelines The cornerstone of concussion management is physical and cognitive rest until symptoms start to resolve and then a graded program of exertion and return-to-learn program prior to medical clearance and return to play. Graduated return to play following a concussion will follow a stepwise process. If any post-concussion symptoms occur while in the stepwise program, then the student-athlete should drop back to the previous asymptomatic level and try to progress again after a further 24 hour period of rest has passed. Time frames within each level are not established, but dictated by monitoring of symptoms. Listed below are general guidelines to be used as a stepwise process for return to activity. Other stepwise programs for return to activity such as the UPMC Sports Medicine Concussion Program Guidelines for Post-Concussion Rehabilitation may also be used. There is typically a period of time of complete rest between stages to assess reaction to activity and subsequent progress. The student-athlete will be returned to full play only with clearance by the team physician following a diagnosed concussion. Rehabilitation Stage 1. No Activity 2. Light Aerobic Exercise 3. Sport-Specific Exercise 4. Non-Contact Training Drills 5. Full Contact Practice 6. Return to Play Functional Exercise at Each Stage of Rehabilitation Complete physical and cognitive rest Walking, swimming or stationary cycling keeping intensity <70% HR max, no strength training Sport related individual skill type drills with NO risk of head impact activities Progression to more complex training drills with no contact. May return to low load, high repetition strength training activities Following medical clearance, participate in normal training/practice activities Stage Objective Recovery Increase Heart Rate Add movement Exercise, coordination, and cognitive load Restore confidence and assess functional skills by coaching staff Normal game play Reducing Exposure to Head Trauma While exposure to head trauma is inherent with many sports, the Iowa State University Department of Athletics and its coaches are committed to reducing unnecessary exposure to head trauma. Coaches will conform to current best practices and recommendations for their sport in regards to reducing exposures to head trauma. This may include, but not be limited to: Updated: April, 2014 -Adherence to the Inter-Association Consensus: Year-Round Football Practice Contact Guidelines -Adherence to Inter-Association Consensus: Independent Medical Care Guidelines -Reducing gratuitous contact in practices -Always taking a “safety first” approach to the sport -Taking the head out of contact -Utilizing proper coaching techniques and student-athlete education regarding safe play. -Tracking of injury data in regards to injury rates in different activities and equipment types with recommendations for change annually to reduce injury risk as indicated. Resources 1. National Athletic Trainers Association Position Statement: Management of Sport Concussion (NATA, 2014) 2. American Academy of Neurology Guidelines. Neurology, 1997 3. McCrea, Kelly, Randolph etal. Standardized assessment of concussion (SAC): on-site mental status evaluation of the athlete. J Head Trauma Rehabil. 1998 4. ImPACT Neuropsychological Testing Procedural Manual, 2013 5. Consensus Statement on Concussion in Sport: 4th International Conference on Concussion in Sport Held in Zurich, November, 2012. Br. J Sports Med 2013 47:250-258 6. C3 Logix Testing System Protocols 2014 7. Bell, Guskiewicz, Clark, Padua. Systematic Review of the Balance Error Scoring System. Sports Health May 2011 3(3); 287-295 Updated: April, 2014 Iowa State University Athletic Health Care Concussion Management Plan Overview (Updated April 2015) Baseline Testing Complete and Available at Athletic Site (C3 Logix, ImPACT Test, King-Devick Test) - (C3 Logix includes SAC, Balance, Vest/Occ, Reaction Time, M t C d) Concussion Symptoms Reported or Suspected ●Remove from participation ●Move to a controlled location if possible, evaluated by licensed athletic trainer or licensed physician ●Neurocognitive and Balance Testing (SAC, King-Devick, C3 Logix, BESS or combination for baseline/norms comparison) ●Symptom Scoring Scale ●Pupils equal and reactive to light? Visual tracking problems? Yes All results WNL? Concussion Diagnosed No ●No activity for remainder of day ●Continue to monitor for symptom deterioration, transport to medical No Concussion Diagnosed facility if Return to play, but monitor symptoms deteriorate. ●Home care/monitoring instruction Minimum card sent 24-48 home with responsible hours post-injury party, Post-Concussion Assessment confirm follow-up appointment ●Minimum of 24 hours post-injury ●Initiate follow-up management plan ●Symptom Scoring Scale ●ImPACT Neurocognitive Testing ●C3 Logix Full Test ●(Any abnormalities, athlete considered to have ongoing concussion problems. No activity, educate on proper rest. Symptom scores monitored daily, retest ImPACT & C3 Logix at 72 hours and 1 week if necessary) Rehabilitation stage 1 only. Return-to-Learn Stages ●C3 Logix scores may indicate specific areas of deficiency and focused recovery methods Stage Stage Description Stage Objective ●Once symptoms are resolving move on to step-wise graduated Return-to-Play and Return-to-Learn programs 1 Cannot tolerate cognitive activity, symptoms present at rest ●Remain at home, avoid classrom work for at least one day, avoid school work, video games, reading, texting, and watching television, no team meetings. ●As symptoms resolve, move into Stage 2. ●Letter to academic services notifying related parties of concussion and accommodation considerations. ●If symptoms exceed two weeks initiate meeting with academic services and campus officials for potential formal accommodations. 2 Ability to perform cognitive activites for up to an hour with no increase in symptoms. Allow for cognitive rest periods. 3 Return to all activities team meetings as part of cognitive activities as tolerated. Likely will start return to play progression once cognitive activities are tolerated for multiple hour time periods. ●Return to all cognitive activities including classes and team meeting activities. Return-to-Play Criteria Functional Exercise at Each Stage of Rehabilitation Rehabilitation Stage 1. No Activity 2. Light Aerobic Exercise ●Monitor symptoms and make appropriate adjustments to exposure to cognitive activities. May return to 5. Full Contact Practice Complete physical and cognitive rest Walking, swimming or stationary cycling keeping intensity <70% HR max, no strength training Sport related individual skill type drills with NO risk of head impact activities Progression to more complex training drills with no contact. May return to low load, high repetition strength training activities Following medical clearance, participate in normal training/practice activities 6. Return to Play Normal game play 3. Sport-Specific Exercise 4. Non-Contact Training Drills Updated: April, 2014 Stage Objective Recovery Increase Heart Rate Add movement Exercise, coordination, and cognitive load Restore confidence and assess functional skills with coaching staff Sports Medicine Student-Athlete Concussion Education Acknowledgement Statement I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician under Iowa State University Athletics Policies to expedite my health care. I have read and understand the NCAA Concussion Fact Sheet After reading the NCAA Concussion Fact Sheet, I am aware of the following information: ___ A concussion is a brain injury, which I am responsible for reporting to my team physician Initial or athletic trainer immediately. ___ A concussion can affect my ability to perform everyday activities, and affect reaction Initial time, balance, sleep, and classroom performance. ___ You cannot see a concussion, but you might notice some of the symptoms Other symptoms can show up hours or days after the injury. right away. Initial ___ If I suspect a teammate has a concussion, I am responsible for reporting the injury to my Initial athletic trainer or team physician. ___ I will not return to play in a game or practice if I have received a blow to the head or Initial body that results in concussion related symptoms. ___ Following a concussion, the brain needs time to heal. I am much more likely to have a Initial repeat concussion if I return to play before my symptoms resolve. ___ In rare cases, repeat concussions can cause permanent brain damage, and even death. Initial ____________________________ ________ Print Name Updated: April, 2014 Signature ___________________________ Date Sports Medicine Coaches Concussion Program Acknowledgement Statement I understand that it is my responsibility to immediately report any athlete who exhibits signs, symptoms, or behaviors indicating a possible concussion to my athletic trainer and/or team physician under the Iowa State University Athletics Concussion Management Policy I understand the Iowa State University sports medicine staff has unchallengeable autonomous authority to determine management and return to play of any ill/injured student-athlete. I have read and understand the NCAA Concussion Fact Sheet including the signs, symptoms, and behaviors associated with a concussion. I commit to reducing unnecessary exposure to head trauma and will employ the current best practices and coaching techniques to reduce risk of head trauma. This includes, but is not limited to: reducing gratuitous contact during practice, taking a “safety-first” approach to my sport, and coaching and the student-athletes regarding safe play and proper techniques in my sport. ____________________________ Print Name Updated: April, 2014 ___________________________ Signature ________ Date Sports Medicine Medical Staff Concussion Education Acknowledgement Statement I confirm I have read and fully understand responsibilities in the evaluation and management of any athlete who exhibits signs, symptoms, or behaviors indicating a possible concussion in accordance with the ISU Athletics Department Concussion Management plan. I understand the Iowa State University sports medicine staff has unchallengeable autonomous authority to determine management and return to play of any ill/injured student-athlete. I have read and understand the NCAA Concussion Fact Sheet including the signs, symptoms, and behaviors associated with a concussion. ____________________________ Print Name Updated: April, 2014 ___________________________ Signature ________ Date KANSAS ATHLETICS CONCUSSION MANAGEMENT POLICY Kansas Athletics is committed to the prevention, identification, evaluation and management of concussion. To ensure that the health and safety of our student-athlete is protected, the following guidelines will be followed. 1. Kansas Athletics will have on file and annually update emergency actions plans for all practice, strength and conditioning, treatment and competition sites. All athletics healthcare providers and coaches should review annually and be familiar with plans. 2. Athletics healthcare providers shall review concussion evaluation and management annually. 3. Coaches and Administrators shall be given education on concussions annually (Concussion: a Fact Sheet for Coaches, NCAA/CDC) 4. Kansas Athletics shall require student-athletes to sign a statement in which studentathletes accept the responsibility for reporting their injuries and illnesses, including signs and symptoms for concussions to the institutional medical, staff. During the review and signing process student-athletes should be presented with educational material on concussions. (Concussion: a Fact Sheet for Student-Athletes, NCAA/CDC) 5. Athletics’ healthcare providers should record a baseline evaluation (IMPACT, C3 Logix, SAC, BESS) prior to the first practice in all sports, including Spirit Squad sponsored by Kansas Athletics, Inc. 6. Any student-athlete exhibiting signs, symptoms or behaviors consistent with a concussion, at rest or with exertion, shall be removed from practice or competition and referred to the team athletic trainer or team physician with experience in concussion management. 7. A student-athlete diagnosed with a concussion shall not be allowed to return to play in the current game or practice and shall be withheld from activity for the remainder of the day. 8. Student-athletes diagnosed with a concussion shall receive serial monitoring for deterioration documented by a standardized flow sheet which will become part of the medical record. 9. Student athletes diagnosed with a concussion shall be provided with written instructions, to be given to their roommate, guardian or someone who can follow the instructions and assist them in their recovery. 10. All student-athletes with a concussion shall be evaluated by a team physician prior to return to activity. In addition, final clearance for participation shall be by a team physician. 11. Once asymptomatic and post-exertion assessments are within normal baseline limits, return to play shall follow a medically supervised stepwise process. 12. The Head Team Physician or his designee shall be empowered to have the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete. A countable coach should not serve as the primary supervisor for an athletics healthcare provider nor should he/she have sole hiring or firing authority over that provider. 13. An athletic health care provider experienced in the diagnosis and management of concussion should conduct and document serial clinical evaluation inclusive of symptoms, cognition, and balance. SUMMARY: Kansas Athletics, Inc. Sports Medicine Department is committed to providing quality health care services for all student-athletes. As such, the athletic department is very proactive in the assessment, diagnosis, and management of concussions. To do so limits the risks of concussions associated with athletics, and the potential catastrophic and long-term complications from said concussions. KANSAS ATHLETICS, INC. DEPARTMENT OF SPORTS MEDICINE Concussion Assessment, Management, Return to Play and Academics Guidelines The following policy and procedures on neurocognitive baseline testing and subsequent assessment and management of concussions as well as return to play guidelines have been developed to provide quality healthcare services and assure the well-being of each student-athlete at the University of Kansas. BACKGROUND: Purpose: The Kansas Athletics Sports Medicine Department recognizes that sport induced concussions pose a significant health risk for those student-athletes participating in athletics at The University of Kansas. With this in mind, the Sports Medicine Department has implemented policies and procedures to assess and identify those student-athletes who have suffered a concussion. The Department also recognizes that baseline neurocognitive testing on student-athletes who participate in sports sponsored by Kansas Athletics, Inc. and/or who have had a history of concussions prior to entering The University of Kansas will provide significant data for return to competition decisions. This baseline data along with physical examination by team physician and/or certified athletic trainer, along with diagnostic testing will be used in conjunction in determining when it is safe for a student-athlete to return to competition. Concussion Definition: A traumatically induced transient disturbance of the brain function and involves a complex pathophysiological process affecting the brain. This may be due to directed or indirect contact sustained by a student-athlete with or without the loss of consciousness. Signs and Symptoms of Concussion: Team Physicians and Certified Athletic Trainers (ACTs) along with athletic training students all need to be aware of the signs and symptoms of a concussion to properly recognize and intervene on behalf of the student-athlete. The suspected diagnosis of concussion can include one or more of the following clinical domains: Physical Symptoms Headache, Vision Difficulties, Nausea, Dizziness, Balance Difficulties, Light Sensitivity, Fatigue, Feeling like in a fog, Loss of Consciousness, Amnesia Cognitive Symptoms Memory Loss (Amnesia), Attention Disorders, Reading Difficulties, Slowed Reaction Times Emotional Symptoms Irritability, Sadness, Nervousness, Sleep Disturbances EDUCATIONAL PROGRAMMING: Kansas Athletics shall provide annually to all student-athletes, coaches, team physicians, ACTs and the Director of Athletics the NCAA concussion fact sheets, or other applicable materials discussing concussions in athletic environments. Each person shall sign an acknowledgement that he/she has received, read, and understood the material. RECOGNITION AND DIAGNOSIS OF CONCUSSION: Baseline Assessment: All incoming freshman and transfer student-athletes to the University of Kansas who are participating in all sports sponsored by Kansas Athletics and/or who have had a previous history of concussions as identified by their health history will have as part of their pre-participation examination (PPE), a baseline concussion assessment which shall include the following tests: • • • • A brain injury and concussion history (the PPE should include concussion-related questions including a past history of concussion (number, frequency, severity and recovery) and the presence of mood, learning, attention or migraine disorders); A symptom evaluation; a baseline neurocognitive test (ImPACT) or (C3 Logix) a Standardized Assessment of Concussion (SAC™); Balance Error Scoring System (BESS) The Kansas Athletics Sports Medicine Department utilizes the ImPACT™ concussion management system (Impact.com) and the C3 Logix system. The ImPACT™ system is a Windows-based userfriendly computer program which consists of 10 modules designed to test cognitive functioning. The Sport Concussion Assessment Tool (SCAT3) and the SAC™ is a series of questions testing orientation, immediate memory, concentration, and delayed memory to measure the immediate neurocognitive effects of a student-athlete with a suspected concussion. Kansas Athletics will record the baseline assessment test for each student-athlete in his/her medical records. All baseline assessment tests will be performed prior to the first practice. The baseline test tools should be used post-injury at appropriate time intervals. The Head Team Physician shall determine pre-participation clearance and/or the need for additional consultation or testing. For student-athletes with a documented concussion history, especially those with complicated or multiple concussions, the Head Team Physician may determine that a later baseline concussion assessment be taken six months or beyond the initial baseline assessment. Concussion Diagnosis and Management: In any circumstance where a concussion is suspected or any student-athlete exhibiting signs, symptoms or behaviors consistent with a concussion, at rest or with exertion, shall be removed from practice or competition and referred to the team athletic trainer or team physician with experience in diagnosis, treatment, and concussion management. Particular attention should be given to excluding a cervical spine injury. The student-athlete should be evaluated serially and monitored for deterioration following injury. The evaluation shall include symptom assessment, a physical and neurological examination, a cognitive assessment (SAC™, C3, and/or BESS test), a balance exam, and a clinical assessment for cervical spine trauma, skull fracture and intracranial bleeding. Concussion evaluation tools can be compared to the student-athlete’s baseline assessment. The student-athlete should be immediately transported to the nearest hospital if any of the following signs or symptoms are present: • • • • • • Glasgow Coma score less than 13; Prolonged period of loss of consciousness (longer than one minute); Focal neurological deficit; Repetitive emesis; Persistently diminished or worsening mental status or other neurological signs or symptoms; Potential spine injury--if a cervical spine injury cannot be eliminated, neck immobilization and immediate transfer to the emergency department capable of advanced neurological imaging and management of cervical trauma should follow. The student-athlete should be assessed every 5 minutes until post-concussive confusion has cleared. In all circumstances, the ATC must document the player’s name, position, circumstance of injury, duration of confusion and any post-concussive symptoms. All student-athletes who sustain a concussion should be referred for neurocognitive testing and evaluation with the Head Team Physician within 24 hours. The student-athlete shall not be permitted to return to play or practice until receiving clearance from the Head Team Physician. Sideline Management (if student-athlete remains on site): 1. A concussed player should not be left alone if the decision is made to keep the player on site, and regular monitoring for deteriorating physical or mental status is essential. 2. Assess the student-athlete for post-concussive clearing of his/her confusion every 5 minutes for the first 30 minutes, then every 15 minutes for the next 2 hours. 3. The athletic trainer must document the player’s name, position, circumstance of injury, duration of confusion and any post-concussive symptoms. 4. The student-athlete should NOT return to the current practice or competition, even if symptoms completely clear. 5. The student-athlete should be referred for neurocognitive testing and evaluation by the Head Team Physician within 24 hours of the injury. 6. Student-athletes with a concussion need appropriate disposition to home, to remain onsite until the end of the contest, or if needed transfer to an emergency facility. Post-Concussion Management: If a concussion is confirmed, the student-athlete shall be removed from practice or play for that calendar day. Upon discharge from the initial medical care, both oral and written instructions for home care should be given to the student-athlete and to a responsible adult (e.g., parent or roommate—the “caretaker”) who should continue to monitor and supervise the student-athlete during the acute phase of sport-related concussion. Documentation of the instructions should be recorded in the student-athlete’s medical record. Student-athletes with concussions should have medical follow-up. A detailed history of the event mechanism, course of symptoms and previous history of concussion should be elicited. Serial monitoring of standardized symptoms scores can be helpful to more objectively assess resolution of symptoms or return to their pre-injury baseline. The Head Team Physician shall monitor the concussion symptoms and evaluate the studentathlete’s recovery in order to consider additional diagnosis and best management options. Additional diagnoses may include, but are not limited to, post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression, ocular or vestibular dysfunction. Some issues to be observed or considered include the following: • • • • • • • Student-athletes that are recovering from a concussion should not have their sleep interrupted. Caretakers should be informed that it is desirable to let the student-athlete sleep. Sleep disturbance is a common and important symptom experienced throughout the course of a concussion. Sleep issues in the first few days following injury onset should be addressed conservatively, without medications, and with particular attention to good sleep hygiene. After the acute phase, medications may be considered for symptomatic relief. Those that affect the CNS, such as stimulants, certain anti-nausea and antidepressants should be used with caution as they may cloud the neurological and cognitive examination. Treatment options for headaches are limited. Acetaminophen offers a possible benefit without significant increased bleeding risk. A dim, quiet environment may moderate head pain, as well as symptoms of photophobia and phonophobia. Headaches that continue as part of a post-concussion syndrome (symptoms lasting longer than 6 weeks) often require a multidisciplinary approach. Alteration in mood is also a common manifestation of concussion, particularly in the acute setting. If mood issues persist beyond 6-12 weeks, treatment with medications and/or cognitive therapy should be considered. Decreasing academic responsibilities and other cognitive demands should be considered for any significant decrease in cognitive performance. The Sports Medicine Department recognizes that it may not be possible for neurocognitive testing to take place within a 24 hour time frame due to team travel and other difficulties. With that in mind, it is necessary to plan for an evaluation with the Head Team Physician and for neurocognitive testing and SAC testing as soon as possible for the student-athlete, after he/she returns to campus. RETURN-TO-PLAY GUIDELINES: The initial management of sport-related concussion is relative physical and cognitive rest. The student-athlete diagnosed with a concussion must be removed from play and not return to play or practice for at least one calendar day and will be evaluated as soon as possible by the Head Team Physician. Once the concussed student-athlete has returned to baseline level of symptoms, cognitive function and balance, then the return-to-play progression can be initiated. Each student-athlete with a concussion must undergo a supervised stepwise progression management plan (see sample plan below) by the Head Team Physician or the ACT with expertise in concussion. The plan shall specify that the student-athlete have limited physical and cognitive activity until he/she has returned to baseline, then progresses with each step below without worsening or new symptoms: • • • Light aerobic exercise without resistance training; Sport-specific exercise and activity without head impact; Non-contact practice with progressive resistance training; • • Unrestricted training; Return to competition. The student-athlete should be free of concussion symptoms at rest as well as during and after exertional activity before returning to full participation. The student-athlete should also have a normal neurological exam including a normal cognitive and balance evaluation compared to a preinjury baseline. Neurocognitve testing in conjunction with the team physician physical exam and additional diagnostic tests as needed may determine when a student-athlete will return to activity. Neurocognitive testing will be scheduled for 24 hours post initial injury and then subsequently every 48 hours, until the student-athlete scores at his/her baseline level, or an equivalent score that is acceptable by the Head Team Physician. Continued post-concussive symptoms, prior concussion history and any diagnostic testing results along with neurocognitve testing and physical exam, will be utilized by the Head Team Physician in establishing a timeline for a student-athlete’s return to activity. It is important to note that this timeline could last over a period of days to weeks or months, or potential medical disqualification from Kansas Athletics sponsored teams. All cases and progression management plans will be handled on a individualized, case-by-case basis. The decision by the Head Team Physician for all cases of an athletes return to activity is final. Post-Concussion Follow-Up (24-48 hours post-injury)Students-athletes will perform the following: • • • • • Post-Concussion Symptom Check List SAC Test Neuropsychological Assessment – ImPACT BESS Test C3 Logix NoteThe Mild Traumatic Brain Injury Post Concussion Symptom Check List will be repeated every day until the student-athlete Self-Reports Asymptomatic (SRA), at which time the studentathlete will begin with Day 1 SRA Procedures. Day 1 Self-Report Asymptomatic (SRA) Mild Traumatic Brain Injury Post-Concussion Symptom Check List Neuropsychological Assessment – ImPACT Cardiovascular exercise in controlled settingMode, duration and intensity dependent upon sport Monitor symptoms If student-athlete becomes symptomatic, return the student-athlete to the concussed state / procedures until he/she Self-Report Asymptomatic (SRA) Weight Training (under the direction of a certified athletic trainer) Mode, duration and intensity dependent upon sport If Day 2 does not fall within the student-athlete’s scheduled weight lifting schedule, the studentathlete should still perform weight training exercises under the direction of an ACT. Monitor symptoms If student-athlete becomes symptomatic, return the student-athlete to the concussed state / procedures until he/she Self-Report Asymptomatic (SRA) Day 2 Self-Report Asymptomatic (SRA) – with no increase in symptoms a. Exertional Functional Activity without contact • • Mode, duration and intensity dependent upon sport Monitor symptoms If student-athlete becomes symptomatic, return the student-athlete to the concussed state he/she procedures until he/she Self-Report Asymptomatic (SRA) b. Mild Traumatic Brain Injury Evaluation Post Concussion Symptom Check List IF – The student-athlete is symptomatic during and/or after any of the test, return him/her to the concussed state procedures until the SRA and consult with the Team Physician for further evaluation The student-athlete is asymptomatic with all activity; consult with the Head Team Physician for return to play clearance. The final determination of a student-athlete’s return to play shall be made by the Head Team Physician. The ACT should not permit a student-athlete to return to play without this determination. RETURN TO ACADEMICS GUIDELINES: Return to academics (return-to-learn) is a parallel concept to return-to-play, but has received less scientific evaluation than its counterpart. The foundation of return-to-learn includes: • Return-to-learn should be managed in a stepwise program that fits the needs of the individual. • Return-to-learn guidelines assume that both physical and cognitive activities require brain energy utilization, and they similarly assume that such brain energy is not available for physical and cognitive exertion because of the concussion-induced brain energy crisis. • Return-to-learn recommendations are based on consensus statements, with a paucity of evidence-based data to correlate with such consensus recommendations. • Return-to-learn recommendations and academic adjustments should be made within the context of a multi-disciplinary team, including but not limited to includes physicians, athletic trainers, coaches, administrators as well as academic (e.g. professors, deans, academic advisors) and office of disability services representatives. The level of multi-disciplinary involvement should be made on a case-by-case basis. An individual shall be identified at Kansas Athletics who will be the designated “point” person who will navigate the return-to learn process for the student-athlete (generally the academic counselor). Like return-to-play, it is not always easy to provide prescriptive recommendations for return-tolearn because the student-athlete may appear physically normal but is unable to perform at his/her expected baseline due to concussive symptomatology. The first step of return-to-learn is physical and cognitive rest immediately following any type of concussion, just as the first step of return-to-play is physical and cognitive rest. Cognitive rest means minimizing potential cognitive stressors such as school work, video games, reading, texting and watching television. The student-athlete should not return to classroom activity on the same day as a concussion. When a student-athlete is diagnosed with a concussion the academic advisor will be informed, the academic advisor will then notify professors and instructors. The period of time needed to avoid class or homework should be individualized. The gradual return to academics is based on the return of concussion symptoms following cognitive exposure. The consensus to date includes: • If the student-athlete cannot tolerate light cognitive activity, he or she should remain at home or in the residence hall. • Once the student-athlete can tolerate cognitive activity without return of symptoms, he/she should return to the classroom and studying as tolerated. At any point, if the studentathlete becomes symptomatic, or scores on clinical measures decline, the Head Team Physician should be notified and the student-athlete’s cognitive activity reassessed. A concussion is a challenging injury for student-athletes and unlike other injuries, the timeline for return to full activity is often difficult to project. Modification of schedule or academic accommodations for up to two weeks may be indicated. It is important that health care providers continue to communicate and document the status of the student-athlete as he/she continues their recovery. When a student-athlete has not recovered in the anticipated period of time, the student-athlete may need a change in his/her class schedule; special arrangements may be required for extended absences, test, term papers and projects. The Head Team Physician may recommend to academic counselor the possibility of arrangements. Such accommodations can often be assessed through KU Academic Achievement and Accessibility Center. When the student-athlete experiences prolonged cognitive difficulties, the academic counselor can develop a detailed academic plan that specifies the support services specifically available for the student-athlete. The academic counselor along with the Head Team Physician can discuss/disclose the documentation to the disability office in order to seek long-term accommodations or academic adjustments. The disability office will need to verify if the impairment is limiting a major life activity per the Americans with Disabilities Act. A detailed academic plan coupled with accommodations can provide the needed support for a student-athletes as he/she returns to learning after a concussion. The academic counselor, professor or instructor can best support a student-athletes return to academics and recovery by understanding possible concussion effects and providing the student with needed accommodations and support. Understanding concussion symptoms can help the student and members of the team identify individual needs of the student, monitor changes, and with proper permission, take action when necessary. This will help facilitate a full recovery and discourage students from minimizing the symptoms due to embarrassment, shame, or pressure to return to activities. RETURN TO LEARN (sample plan) LEVEL 1 or Phase 1 Rest. No reading, computer, TV, class, tutor, team meetings, video games No Concentrating (No physical activity) LEVEL 2 or Phase 2 Class and team meetings if tolerated. Mild Concentration (Low level training room activity--bike, etc.) Target Heart Rate 40%-60% Exercises in quite room LEVEL 3 or Phase 3 Add tutoring and position meetings as tolerated Mild/Moderate Concentration Exercises in gym or more active environment Team Warm up On field conditioning, drills Target Heart Rate 60%-80% LEVEL 4 or Phase 4 Add class related computer work and team-related film sessions if tolerated. Exams “?” Sports Specific Activity Target Heart Rate 80% (+) Aggressive Strength Training (Non-contact practice) LEVEL 5 or Phase 5 Progress to regular mental activity as tolerated, drills) (Progress to full activity, contact) The student-athlete must be symptom free before moving to next level or phase. REDUCING HEAD TRAUMA EXPOSURE: To best reduce head trauma exposure, Kansas Athletics shall adhere to the Inter-Associate Consensus: Year Round Football Practice Guidelines and the Inter-Association Consensus: Independent Medical Care Guidelines. Kansas Athletics also will take a “safety first” approach to athletic practice and competitions and shall work with coaches and student-athletes on safe play and proper techniques, reducing gratuitous contact during practice, and “taking the head out of contact.” SUMMARY: Kansas Athletics’ Sports Medicine Department is committed to providing quality health care services for all student-athletes. As such, Kansas Athletics is very proactive in the assessment, diagnosis, and management of concussions. By following this program, the risks of concussions associated with athletics and the potential catastrophic and long-term complications from concussions shall be limited. Return to Academics: Return to academics (return-to-learn) is a parallel concept to return-to-play, but has received less scientific evaluation than its counterpart. The foundation of return-to-learn includes: • Return-to-learn should be managed in a stepwise program that fits the needs of the individual. • Return-to-learn guidelines assume that both physical and cognitive activities require brain energy utilization, and they similarly assume that such brain energy is not available for physical and cognitive exertion because of the concussion-induced brain energy crisis. • Return-to-learn recommendations are based on consensus statements, with a paucity of evidencebased data to correlate with such consensus recommendations. • Return-to-learn recommendations should be made within the context of a multi-disciplinary team that includes physicians, athletic trainers, coaches, administrators as well as academic (e.g. professors, deans, academic advisors) and office of disability services representatives. • Like return-to-play, it is not always easy to provide prescriptive recommendations for return-to-learn because the student-athlete may appear physically normal but is unable to perform at his/her expected baseline due to concussive symptomatology. The first step of return-to-learn is physical and cognitive rest immediately following any type of concussion, just as the first step of return-to-play is physical and cognitive rest. Cognitive rest means minimizing potential cognitive stressors such as school work, video games, reading, texting and watching television. The rationale for cognitive rest is that the brain is experiencing an energy crisis, and providing both physical and cognitive rest allows the brain to heal more quickly. Data from small studies suggest a beneficial effect of cognitive rest on concussion recovery. For the college student-athlete, cognitive rest following concussion means avoiding the classroom for at least the same day as concussion. When a student-athlete is diagnosed with a concussion the academic advisor will be informed, the academic advisor will then notify professors and instructors. The period of time needed to avoid class or homework should be individualized. The gradual return to academics is based on the return of concussion symptoms following cognitive exposure. The consensus to date includes: If the student-athlete cannot tolerate light cognitive activity, he or she should remain at home or in the residence hall. Once the student-athlete can tolerate cognitive activity without return of symptoms, he/she should return to the classroom. At any point, if the student-athlete becomes symptomatic, or scores on clinical measures decline, the team physician should be notified and the student-athlete’s cognitive activity reassessed. The extent of academic adjustments needed should be decided by a multi-disciplinary team that may include the team physician, athletic trainer, faculty athletic representative or other faculty representative, coach, individual teachers and psychologist. The level of multi-disciplinary involvement should be made on a caseby-case basis. A concussion is a challenging injury for student-athletes and unlike other injuries, the timeline for return to full activity is often difficult to project. The psychological response to injury is also unpredictable. Student-athletes with concussions often appear “normal”, without cast or crutches or other identifiable clues to being injured. It is important that health care providers continue to communicate and document the status of the student-athlete as he/she continues their recovery. When a student-athlete has not recovered in the anticipated period of time, the student-athlete may need a change in his/her class schedule; special arrangements may be required for extended absences, test, term papers and projects. The team physician will recommend to academic counselor the possibility of arrangements. Such accommodations can often be assessed through KU Academic Achievement and Accessibility Center. When the student-athlete experiences prolonged cognitive difficulties. The academic counselor can develop a detailed academic plan that specifies the support services specifically available for the student-athlete. The academic counselor along with team physician can discuss/disclose the documentation to the disability office in order to seek long-term accommodations or academic adjustments. The disability office will need to verify if the impairment is limiting a major life activity per the Americans with Disabilities Act. A detailed academic plan coupled with accommodations can provide the needed support for a student-athletes as he or she returns to learning after a concussion. The academic counselor, professor or instructor can best support a student-athletes return to academics and recovery by understanding possible concussion effects and providing the student with needed accommodations and support. Understanding concussion symptoms can help the student and members of the team identify individual needs of the student, monitor changes, and with proper permission, take action when necessary. This will help facilitate a full recovery and discourage students from minimizing the symptoms due to embarrassment, shame, or pressure to return to activities. RETURN TO LEARN LEVEL 1 or Phase 1 Rest. No reading, computer, TV, class, tutor, team meetings, video games No Concentrating (No physical activity) LEVEL 2 or Phase 2 Class and team meetings if tolerated. Mild Concentration (Low level training room activity--bike, etc.) Target Heart Rate 40%-60% Exercises in quite room LEVEL 3 or Phase 3 Add tutoring and position meetings as tolerated Mild/Moderate Concentration Exercises in gym or more active environment Team Warm up On field conditioning, drills Target Heart Rate 60%-80% LEVEL 4 or Phase 4 Add class related computer work and team-related film sessions if tolerated. Exams “?” Sports Specific Activity Target Heart Rate 80% (+) Aggressive Strength Training (Non-contact practice) LEVEL 5 or Phase 5 Progress to regular mental activity as tolerated, drills) (Progress to full activity, contact) Student-athlete must be symptom free before moving to next level or phase. SIGNS AND SYMPTOMS OF A CONCUSSION • SIGNS OBSERVED BY PARENTS OR GUARDIANS - Appears dazed or stunned Is confused about events Answers questions slowly Repeats questions Can’t recall events prior to hit, bump, or fall Can’t recall events after the hit, bump, or fall Losses consciousness (even briefly) Shows behavior or personality changes Forgets class schedule or assignments • SYMPTOMS REPORTED BY STUDENTS Physical - Headache or “pressure” in head - Nausea or vomiting - Balance problems or dizziness - Fatigue or feeling tired - Blurry or double vision - Sensitivity to light or noise - Numbness or tingling - Does not “feel right” - Thinking/Remembering - Difficulty thinking clearly - Difficulty concentrating or remembering - Feeling more slowed down - Feeling sluggish, hazy, foggy, or groggy Emotional - Emotional: - Irritable - Sad - More emotional than usual - Nervous - Difficulty thinking clearly - Difficulty concentrating or remembering - Feeling more slowed down - Feeling sluggish, hazy, foggy, or groggy Sleep - Drowsy - Sleeps less than usual - Sleeps more than usual - Has trouble falling asleep KANSAS ATHLETICS, INC. DEPARTMENT OF SPORTS MEDICINE 1651 Naismith Dr., Lawrence, Kansas 66045-4069 (785) 864-7938 ACKNOWLEDGEMENT OF RISK FOR COACHES, ADMINISTRATORS, SPORTS MEDICINE STAFF INCLUDING THE DIRECTOR OF SPORTS MEDICINE REGARDING CONCUSSION PROTOCOL I, _______________________, have received and read the NCAA Concussion Fact Sheet and the Kansas Athletics’ Concussion Guidelines and Policy and understand that it is my responsibility to report any concussion-like symptoms that occur in connection with a student-athlete’s participation in athletic activity. I also acknowledge that if I suspect a concussion, I am responsible for removing the student-athlete from the activity, reporting it to the appropriate medical staff, and not permitting the student-athlete to return to athletic participation until I have received clearance from the Head Team Physician. This consent shall remain in full force and effect for a period of one year from the date of its execution, unless it is specifically revoked in writing prior to that date. I have read this form and fully understand and accept its terms and conditions. Signature/Department Date April 2015 KU Sports Medicine POST CONCUSSION SYMPTOM CHECKLIST Name: Date:_ Sport: Date of Injury: Description of Injury: Has the athlete ever had a concussion? Yes No Date: Was there a loss of consciousness? Yes No Unclear Does he/she remember the injury? Yes No Unclear Did he/she have confusion after the injury? Yes No Unclear Please place the corresponding number in the space provided to rate the concussion symptom: 0- none; 1 - mild; 2 – moderate; 3 – severe Symptoms At time of concussion Today Dizziness __________ ________ Headache __________ ________ Bell Rung __________ ________ Ringing in Ears __________ ________ Nausea/Vomiting __________ ________ Excessive Sleep __________ ________ Drowsy/Sleepy __________ ________ Sleeping More than Usual __________ ________ Fatigue/Low Energy __________ ________ Feel “in a fog” __________ ________ Feel “Dazed/Slowed Down” __________ ________ Irritability __________ ________ Poor Balance/Coord. __________ _________ Difficulty Remembering (presently) Loss of Orientation __________ _______ __________ _______ Poor Concentration __________ _______ Joint Stiffness __________ _______ Sadness __________ _______ Blurred Vision __________ _______ Sensitivity to Light __________ _______ Sensitivity to Noise __________ _______ Vacant Stare/Glassy Eyed __________ _______ Trouble Falling Asleep __________ _______ Numbness/Tingling __________ _______ Additional Findings/Comments: Recommendations/Limitations: Signature: Date: Concussion Management Protocol for Kansas State University Sports Medicine Prior to participation in any athletic activity for Kansas State University, a student-athlete will have a pre-participation medical exam, complete a medical history, including concussion history, and undergo baseline cognitive and posturalstability testing (SAC, ImPact, and BESS) in addition to completing a SCAT 2 card. The Team Physician will determine pre-participation clearance for activity and/or determine if any consultation or additional testing is needed once all baseline tests are completed. All student-athletes, coaches, team physicians, athletic trainers, and directors of athletics will sign a concussion fact sheet in which they accept the responsibility for reporting student-athlete injuries and illnesses to the medical staff of Kansas State University, including signs and symptoms of concussions. Once a student-athlete is suspected of having a head injury, as reported by a coach, teammate, or individual, the medical staff (Team physician and/or Athletic Trainer) of Kansas State University will be immediately notified. From that moment, the student-athlete of concern may not return to play until cleared by the medical staff. In football, the athlete’s helmet will remain in the possession of the medical staff until the student-athlete has been cleared to return to play by the medical staff. Upon notice of a possible head injury, the athletic trainer will conduct an immediate assessment of the student-athlete. The assessment will consist of cognitive testing (SAC) and may include postural-stability testing (BESS) or completing a SCAT 2 card. Simultaneously, the team physician will be notified of the head injury. If the athletic trainer suspects that the student-athlete may have suffered a concussion, then the student-athlete will be held from further participation until evaluated by a team physician. The team physician will then conduct an independent assessment of the student-athlete’s condition that includes, but is not limited to physical examination and history, cognitive assessment, review of BESS, SAC, and SCAT 2, and clinical assessment for cervical spine, skull fracture, and intracranial bleed. Based upon this assessment, the physician will determine the extent of the head injury. If a diagnosis of concussion is declared, then the student-athlete may not return to play for the remainder of the day. Postconcussion management will be initiated, involving repeated assessment of the student-athlete’s medical condition every 5 minutes, monitoring for signs of deterioration of neurological signs/symptoms, spine injury, Glasgow Coma Scale < 13, focal neurological deficit, and/or repetitive vomiting. Should the student-athlete exhibit any sign of deterioration or prolonged loss of consciousness, the studentathlete will be immediately transferred to the nearest medical facility for further medical evaluation. If the degree of deterioration requires life-saving measures, immediate treatment will commence, including CPR, until emergency medical personnel can be summoned to provide stabilizing measures and ambulance transport to a medical facility. Should the student-athlete’s medical condition remain stable, he/she may remain at the sporting event/practice site. The student-athlete will provide any and all information requested by medical personnel. For the stable post-concussion condition, a repeat cognitive and postural stability test will be performed after the game/practice. Additionally, the studentathlete will complete a SCAT 2 card to document the presence and severity of postconcussion symptoms. A complete evaluation of the student-athlete will be conducted by a physician at the completion of the practice/game, assuming the student-athlete’s medical condition remains stable. Based upon this examination, the physician will determine the student-athlete’s disposition. If the student-athlete’s medical condition is deemed stable enough to leave the premises, arrangements will be made for monitoring of the student-athlete through the night by a responsible adult, and oral and written instructions to the student-athlete and the adult will be documented. Parents of the student-athlete may also be contacted and apprised of the situation. The student-athlete will be instructed to report any changes in his condition during the night, being given the phone number of the athletic trainer to contact should problems arise. The studentathlete will be advised to avoid drinking alcohol and to not take any NSAIDS or aspirin for their headache. Tylenol may be taken for headache relief. The studentathlete will be given a document that has at-home instructions. The day following the concussion, the student-athlete will undergo a repeat thorough examination, including cognitive and postural stability testing (SAC, ImPact, and BESS). The student-athlete will complete a SCAT 2 card to document their post-concussion symptoms. Based upon review of these assessments, a treatment plan for the student-athlete will be created. The Team Physician will monitor and evaluate each student-athlete during their recovery and determine the rate of progression/recovery. The student-athlete with prolonged recovery will be evaluated by the Team Physician with consideration to additional diagnosis including but not limited to post-concussion syndrome, migraine or headache disorders, sleep dysfunctions, anxiety, depression, etc. No physical exertion activity by the student-athlete will be allowed until medically cleared by the Team Physician. In order for physical exertion to be allowed, the student-athlete must be clear of any post-concussion symptoms, and exhibit no signs of cognitive deficits or postural instability. Once medically cleared to begin exercise, the student-athlete will be progressed through an exercise protocol (return-to-play, RTP), with an initial cardiovascular challenge, followed by sport-specific activities that do not place the student-athlete at risk for concussion. The athlete will be required to perform each step of the protocol without exacerbation of post-concussion symptoms. If the student-athlete is able to perform the day’s activity without symptoms, they will be allowed to advance their activity per protocol. When the athlete is 4-7 days (as directed by the Team Physician) postconcussion diagnosis, the athlete will be required to complete another ImPact post- injury test. If the athlete successfully tests at or above their baseline then follow-up ImPact testing will not be needed. If the athlete fails to meet their baseline score according to the ImPact report then they must repeat the ImPact post-injury test until baseline is met. The post-injury re-test will be dictated according to the Team Physician. Once satisfactorily completing the protocol asymptomatically and successfully reaching the ImPact baseline score, the student-athlete may return to full competition in their sport, if approval from Team Physician is obtained. The student-athlete will be advised that they are more susceptible to future concussions because of their previous concussion. Any student-athlete sustaining a concussion during the previous season will have repeat baseline testing at the start of the next season. The student-athlete will be reminded to report any and all symptoms suggestive of a concussion. In addition to physical activity and exertion, any student-athlete who is diagnosed with a concussion will be held from all academic requirements until asymptomatic and baseline requirements have been met, including the day of diagnosis. Once medically cleared for exercise, a student-athlete will be progressed through a return-to-learn progression in addition to the return-to-play progression. This progression will be directed by the Team Physician and will be communicated to the athletic trainer, academic counselor, instructors/professors, and any other individual that the Team Physician deems necessary. The student-athlete will be required to perform each step of the progression without exacerbation of postconcussion symptoms. If the student-athlete is able to perform the day’s activity without symptoms, they will be allowed to advance their activity per protocol. The student-athlete will receive reasonable academic accommodations, which may include a modified schedule, an individualized plan, and/or other campus resources in accordance with ADAAA /Section 504. The Team Physician will also re-evaluate the student-athlete. K-State Athletics highly encourages all student-athletes to use proper judgement and practice safe techniques as it relates to head injuries while participating in practice/competition. Education and demonstrations of proper and safe techniques as it relates to the head should be practiced daily. K-State Athletics also supports the best practice guidelines listed below. If any student-athlete has a question or concern as it relates to a head injury they should immediate contact a member of the Sports Medicine Department. http://www.ncaa.org/health-and-safety/independent-medical-care-guidelines http://www.ncaa.org/health-and-safety/football-practice-guidelines Return to Play (RTP) Guidelines/Progression Once medically cleared to begin exercise, the student-athlete will be progressed through an exercise protocol using the following guidelines/progression. Each phase of the progression is considered complete only if the student-athlete remains asymptomatic during and after the workout is completed. The Team Physician will re-evaluate the student-athlete prior to medical clearance for participation. 1. Day 1, Cardiovascular workout utilizing a stationary bicycle- 30 minute workout 2. Day 2, Run/Jog on treadmill- 20 to 30 minute workout 3. Day 3, Sports Specific agility drills on playing surface and can lift weightsApproximately 30 minute workout 4. Day 4, Participate in non-contact sport practice. 5. Day 5, Participate in normal practice. **If student-athlete has any recurring symptom(s) during the above mentioned progression, they must repeat that specific step of the progression when asymptomatic, and can only advance to the next if they remain asymptomatic upon completion of the workout. Any RTP progression that must be repeated cannot occur on the same day as the step that symptoms recurred. Return to Learn (RTL) Guidelines/Progression The student-athlete diagnosed with a concussion shall be withheld from classroom activity and tutoring/study hall the remainder of the day, and may be required to remain at home/dorm. There will be no academic requirements including classroom activities, study sessions, testing, etc… until the student-athlete has been medical cleared by the team physician. Once medically cleared to initiate academic activities, the student-athlete will be progressed through an exercise protocol using the following guidelines/progression. Each phase of the progression is considered complete only if the student-athlete remains asymptomatic during and after the progression is completed. Following is the RTL protocol*: 1. Day 1, 30 minutes of mental activity/exertion in a controlled environment. No computer work, no testing, and no visual work requirements. 2. Day 2, 30 minutes of mental activity/exertion in a controlled environment followed by 15 minutes of rest, then 30 more minutes of mental activity/exertion. No computer work or testing allowed. 3. Day 3, Resume class room attendance and study table requirement. No computer work or testing allowed. 4. Day 4, Resume all class work and study table requirements, resume normal computer use. No testing allowed. 5. Day 5, Resume all academic requirements. *If student-athlete has any recurring symptom(s) during the above mentioned progression, they must repeat that specific step of the progression when asymptomatic, and can only advance to the next if they remain asymptomatic upon completion of the workout. Any RTL progression that must be repeated cannot occur on the same day as the step that symptoms recurred. A multi-disciplinary team consisting of a team physician, athletic trainer, academic counselor, and representative from the Student Access Center will be available to navigate more complex cases of RTL. Bill Banks, Academic Counselor for Football, will serve as the point person to assist the student-athlete and to coordinate with professors and instructors and the Student Assistance Center regarding the student-athlete’s RTL progression and reasonable academic accommodations, which may include a modified schedule, an individualized plan, and/or other campus resources in accordance with ADAAA /Section 504. Should the student-athlete describe symptoms lasting greater than two weeks, the student-athlete will be re-evaluated by the Team Physician (and members of the multi-disciplinary team, as determined by the Team Physician). Sports Medicine 2201 Kimball Ave Manhattan, KS 66502 INJURY AWARENESS LETTER Regarding Your Student: _____________________________________ K-State Athletics Sports Medicine and Academic Counseling Departments would like to inform you that this student-athlete sustained an injury on _________________________________ that prohibits him/her from all cognitive and visual stimulation tasks and limits his/her academic participation. He/she was evaluated by ____________________________________________________, team physician. This student-athlete will undergo additional testing over the next several days. As a department, we wanted to make you aware of this injury and the need for reasonable academic accommodations. Assuming that this student-athlete does not suffer any setbacks, a typical return-to-learn progression works as follows: 1. 2. 3. 4. Day 1, No computer work, no testing, and no visual work requirements. Day 2, No computer work or testing allowed. Day 3, No computer work or testing allowed. Day 4, Resume all class work and study table requirements, resume normal computer use. No testing allowed. 5. Day 5, Resume all academic requirements. When this student-athlete attends class, please be aware that the side effects of the injury may adversely impact his/her academic performance. Please excuse him/her from all class assignments, quizzes, tests, and note taking at this point in time. We will continue to monitor the progress of this student-athlete and anticipate a full recovery. The K-State Athletics Academic Counseling Department will be kept updated regarding his/her status and will let you know when they can return to full academic participation. Should you have any questions or require further information, please do not hesitate to contact Matt Thomason at 785-532-6384. Thank you in advance for your time and understanding. Sincerely, University of Kentucky Concussion Management Plan In response to the growing concern over concussion in athletics and the memorandum issued by the NCAA (dated April 29, 2010) requesting that “institutions shall have a concussion management plan on file”, the following document serves as such. The Sports Medicine staff at the University of Kentucky proposes the following management plan. These are based on the most current recommendation from the NCAA, the CDC, and the 3rd International Conference on Concussion in Sport. This policy represents a multi-faceted approach to treating concussion that includes educating the athletes, coaching staff, and strength/conditioning personnel. It also delineates the role of the members of the Sports Medicine staff and includes a baseline assessment for those who participate in sports with a meaningful risk of concussion. These are adopted from both NCAA guidelines (**) as well as the InterAssociation Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines. This policy is reviewed annually. Examples from the NCAA Sports Medicine Handbook include but are not limited to:  All University of Kentucky Student‐Athletes will undergo a baseline assessment before the first practice.    The baseline assessment consists of a symptoms checklist and the SCAT3 Standardized Cognitive and Balanced  Assessment.   The concussed student‐athlete will be evaluated by a Team Physician regularly.  Once asymptomatic and post‐ exertion assessments are within normal baseline limits return‐to‐play will follow a medically supervised stepwise  process.      Education & Pre-participation Planning 1) All athletes are required to sign a waiver acknowledging they accept “responsibility for reporting their injuries to the medical staff, including signs and symptoms of a concussion.”** During this process, athletes will be presented education material regarding the signs and symptoms of concussion and will acknowledge they have reviewed the material and have had the opportunity to have any questions answered. Fact Sheet for student-athletes can be viewed at (http://web1.ncaa.org/web_files/health_safety/ConFactSheetsa.pdf). 2) All members of coaching, strength and conditioning, team physicians, administrative A.D’s who serve as liaisons, and athletic training staffs will receive educational material (NCAA Concussion Fact Sheet) to assist in identifying the signs and symptoms of a concussion. This educational material will also identify the steps to be taken once the injury has been recognized. A signed acknowledgment of document receipt will be required. Subsequent to the dissemination of the educational material, a form will be signed acknowledging they have received and understand the information. “Concussion, A Fact Sheet for Coaches” can be viewed at (http://web1.ncaa.org/web_files/health_safety/ConFactSheetcoaches.pdf). 3) The University of Kentucky will maintain an emergency action plan** for each venue to respond to catastrophic injuries and illnesses. This will include, but not limited to concussion and head injuries. (All athletics healthcare providers will review and practice the plan annually, while the coaches will review the plan annually). 4) Athletes participating in sports at the University of Kentucky or, an athlete who presents for their annual pre-participation exam with history of a concussion, will undergo pre-participation baseline screening. At this time, this will include SCAT3. Additionally, the Team Physician will determine pre-participation clearance and/or the need for additional consultation or testing. The NCAA has determined this to be “effective in the evaluation and management of concussion.” As our knowledge about the utility of these tests changes over time, we anticipate changes to our protocol as they become available. April 2015    Concussion Management Plan 1. When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, the athlete shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. This professional will have unchallengeable authority. The evaluation will consist of:  Symptom assessment  Physical and neurological exam  Cognitive assessment  Balance exam  Clinical assessment for cervical spine trauma, skull fracture, and intracranial bleed. 2. A student-athlete diagnosed with a concussion shall be withheld from the competition or practice and not return to activity for the remainder of the day. 3. The University of Kentucky will have an athletics healthcare provider with experience in the management of concussion either on-site or on-call for all home events. A team physician with experience in the management of concussions and knowledge of the Inter-Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines will be available for phone consultation. This access applies to all NCAA sports at the University of Kentucky. 4. If an athlete is determined to have a concussion, with any of the following associated signs and symptoms, the emergency action plan for that venue will be exercised (including transportation to nearest medical facility).  Glasgow Coma Scale <13  Prolonged loss of consciousness  Focal neurological…  Repetitive vomiting (emesis)  Persistent diminished/worsening…  Spine injury 5. The student-athlete will receive serial monitoring for deterioration. Athletes will be provided with instructions upon dismissal from practice/game that are consistent with the Inter-Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines, preferably with a roommate, guardian, or someone that can follow the instructions provided. 6. Subsequent to suffering a concussion, SCAT3 testing will be repeated and reviewed by a team physician. Academic advisors will be notified once an athlete has suffered a concussion for academic adjustments and return-to-learn guidelines. a. The Assistant Athletics Director for Academics & Eligibility will serve as the point person within our athletics department who will navigate return-to-learn with the student-athlete. He/she works in the departmental “CATS” Center. b. A multi-disciplinary team consisting of a team physician, sport ATC, Assistant Athletics Director for Academics & Eligibility, academic counselor, and representative from the Office of Disability Resources will navigate more complex cases of return-to-learn. The inclusion of the Office of Disability Resources will ensure compliance with The Americans with Disabilities Act Amendments Act of 2008 guidelines. c. The student-athlete diagnosed with a concussion shall be withheld from classroom activity and tutoring/study hall the remainder of the day. April 2015    d. The team physician will determine individualized cases that include, but not limited to, remaining at home/dorm if a student-athlete cannot tolerate light cognitive activity and the ensuing gradual return-to-learn activities. e. A modification of schedule/academics accommodations for up to two weeks will be implemented with help from the Assistant Athletics Director for Academics & Eligibility (point person) in collaboration with the sport ATC and team physician. Campus resources to include either the Office of Disability Resources or a CATS Learning Specialist will be consulted. f. Should the student-athlete describe symptoms lasting greater than two weeks, the studentathlete will be re-evaluated by the Team Physician (and members of the multi-disciplinary team as determined necessary by the Team Physician). 7. Once a concussion is diagnosed, the athlete will be evaluated by a team physician or medically qualified physician designee with experience in the management of concussions who will outline a plan for a return to play. The plan will follow these steps and be supervised by the above professional to ensure a step wise progression is being followed. Should symptoms reoccur during any step in the progression, the activity will be halted and the athlete will be re-evaluated the following day.        Rest until asymptomatic (physical and mental rest). Light aerobic exercise Sport specific exercise Non-contact training drills Full contact training after medical clearance** Return to competition (game play) Return-to-learn guidelines i. A multi-disciplinary team (team physician, ATC, Assistant Athletics Director for Academics & Eligibility, academic counselor) will communicate on more complex cases of prolonged return-to-learn. **The final decision for return to play rests with the physician and is unchallengeable. 8. For those athletes who are not improving in an expected fashion, the team physician will arrange for appropriate consultations and/or testing to consider additional diagnoses and best management options. Reducing Exposure to Head Trauma The University of Kentucky acknowledges the importance of emphasizing ways to reduce exposure to head trauma. Coaches and athletes will be responsible for taking a “safety first” approach to their sport and exercise proper technique. Specific to the sport of football, the Sports Medicine Staff will incorporate the NCAA Inter-Association Consensus: Year-Round Football Practice Contact Guidelines. Resources      NCAA Memorandum on Concussion Management Plan, April 29, 2010  NCAA and CDC Educational Material on Concussion in Sport.  www.ncaa.org/health‐safety  Consensus Statement on Concussion in Sport.  3rd International Conference on Concussion in Sport.   Zurich, 2008.  Clinical Journal of Sports Medicine, 2009; 19(3) 185‐200.  NCAA Sports Medicine Handbook 2014‐2015, Guideline 2I; pgs. 56‐64.  Concussion Safety Protocol Checklist (NCAA document 2015).  April 2015    APPENDICES Appendix 1 - Personnel Roles Appendix 2 - Concussion/Assumption of Risk Waiver Appendix 3 - NCAA Concussion Fact Sheet for Coaches Appendix 4 - NCAA Concussion Fact Sheet for Student-Athletes April 2015    APPENDIX 1 PERSONNEL ROLES Coach:  Remove any student-athlete that shows signs of concussion after direct or indirect head trauma  Make sure they are evaluated by the appropriate health care professional  Allow the student-athlete to return to play only after receiving clearance from the appropriate health care professional Certified Athletic Trainer:  Remove any student-athlete that shows signs of concussion after direct or indirect head trauma  Has unchallengeable authority  Perform a concussion evaluation and subsequent evaluations as Physician desires  Supervise activities during the return to play protocol, including exertion tests  Make proper referral to Physician, provide home instructions to responsible care giver when athlete goes home  Allow the student-athlete to return to play after receiving clearance from the Physician Physician:  When present, remove any student-athlete that shows signs of concussion after direct or indirect head trauma  When present, perform a concussion evaluation and subsequent evaluations as needed  Make proper referral to specialists if needed  Direct the Certified Athletic Trainer in caring for the Student-Athlete  Determine when the student-athlete can return to play and/or return-to-learn  Has unchallengeable authority  Stay contemporary with Inter-Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines Other Health Professionals: Consulted by Physician to aid in diagnosis and treatment of concussions April 2015    APPENDIX 2 UNIVERSITY OF KENTUCKY Declaration of Student-Athlete Responsibility for Reporting Injuries/Illnesses 1) ASSUMPTION OF RISK I accept the responsibility for reporting my injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. I have received educational material on the signs and symptoms of concussions, and understand these signs and symptoms. 2) CONCUSSIONS A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If you notice the symptoms or signs of concussion OR if your teammates, friends, coaches, or parents notice any of these symptoms, it is important to seek medical attention right away. Signs and Symptoms of Concussion* *Loss of consciousness (LOC) *Visual Disturbances (Photophobia, blurry, Phono/photophobia vision, double vision) *Confusion *Disequilibrium *Delayed verbal and motor responses *Inability to focus *Headache *Nausea/Vomiting *Excessive drowsiness *Post-traumatic amnesia (PTA) *Retrograde amnesia (RGA) *Feeling “in a fog,” “zoned out” *Vacant stare *Emotional lability *Dizziness *Slurred/incoherent speech   *taken from NCAA 2008‐09 Sports Medicine Handbook, table 1, page 49    It is important that if you, the student-athlete suffer any of the above signs or symptoms OR notice the same in a teammate, it is your responsibility to report this to the athletic training staff. Once a concussion has been reported or identified, the athlete will be removed from activity and not allowed to return on that same day. Subsequently, the athlete will be evaluated by the athletic trainer as well as a team physician. Further observation and specific testing will be done as symptoms dictate to ensure a safe return to activity. Continuing to play with the signs and symptoms of a concussion leaves the athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling with devastating and even fatal consequences. It is well known that athletes will often under report symptoms of injuries and concussions are no different. As a result, education of administrators, coaches, and the athlete themselves is important to the student-athlete’s safety. Please take the time to review the material in this document as well as the NCAA “Concussion Fact Sheet for StudentAthletes” and ask any questions you may have. Additionally, it’s our expectation that you are honest and thorough regarding any history of concussions you may have suffered prior to joining the University of Kentucky. 3) SIGNATURE OF STUDENT-ATHLETE RESPONSIBILITY My signature below acknowledges that I have reviewed the material on concussions and head injuries along with my responsibility to report injuries/illnesses to the medical staff as it relates to student-athletes at the University of Kentucky. I have been given the opportunity to ask any questions and have them answered to my satisfaction. I further understand that I share the responsibility for honestly and promptly reporting the symptoms of a head injury to the athletic training staff. _______________________________________________ _____________________________________ Student-Athlete Date _______________________________________________ _____________________________________ Witnessed by: Date University of Kentucky Athletic Training Staff April 2015    APPENDIX 3 CONCUSSION A FACT SHEET FOR COACHES THE FACTS WHAT IS A - A concussion is a brain injury. A concussion is a brain injury that may be caused by a blow to the a All concussions are serious. head, face, neck or elsewhere on the body with an ?impulsive? force - Concussions can occur without loss of consciousness or other transmitted to the head. Concussions can also result from hitting a obvious signs. hard surface such as the ground, ice or ?oor, from players colliding - Concussions can occur from blows to the body as well as to the head. I with each other or being hit by a piece of equipment such as a hat, I - Concussions can occur in any sport. lacrosse stick or ?eld hockey ball. I - Recognition and proper response to concussions when they ?rst occur can help prevent further injury or even death. - Athletes may not report their for fear of losing playing time. - Athletes can still get a concussion even if they are wearing a helmet. RECOGNIZING A POSSIBLE CONCUSSION To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; I 2. Any change in the student-athlete?s behavior, thinking or physical functioning (see signs and - Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries, depending on the Sport. SIGNS AND Signs Observed By Coaching Staff Reported By Student-Amish; - Appears dazed or stunned. - Headache or ?pressure? in head. 0 Is confused about assignment or position. - Nausea or vomiting. - Forgets plays. - Balance problems or dizziness. - ls unsure of game, score or opponent. - Double or blurry vision. - Moves clumsily. 0 Sensitivity to light. 0 Answers questions slowly. - Sensitivity to noise. - Loses consciousness (even briefly). - Feeling sluggish, hazy, foggy or groggy. - Shows behavior or personality changes. 0 Concentration or memory problems. - Can?t recall events before hit or tall. - Confusion. - Can't recall events after hit or fall. 0 Does not "feel right. . suite; 3* g1?: APPENDIX 3 PREVENTION AND PREPARATION As a coach, you play a key role in preventing concussions and responding to them properly when they occur. Here are some steps you can take to ensure the best outcome for your studentaathletes: - Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to-play. - Review and practice your emergency action plan for your facility. Know when you will have sideline medical care and when you will not, both at home and away. Emphasize that protective equipment should ?t properly, be well maintained, and be worn consistently and correctly. Review the Concussion Fact Sheet for Student-Athletes with your team to help them recognize the signs of a concussion. - Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury in the Athlete. - Insist that safety comes ?rst. Teach student~athletes safe- play techniques and encourage them to follow the rules of play. Encourage student- athletes to practice good sportsmanship at all times. Encourage student- athletes to immediately report of concussion. - Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death. IF YOU THINK YOUR STUDENT-ATHLETE HAS SUSTAINED A CONCUSSION: Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion. An athlete who exhibits signs, or behaviors consistent with a concussion, either at rest or during exertion, should be removed immedhtely from practice or competition and should not return to play until cleared by an appropriate health care professional Sports have injury timeouts and player substitutions so that student-athletes can get checked outCONCUSSION IS SUSPECTED: 1. Remove the student-athlete from play. Look for the signs and of concussion if your student?athlete has experienced a blow to the head. Do not allow the student-athlete to just ?shake it off?? Each individual athlete will respond to concussions differently. 2. Ensure that the student?athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the student- athlete to the appropriate athletics medical staff, such as a certi?ed athletic trainer, team physician or health care professional experienced in concussion evaluation and management. 3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return?to-play progression should occur in an individualized, step-wise fashion with gradual increments in physical exertion and risk of contact. 4. Develop a game plan. Student- athletes should not return to play until all have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact, as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change. BETTER THEY MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, SIT THEM OUT. For more information and resources, visit and WW. CDCgovf Concussion. Reference to any commercial entity or product or service on thispage should not be construed as an endorsement by the Government ofth company or its products or services. CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A A concussion is a brain injury that: [5 caused by a blow to the head or body. From contact with another player. hitting a hard surface such as the ground. ice or floor, or being hit by a piece oi. equipment such as a hat, lacrosse stick or ?eld hockey hall. Can change the way your brain normally works. I Can range from mild to severe. - Presents For each athlete. - Can occur during practice or competition in ANY sport. - Can happen even if you do not lose consciousness. HOW CAN I PREVENT A Basic steps you can take to protect yourself from concussion: Do not initiate contact with your head or helmet. You can still get a concussion ifyou are wearing a helmet. Avoid striking an opponenl in the head. Undercutting. [lying elbows. stepping on a head. checking an unprotected opponent. and sticks to the head all cause concussions. - Foliow your athletics department's rules for safety and the rules of the sport. a Practice good sportsmanship at all times. - Practice and perfect the skills of the sport. WHAT SHOULD I DO IF I THINK I HAVE A Dou?thide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also. tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with The sooner you get checked out. the sooner you may be able to return to play. Get checked out. Your team physician. athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can a?'ectyour ability to perform everyday activities. your reaction time. balance. sleep and classroom performance. Take time to recover. Ifyou have had a concussion. your brain needs time to heal. While your brain is still healing. you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage. and even death. Sew-.re brain injury can change your whole life. . . WHAT ARE THE OF A You can't see a concussion. but you might notice some of the right away. Other can show up hours or days after the injury. Concussion include: - Amnesia. 0 Confusion. - Headache. Loss of consciousness. - Balance problems or dizziness. - Double or fuzzy vision. 0 Sensitivity to light or noise. - Nausea (feeling that you might vomit}. - Feeling sluggish, foggy or groggy. - Feeling unusually irritable. - Concentration or memory problems (forgetting game plays, facts, meeting times). - Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying. working on the computer. or playing video games may cause concussion (such as headache or tiredness) to reappear or get worse. BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. For more information and resources. visit MWNCAAorgIhcalthsafety and wwaDCgovlConcussion. Rr?mrrc to any (ninmerci?l entity or or service un this page should not be not as an endorsement by the Gorerumem or the company or its pmductx or semen; Athlete?s signature indicates receipt and acknowledgement of understanding. Signature Date University of Louisville Concussion Management Plan On April 29, 2010, the NCAA distributed a policy reinforcing their commitment to the prevention, identification, evaluation, and management of concussions. As part of that policy, institutions were to create a concussion management plan to utilize for any student-athlete that “exhibits signs, symptoms, or behaviors consistent with a concussion.” The Sports Medicine staff at the University of Louisville proposes the following management plan. These are based on the most current recommendations from the NCAA, the CDC, and the International Conference on Concussion in Sport. This policy represents a multi-faceted approach to treating concussion that includes educating the all student-athletes, coaching staff, and strength/conditioning personnel. It also delineates the role of the members of the Sports Medicine staff as well as baseline testing for those who participate in sports at risk for concussion. These are adopted from both NCAA requirements (**) as well as additional “best practice” recommendations. Education & Pre-participation Planning: 1) All student-athletes are required to sign a waiver acknowledging they accept “responsibility for reporting their injuries to the medical staff, including signs and symptoms of a concussion.” ** During this process, student-athletes will be presented education material regarding the signs and symptoms of concussion and will acknowledge they have reviewed the material and have had the opportunity to have any questions answered. The information will be provided both within the waiver form as well as an NCAA-developed fact sheet. 2 ) A l l student-athletes will undergo pre-participation baseline screening. A thorough history including symptom evaluation, brain injury history, concussion injury history and cognitive assessment will be obtained at the preparticipation physical exam. The baseline testing will include, but is not limited to: a. Paper-based cognitive testing (e.g. SAC) b. Symptom evaluation (e.g. PCSS) c. Balance evaluation (e.g. BESS) d. Computerized Neurocognitive evaluation (e.g. Impact) The NCAA has determined these to be “effective in the evaluation and management of concussion.” As our knowledge about the utility of these tests changes over time, we anticipate changes to our protocol in the future. A Team Physician will determine pre-participation clearance and/or the need for additional consultation or testing. 3) All members of coaching, strength and conditioning, and athletic training staff, team physicians and sport administrators will receive educational material to assist in identify the signs and symptoms of concussion. This training will also identify the steps to be taken once the injury has been recognized. Subsequent to the education session, a form will be signed acknowledging they have received and understand the information. 4) The University of Louisville will maintain an emergency action plan ** for each venue to respond to catastrophic injuries and illness. This will include, but not be limited to concussion and head injuries. The athletic training staff will receive education reviewing the signs and symptoms of concussion that warrant implementing the emergency action plan. See Attachment for Example of Emergency Action Plan for one of our facilities (e.g., Papa John’s Cardinal Stadium.) Concussion Management Plan 1) Once the signs and/or symptoms of a concussion have been identified, the student-athlete will be removed from play and shall not return to athletics activity on that calendar day. ** 2) Initial evaluation of the concussed student-athlete will be performed by the athletic training staff or the on-site or on-call physician. The initial exam will include symptom assessment, physical and neurological exam, cognitive assessment, balance exam as well as clinical assessment for cervical spine trauma, skull fracture and intracranial bleed.** 3) The Emergency Action Plan will be activated if the following are present during the initial evaluation of a student-athlete with a suspected head or neck injury: cervical spine injury/trauma, skull fracture, Glascow Coma Scale <13, prolonged loss of consciousness, focal neurological deficit suggesting intracranial trauma, repetitive emesis, persistently diminished/worsening mental status or other neurological signs/symptoms, or other spine injury. Example of Emergency Action Plan is attached to this document. Each Emergency Action Plan is specific to site or venue. 4) The University of Louisville will have a sports medicine-trained physician with experience in the management of concussion either on-site or on-call for all home events. At all times, a physician with experience in the APRIL 2015 (REVISED JUNE 2015 & JULY 2015) management of concussions will be available for phone consultation. This access applies to all NCAA sports at the University of Louisville. ** 5) Subsequent to suffering a concussion, the student-athlete is to be monitored for deterioration in the ensuing hours. The on-site medical staff is to determine the appropriate steps after the injury and written instructions may be provided to help guide this supervision. Oral and/or written care given to both the student-athlete and another responsible adult will be documented. In the absence of an adequate support structure for the student-athlete, overnight hospitalization may be considered depending on the extent of the injury. 6) Student-athletes with prolonged symptoms may require additional diagnosis and best management options. These student-athletes may need additional referral for vestibular therapy, post-concussion syndrome, mood disorders, sleep deprivation, migraines or nutritional disorders. In such instances, team physicians will conduct follow-up evaluations to consider additional treatment and management options. 7) Subsequent to suffering a concussion, the student-athlete may necessitate some time away from class or additional time to complete assigned coursework. This is to be individualized and is dependent on the extent of the symptoms. The Athletic Trainer with the assigned sport will serve as the point person within athletics who will navigate return-to-learn with the studentathlete. The Athletic Trainer will serve as just one portion of the multidisciplinary team that will navigate more complex cases of prolonged returnto-learn. The other members of this team may include, but are not limited to: Team Physician, Psychologist/counselor, Neuropsychologist consultant, Faculty Athletics Representative, Athletic/Academic Counselor(s), course instructor (s), college administrators, Disability Resource Center staff, coaches, as well as family and friends of the student-athlete. The “return to learn” includes these provisions: a. Academic advisors will be notified by the Sports Medicine staff promptly after a student-athlete has suffered a concussion. b. The student-athlete will not participate in academic activities (e.g. class, tutoring, “screen time,” etc.) on the same day as concussion. c. The academic environment allows for an individualized progression of more prolonged and sustained mental activity. This may include remaining at home/dorm if student-athlete cannot tolerate light cognitive activity and a gradual return to classroom/studying as tolerated. d. Compliance with ADAAA e. Re-evaluation by team physician if concussion symptoms worsen with academic challenges. APRIL 2015 (REVISED JUNE 2015 & JULY 2015) f. Re-evaluation by team physician and members of the multidisciplinary team, as appropriate, for student-athlete with symptoms > two weeks. g. Modification of schedule/academic accommodations for up to two weeks, as indicated, with help from the sport’s Athletic Trainer and/or Academic counselor(s). h. Engaging Learning Specialists for cases that cannot be managed through schedule modification/academic accommodations. 8) Following concussion diagnosis, the student-athlete’s return-to-play stepwise progression is overseen by a health care provider with expertise in concussion. For a student-athlete to return-to-play, he or she must meet the following progressive standards: a. Be at or above his or her previous baseline testing; b. Undergo an appropriate step-by-step return to activity plan and has tolerated a graded exertional protocol without symptoms returning, including the following: i. Light aerobic exercise without resistance training ii. Sport-specific exercise and activity without head impact iii. Non-contact practice with progressive resistance training iv. Unrestricted training v. Return to competition c. The final decision for return to play rests with the team physician and is unchallengeable. The timetable for a return to play will be individualized and dependent on numerous factors. As with all conditions, no one clinical factor can be used to either diagnose concussions or determine when return to activities is safe after concussion. Symptoms, clinical evaluation, diagnostic studies and testing such as neurocognitive tests all must be weighed in the decision. Clinical judgment makes the final determination. 9) The University of Louisville acknowledges the importance of emphasizing ways to reduce exposure to head trauma. Coaches and athletes will be responsible for taking a “safety first” approach to their sport and exercise proper technique. Specific to the sport of football, the Sports Medicine Staff will incorporate the NCAA Inter-Association Consensus: Year-Round Football Practice Contact Guidelines. 10) Medical specialists, including those from Neurology and Neuropsychology, which may assist in the care of an affected student-athlete have been identified. They are available for consultation when appropriate and their assistance has been called upon in the development of this policy. APRIL 2015 (REVISED JUNE 2015 & JULY 2015) Resources NCAA Memorandum on Concussion Management Plan, April 29, 2010. NCAA and CDC Educational Material on Concussion in Sport. www.ncaa.org/healthsafety Consensus Statement on Concussion in Sport. 3rd International Conference on Concussion in Sport. Zurich, 2008. Clinical Journal of Sports Medicine, 2009; 19(3) 185-200. Halstead M, McAvoy K, et al. Returning to Learning Following a Concussion. Pediatrics, 2013; 132, 948-57. Harmon K, Drezner J, et al. American Medical Society for Sports Medicine position paper: Concussion in Sport. British Journal of Sports Medicine, 2013; 47, 15-26. APRIL 2015 (REVISED JUNE 2015 & JULY 2015) LOUISIANA STATE UNIVERSITY Athletic Training Concussion Management Policy LSU is committed to the prevention, identification, evaluation and proper management of concussions. While we recognize that the medical staff plays an important role in the identification of concussions, all student-athletes are equally responsible for notifying the medical and athletic training staff if they believe they may have suffered a concussion. A coordinated effort will always be made between the medical staff, coaching staff, equipment managers and the studentathlete to ensure the health and safety of the individuals involved in the athletic program at LSU. The following policy and procedures will be adhered to by all involved in the medical care of the student-athletes. Education Management: o o o Student-Athlete As part of Pre-Participation Physicals, all student-athletes will be asked to complete a number of forms that request disclosure of any concussions (no matter how mild) they may have suffered prior to enrollment at LSU. In addition to discussing their concussion history with a team physician, LSU studentathletes will receive concussion education in the form of a flyer given at the time of physicals (StudentAthlete Statement of Accountability). This flyer provides critical information regarding the facts, signs and symptoms, and the seriousness of concussions. A copy will be kept on file as a part of the PreParticipation documentation. In addition, posters that are distributed annually by the SEC to provide education to student-athletes and coaches on concussions will be placed in strategic areas in the locker room and/or athletic training rooms at athletic facilities. Coaches At the beginning of the Fall academic year, a presentation will be delivered by the Director of Athletic Training to the Athletic Administration as well as the coaching staff that educates them on the significance and seriousness of concussions. The coaching staff will receive an educational flyer and will sign the Coaches Statement of Accountability acknowledgment form as assurance that they have a general understanding of how concussions can be prevented or how to minimize exposure as well as the impact that concussions have to the short and long term health and well-being of their student-athletes. A copy will be kept on file with the Compliance Department as a part of the annual Athletic Department meeting. Medical Staff At the beginning of the Fall pre-season, the medical staff and all ATCs will familiarize themselves with the policies and procedures for concussion management. Any procedural changes will be discussed at this time. The medical staff will sign the Medical Team Statement of Accountability acknowledgment form to remind them of the responsibility they have to identify, manage, and safely return to play the studentathletes at LSU. A copy will be kept on file with the Compliance Department as a part of the annual reeducation process. Pre-Participation Management: To ensure the proper evaluation of all student-athletes over the time that they are at LSU, a baseline concussion assessment will be performed on each student-athlete. This extensive assessment tool will involve the following: o Brain Injury and Concussion History General medical questions on each student-athlete’s history of actual or possible concussions will be asked on the pre-participation physical examination. If a history is identified, an addendum will be completed by the student-athlete that details the significance of his or her head injury history. This addendum is to be reviewed by the team physician before final participation clearance is granted. Preparticipation physical exams are performed annually by our team physicians. Final medical clearance to participate will be determined by the team physician. o Evaluation A variety of assessment tools will be used in the baseline evaluation so that a current snapshot of the student-athlete prior to concussion can be documented. A computerized neurocognitive tool (ImPact, C3 Logic or similar module) will be completed by all student-athletes. These baseline scores for cognitive functioning and balance will be documented and used as a reference point in the event that a concussion is sustained or suspected. Reducing Exposure to Head Trauma: With the intent to further educate the coaches and the student-athletes regarding ways to reduce the exposure to head trauma, the following practices are employed at our training and competition venues: o Annual re-education for coaches and student-athletes to review the signs and symptoms of concussions as well as the importance of reducing the amount of exposures to head trauma, including but not limited to: 1. Reminders and teaching of proper technique to limit head contact; and 2. Limiting the amount of contact that ends up on the ground during practice, as ground impact can cause additional head trauma. o Equipment Inspection 1. Daily inspection of gear and helmets to ensure proper fit and usage; 2. Facility inspection prior to activity that may identify additional risk factors that could add to potential concussions (e.g.: unintended equipment on courts or fields, protective padding that covers equipment, and slick playing surfaces); and 3. Upon the student-athlete’s return from a concussion, an “off-colored” jersey will be worn to signify that there is to be “no contact or trauma” with the student-athlete until the jersey has been removed and the student-athlete has received medical clearance to fully participate in practice and competition from the team physician. o Practice Schedules 1. Mandate that rules and regulations that are set by the NCAA regarding practice opportunities are followed as their intent is to protect and limit over-exposure to injury (eg: two-a-days, weekly hour rules, off days); 2. Coaches must be willing to listen to the suggestions of the team physicians and athletic trainers relative to altering practice schedules as to reduce head contact exposure;and 3. Limiting heat exposure, evaluating hydration status, and providing adequate nutrition are all important factors to providing an effective practice environment that can help in reducing head trauma and injury exposure. o Research and Education 1. LSU remains focused on learning and developing the best practices to limit and reduce incidents of injury and head trauma. In doing so, the Athletic Training Department remains thoughtfully engaged in research and data collection that has the potential to positively change the way athletics approaches concussions; and 2. Using state-of-the-art equipment such as: microchipped mouthpieces, internal and external helmet sensors, and blood-collection studies, we have been able to better assess the physiological response to head trauma. This active research will continue to improve the way we alter our practice and competition habits to ensure an even safer practice and competition environment for our student-athletes. Recognition and Diagnosis of Concussion: If a possible concussion has occurred and an initial assessment by a certified athletic trainer or team physician has been completed, the student-athlete will be removed from practice or competition until a complete and full evaluation by a team physician has occurred. It will be necessary to withhold the student-athlete for at least one calendar day if a diagnosis of concussion is confirmed. o Initial Suspected Concussion Evaluation 1. Once removed from play or practice, a clinical evaluation must be completed. A physical and neurological exam will be done to determine the significance of the injury. Once it is deemed safe to continue the assessment, additional evaluation tools will be utilized. 2. The most current version of the SCAT evaluation tool will be implemented to determine the current cognitive state of the student-athlete. 3. A portion of the evaluation will be directed towards balance and more advanced measures of cognitive ability. Post-Concussion Management: If the situation warrants advanced emergency medical care, the Emergency Action Plan will be activated. If immediate transportation to the hospital is necessary, EMS will be called and the team physician will be contacted and fully informed of the student-athlete’s current status. The certified athletic trainer will work directly with the team physician in the monitoring of the student-athlete’s current medical status or possible deterioration. If any of the following signs are present, the need for emergency medical transport should be imminent: 1. Glasgow Coma Scale <13 2. Prolonged Loss of Consciousness 3. Focal Neurological Deficit suggesting Intracranial Trauma 4. Repetitive Emesis 5. Persistently diminishing/worsening mental status or other signs and symptoms 6. Spine Injury o Follow-up Care 1. Once the student-athlete is deemed safe to be released from the care of the medical personnel, they may be released to a responsible individual that will be able to follow basic instructions to assist in the monitoring of the athlete. 2. A Concussion Care Packet will be given to an individual who will be caring for the concussed student-athlete. The name of the individual providing care as well as his or her relationship to the student-athlete will be documented in the medical database. 3. A self-report concussion symptom scale in addition to routine evaluation will be completed within the first 24 hours. Subsequent symptoms scales and evaluations will be done daily or at the request of the team physician. 4. If the doctor feels it is warranted, a prescription of DHA may be given to aid in the recovery and inflammation process that could occur with a concussion. A copy of the letter/RX will be kept in the student-athlete’s permanent medical records. o Prolonged Recovery Care If there is not considerable or consistent improvement in the self-reported signs and symptoms of the concussion or an improvement in the evaluation outcome after 7 days, follow-up imaging and/or referral to a neurologist will be considered. Additional diagnoses include but are not limited to: 1. Post-Concussion Syndrome 2. Sleep Dysfunction 3. Migraine or Headache Disorder 4. Mood Disorders such as Anxiety or Depression 5. Ocular or Vestibular Dysfunction Return to Play: The concussed student-athlete will not be permitted to return to any physical activity until the signs and symptoms have diminished. During this phase of recovery, there will be close communication with the team physician and/or medical staff. Once a decision is made to return the student-athlete to activity, it must be staged in incremental progression to ensure that a return of signs or symptoms does not occur. If at any point signs and symptoms reappear, cease physical activity and refer the student-athlete to the medical staff for follow-up plan. It is the student-athlete’s responsibility to make the certified athletic trainer and team physician aware of the return of any concussion signs or symptoms. At the point in which the student-athlete is being returned to sport and where contact is likely, a different colored jersey should be worn to help identify the student-athlete when he or she has not been cleared for full contact. This off-setting colored jersey will help to remind coaches and fellow student-athletes that they should be avoid activity that could lead to direct head contact. An example of a return to play progression is as follows: o Light biking on stationary cycle for approximately 10-15 minutes or unless symptoms of o o o o o o concussion reemerge. Walking on treadmill with a slow progression in speed and elevation until at a jogging pace. Remain jogging for approximately 10 minutes and remain symptom free. Sport-specific exercises and light drills without head contact. These exercises are meant to mimic activities of the sport. Continue with drill type activity for approximately 15 minutes or until symptoms reoccur. Non-contact practice can begin and monitored closely. If at any time during practice symptoms return, immediate removal must occur. Follow up with medical staff and/or team physician is required. Consideration may be given to return athlete to resistive weight training activity under close monitoring. Final medical evaluation and cognitive reassessment testing done to evaluate ready to return status. Return to practice and competition. Return to Learn: After a concussion diagnosis is made, it is mandatory that a student-athlete will have full cognitive rest for the day of injury. This will include no class, study hall, meetings, etc. After day one, the student-athlete will have an individualized plan for when he or she will return to these activities. This plan will be developed and monitored by the team physician based on the student-athlete’s presentation. In the event a student-athlete has any return or worsening of symptoms due to resuming activities he or she will immediately stop the activity and return to full rest. In the event the student-athlete has prolonged symptoms, the student-athlete’s athletic trainer, academic advisor, and team physician will develop an individualized comprehensive plan. A note will be provided by the attending physician to verify potential academic absences. If it is determined that recovery could linger, coordination between the Learning Specialist at the COX Academic Center for Student-Athletes and the Athletic Trainer will occur for short-term disability services to be activated. The Director of Wellness can assist in completion of the required ODS paperwork. Some of the more frequently requested accommodations are: o Extended Time o Distraction-Reduced Environment o No Scantron o Consideration for Absences o Class Notes Mild Traumatic Brain Injury (mTBI) / Concussion Policy and Management Plan {revised 2015}  OVERVIEW    Our concussion policy and concussion management plan have been developed over the past several years, and is  derived from the most recent literature on sport‐related concussion.    Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by  biomechanical forces.  A concussion may be caused either by a direct blow to the head, face, neck or elsewhere on  the body with an “impulsive” force transmitted to the head.    The majority of concussions resolve in a short period,  although the recovery time frame varies for each student‐athlete.    POLICY  Maryland student‐athletes with concussion‐like signs and symptoms will be removed from activity and evaluated  by  a  sports  medicine  staff  member  with  concussion  expertise.    In  the  event  of  a  suspected  concussion,  the  concussion management plan provides the sports medicine staff with the objective information necessary to return  the athlete to play safely.     PLAN & PROCEDURES  The  following  plan  has  been  adopted  by  the  University  of  Maryland  Sports  Medicine  Department  and  is  to  be  followed by all teams for managing athletes suspected of sustaining a concussion.    1. Maryland  shall  have  on  file  a  written  team  physician–directed  concussion  management  plan.    A  Team  Physician  is  responsible  for  overseeing  the  implementation  of  the  concussion  management  plan  and  overseeing  return  to  play  decisions.    A  University  of  Maryland  Licensed  Athletic  Trainer  acts  under  the  direction of a Team Physician and will assist with the implementation of the concussion management plan.  2. Maryland  will  provide  NCAA  concussion  fact  sheets  and  other  applicable  material  annually  to  student‐ athletes, coaches, team physicians, athletic trainers, and the Director of Athletics.    All  parties  will  be  required  to  sign  a  statement  acknowledging  they  have  read  and  understood  the  concussion material.    i. All student‐athletes will be required to sign a statement in which the student‐athletes accept the  responsibility for reporting their injuries and illnesses to the sports medicine staff, including signs  and symptoms of concussions.   ii. All student‐athletes will be required to sign the Big Ten Concussion Acknowledgement Form.  iii. Maryland  sport  coaches  will  sign  the  Big  Ten  Coaches  Acknowledgment  Form  annually.  The  Maryland compliance office will maintain completed forms on file.   The  University  of  Maryland  Sports  Medicine  staff  will  assist  the  compliance  staff  in  answering  any  questions parties might have regarding the material.  3. Every student‐athlete at the University of Maryland will undergo a pre‐participation evaluation and pre‐ season baseline testing for each sport in which they participate prior to participating in practice or  2  UMD Sports Medicine  04/30/15  4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. competition.  Any athlete sustaining a concussion during the previous season is also re‐baseline tested  prior to the start of the next season.   A Team Physician will determine pre‐participation clearance based on the assessment findings for each  student‐athlete.    During a preseason sport team meeting, student‐athletes will be provided with information on concussions  by athletic trainers and/or team physicians and have the opportunity to ask questions.   Maryland  will  have  on  file  and  annually  update  an  emergency  action  plan  for  each  athletics  venue  to  respond to  student‐athlete catastrophic injuries and illnesses, including but  not limited to  concussions,  heat illness, spine injury, cardiac  arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses.   Maryland sports medicine staff members shall be empowered to determine management and return‐to‐ play  of  any  ill  or  injured  student‐athlete,  as  he  or  she  deems  appropriate.  Conflicts  or  concerns  will  be  forwarded to David Klossner (director of sports performance) and Yvette Rooks, MD (head team physician)  for remediation.  Maryland  sports  medicine  personnel  with  training  in  the  diagnosis,  treatment  and  management  of  concussion will be present at all contact sports games (i.e., football, lacrosse, wrestling, field hockey, soccer,  and basketball, whether a men’s or women’s team).  Maryland  sports  medicine  personnel  with  training  in  the  diagnosis,  treatment  and  management  of  concussion will be available at all contact sports practices (i.e., football, lacrosse, wrestling, field hockey,  soccer, and basketball, whether a men’s or women’s team).    When a student‐athlete shows any signs, symptoms or behaviors consistent with a concussion, the athlete  will be removed from practice or competition, by, a game official, member of the coaching staff or sports  medicine staff dependent on the situation. The student‐athlete will be evaluated by a member of the sports  medicine staff with concussion management experience.    During competitions, on the field of play injuries will be under the purview of the official and playing rules  of the sport. Maryland staff will follow such rules and attend to medical situations as they arise. Visiting  sport team members evaluated by Maryland sports medicine staff will be managed in the same manner as  Maryland student‐athletes.   A student‐athlete diagnosed with a concussion will be withheld from the competition or practice and not  return to activity for the remainder of that day. Student‐athletes that sustain a concussion outside of their  sport will be managed in the same manner as those sustained during sport activity.   The student‐athlete will be provided with the Concussion Home Instruction Sheet.    The student‐athlete may not attend classroom activities on the same day as the concussion event based on  the medical evaluation.    The student‐athlete will receive serial monitoring for deterioration by sports medicine personnel.  The student‐athlete will be monitored for recurrence of symptoms both from physical exertion and also  mental exertion, such as reading, phone texting, computer games, watching film, athletic meetings, working  on a computer, classroom work, or taking a test.   The student‐athlete will follow an individualized return‐to‐learn plan.  Athletic Academic Advisors (AAC)  and professors will be notified of student‐athlete’s concussion, with permission for release of information  from the student‐athlete. An AAC will be assigned to oversee the ADAAA compliant return‐to‐learn plan.  Return to play shall follow a physician supervised stepwise process.    Student‐athletes with prolonged recovery as determined by a team physician will be evaluated to consider  alternative diagnosis and a multidisciplinary management options.   Maryland will document the incident, evaluation, continued management, and clearance of the student‐ athlete  with  a  concussion.    Concussion  outcomes  will  be  submitted  to  the  Ivy  League/Big  Ten  Registry  following approved IRB protocol.    The  Head  Team  Physician  will  coordinate  an  annual  meeting  each  Spring  to  review  and  update  the  Concussion Policy and Management Plan with the sports medicine staff. Any changes to the policy will be  effective August 1 of that year.  3  UMD Sports Medicine  04/30/15  CONCUSSION MANAGEMENT PLAN    University of Maryland Sports Medicine personnel will serially evaluate student‐athletes with signs or symptoms of  a possible mild traumatic brain injury or concussion as per the following guidelines‐      1.  Baseline Testing will be conducted on all student‐athletes, including but not limited to,  a) Physical examination and history questionnaire, including brain and concussion history  b) Symptom Evaluation  c) Neuropsychological Assessment  d) Balance Testing    Baseline testing must be done prior to participating in a practice or game, preferably in conjunction with  the student‐athlete’s pre‐participation physical examination.      2.  At the time of Injury, student‐athletes suspected of a concussion will undergo:  a) Scene assessment, ABCs, r/o cervical spine injury and severe head trauma (skull fx, intracranial bleed)  (a) Emergency Action Plan activation based on initial assessment findings, including but not limited to,  (a) Glasgow Coma Scale < 13; (b) prolonged loss of consciousness; (c) focal neurological deficit  suggesting  intracranial  trauma;  (d)  repetitive  emesis;  (e)  persistently  diminished/worsening  mental status or other neurological signs/symptoms; or (f) spine injury.  b) Physical examination and assessment of concussion symptoms by sports medicine staff   (a) Any  student‐athlete  that  exhibits  signs,  symptoms  or  behaviors  consistent  with  a  concussion  injury including, but not limited to, shall be removed from play and evaluated by sports medicine  staff with concussion management experience.  i. Symptoms ‐ somatic (eg, headache), cognitive (e.g., feeling like in a fog) and/or emotional  symptoms (e.g., lability, mood changes);  ii. Physical signs (e.g., unsteadiness, stumbles, loss of consciousness, amnesia);  iii. Behavioral changes (e.g., irritability, changes in personality);  iv. Cognitive impairment (e.g., confusion, slowed reaction times); or  v. Sleep disturbance (e.g., insomnia, abnormally too long).  (b) A  student‐athlete  diagnosed  with  a  concussion  by  medical  personnel  shall  be  withheld  from  returning to play or participating in any practice or game on the same Day on which he or she  sustained that concussion and must be cleared by a physician before being permitted to return  to play in practice or competition.         3.  Post‐ Concussion Follow‐Up:  a) Serial evaluation and monitoring will be conducted by a licensed athletic trainer and/or team physician  with concussion expertise.    b) Physician evaluation and/or consultation within 24 hours of the event and for possible return to play.    c) During  the  period  of  recovery  and  while  the  student‐athlete  is  symptomatic  following  injury,  the  student‐athlete should engage in physical AND cognitive rest as much as possible until such time that  he/she is asymptomatic.    i. The  student‐athlete  may  not  attend  classroom  activities  on  the  same  day  as  the  concussion  event.  ii. The student‐athlete will follow an individualized return‐to‐learn plan as supervised by the team  physician and sport AAC.    4  UMD Sports Medicine  04/30/15  d) Student‐athlete recovery is individualized and will follow a supervised stepwise progression by the team  physician and athletic trainer with concussion expertise.    e) A range of ‘modifying’ factors may influence the investigation and management of concussion and, in  some cases, may predict the potential for prolonged or persistent symptoms.  f) Cases of concussion where clinical recovery falls outside the expected window (e.g., 14 days) should be  managed  in  a  multidisciplinary  manner  by  health  care  providers  with  experience  in  sports‐related  concussion.    Low‐level  exercise  for  those  who  are  slow  to  recover  may  be  considered.    Further  evaluation by the team physician for the student‐athlete along the course of prolonged recovery will  occur in order to consider additional diagnosis and multidisciplinary care team options. Considerations  should include, but are not limited to:  i. Post‐concussion syndrome  ii. Sleep dysfunction  iii. Migraine or other headache disorders  iv. Mood Disorders such as anxiety and depression  v. Ocular or vestibular dysfunction   g) The multidisciplinary team may consist of a team physician, licensed athletic trainer, licensed clinical  psychologist  with  expertise  in  sports,  consulting  neurologist,  consulting  neuropsychologist,  athletic  academic  advisor,  Speech  Pathologist,  Office  of  Disability  Support  Services  representative,  coaches,  administrators, and faculty representative.  h) Once the student‐athlete has returned to his/her baseline, the return‐to‐play decision is based on a  protocol of a stepwise increase in volume and intensity of physical activity by the team physician and/or  the physician’s designee.      Pre‐season Concussion Baseline testing will include all student‐athletes participating on Maryland  sports teams:     1. Basketball  9. Soccer  2. Baseball  10. Softball  3. Cross Country   11. Spirit Squad / Mascot  4. Field Hockey  12. Tennis  5. Football  13. Track & Field  6. Golf  14. Volleyball  7. Gymnastics  15. Wrestling  8. Lacrosse      5  UMD Sports Medicine  04/30/15  Supervised Stepwise Progression Protocol  Once the student‐athlete has returned to his/her baseline, the return‐to‐play decision is based a stepwise protocol  allows a stepwise increase in volume and intensity of physical activity by the team physician and/or the physician’s  designee. The athlete is monitored for any concussion‐like signs/symptoms during and after each exertional activity.   With this stepwise progression, the athlete should continue to proceed to the next stage level if asymptomatic at  the current level. The individual should remain within baseline measures throughout each step of the protocol.  If  symptoms  reoccur  the  student‐athlete  will  stop  that  activity  and  be  reassessed  by  the  team  physician  before  progressing.      In order to be considered for return to play, the student‐athlete must:  1) Follow the outlined guidelines for management of his/her injury;  2) Be fully asymptomatic at rest, with exertional testing, and with supervised sports‐specific activities; and  3) Be within normal baseline limits on all post‐exertion assessments.  STEP 1: Light Aerobic Exercise.  This stage incorporates an exertional protocol that allows a gradual increase in  volume and intensity during the return to play process. The goal is to increase heart rate.  The athlete is monitored  for any concussion‐like signs/symptoms during and after each exertional activity.  a. Begin exertional testing in a controlled setting under the direction of a certified athletic trainer.   1) For example:    20 minute non‐impact  cardiovascular  challenge (bike, stairmaster, elliptical trainer, etc) – 5  min  warm‐up, 10 min at < 70% maximum heart rate, 5 min cool down; and    Bodyweight circuit: 3 sets of 20 sec Squats+20 sec Push Ups+20 sec Sit‐ups at < 70% maximum heart  rate.   2) No resistance strength room training.  b. If asymptomatic, then the student‐athlete may continue to the next step.    c. If the student‐athlete becomes more symptomatic than baseline during Step 1, the student‐athlete should  immediately stop all activity and be reassessed by the team physician before progressing.    STEP 2:  Sports‐Specific, Progressive Exertional Functional Activity  a. Goal is to add sport movement and continue conditioning activities.  b. Add movement ‐ Mode, duration and intensity dependent upon sport:   Sport specific drills (e.g., running in soccer, throwing, agility, individual routes, shooting, passing, etc)  c. No  potential  head  impact  activities  (e.g.  checking,  blocking,  tackling,  goal  keeping,  batting,  takedowns,  team rebounding, etc).  d. If asymptomatic, then the student‐athlete may continue to the next step.    e. If the student‐athlete becomes more symptomatic than baseline during Stage 2, the student‐athlete should  immediately stop all activity and be reassessed by the team physician before progressing.    STEP 3:  Supervised “modified / non‐contact” Practice  a. Goal is to add progressive exercise, coordination and cognitive load training drills ‐ Mode, duration, and  intensity dependent upon sport.  1) Continue sport specific drills and conditioning ; and   2) Begin progressive strength training program.  3) No  live  contact  or  potential  head  impact  activities  (e.g.  checking,  blocking,  tackling,  goal  keeping,  batting, takedowns, team rebounding, etc).    4) May wear full protective equipment.  6  UMD Sports Medicine  04/30/15  5) Begin Non‐contact practice drills & activities; progression to more complex training drills (e.g. passing  in football, shooting, individual rebounding, game formations, tactical sessions, skill progressions from  Step 2 activities).  b. If asymptomatic, then the student‐athlete may continue to the next step.    c. If the student‐athlete becomes more symptomatic than baseline during Step 3, the student‐athlete should  immediately stop all activity and be reassessed by the team physician before progressing.    If the student‐athlete is asymptomatic with all activities through Step 3, the team physician shall review  and determine full return to competitive activities.        STEP 4: Return to Competitive Team Activities    a. Following  physician  medical  clearance,  the  athlete  will  begin  to  participate  in  normal  sport  training  activities.   b. The athlete should progress, in part, on their confidence level as well as their fitness levels.  c. This stage allows coaching staff to assess the athlete’s functional skills and ability to return to normal  sport game play.  d. Begin live contact activity as indicated (e.g. tackle bags/dummies/sleds, “thud”, drills involving wrapping  up, passing in football, full speed blocking, checking, game formations, tactical sessions, skill progressions)  e. Continue Sport Specific Drills.   f. Continue strength and conditioning program.        7  UMD Sports Medicine  04/30/15  Academic Considerations: Return‐to‐Learn    When a student‐athlete is diagnosed with a concussion that may require academic modifications, the Head Team  Physician, or his/her designee, will contact the Associate Athletic Director for Academic Support and Career  Development Department (ASCDU).  The Head Team Physician, or his/her designee, and an Athletic Academic  Advisor (AAC) will coordinate the return‐to‐learn management plan.  They will solicit input, as needed, from the  consulting neurologist, sports psychologist, sports psychiatrist, speech pathologist, the AAC, and the Director from  the Office of Disability Support Services (DSS).                The student‐athlete will follow a gradual return to classroom/studying/tutoring as tolerated.  The student‐athlete  may not attend classroom activities on the same day as the concussion event based on the medical evaluation.  If  the student‐athlete cannot tolerate light cognitive activity, the student‐athlete may remain at home/dorm until  tolerated.  For most concussion cases, initial athletic schedule and academic modifications could occur for up to  14 days of the initial recovery window, as indicated.    The student‐athlete will be re‐evaluated by the team physician and members of the multidisciplinary care team,  as appropriate, if concussion symptoms continue more than 14 days or worsen with academic challenges.       The Associate Athletic Director for ASCDU or the sport specific AAC will contact the student‐athlete's course  instructors, tutors, and learning specialists; informing them of the student‐athlete’s condition and possible  academic modifications that may be warranted.      When the impact of a concussion diagnosis occurs for an extended duration, the Associate Athletic Director for  ASCDU will contact the Director of Disability Support Services (or designee) regarding the student‐athlete’s  condition. The Director of Disability Support Services or designee, will determine if academic accommodations  through disability services are warranted. Accommodations approved by the Office Disability Support Services will  be implemented consistent with the ADAAA and communicated to the Associate Athletic Director for ASCDU.     Dr. Jo Ann Hutchinson, DSS Director  Disability Support Services  University Counseling Center  jahutch@umd.edu  301‐314‐7681  8  UMD Sports Medicine  04/30/15  Academic Considerations Awareness Letter      The University of Maryland Sports Medicine and Academic Support & Career Development Departments  would like to inform you that ______________________________ sustained an injury or illness while  participating in intercollegiate athletics.  He/she was evaluated by____________________________,  MD, team physician for the University of Maryland. We would like to inform you that  ____________________________ will be/was absent from their class today as a result of this injury.   During the next few weeks this athlete may ask for additional considerations.  Should you have any  questions or require further information regarding academic considerations, please do not hesitate Chris  Uchacz.    Yvette Rooks, MD  Head Team Physician    Steve Nordwall, ATC  Assistant Athletics Director / Athletic Training  Snordwal@umd.edu   301.314.2663    Chris Uchacz   Associate Athletics Director  Academic Support and Career Development Department (ASCDU)  cuchacz@umd.edu   301.405.2731    Thank you in advance for your time and understanding with this circumstance.    9  UMD Sports Medicine  04/30/15  Reducing Head Trauma Exposure    Year‐Round Football Practice Contact Guidelines    Maryland Football’s year‐round emphasis is to limit head contact, regardless of whether the student‐athlete is in  full‐pad, half‐pad, or is participating in a helmet‐only practice.  However, football practice must prepare the  student‐athlete for the rigors of an aggressive, contact, rugged sport.  Without adequate preparation, which  includes live tackling, the student‐athlete could be at risk of unforeseen injury during the season because of  inadequate preparation.  All football student‐athletes review and sign an acknowledgement statement that they  understand the NOCSAE warning and the dangers associated with using the head and/or helmet inappropriately.        The following are football practice descriptions published by the NCAA.     Live contact practice: Any practice that involves live tackling to the ground and/or full‐speed  blocking. Live contact practice may occur in full‐pad or half‐pad (also known as “shell,” in which  the player wears shoulder pads and shorts, with or without thigh pads).  Live contact does not  include: (1) “thud” sessions, or (2) drills that involve “wrapping up;” in these scenarios players  are not taken to the ground and contact is not aggressive in nature.  Live contact practices will  be conducted in a manner consistent with existing rules that prohibit targeting to the head or  neck area with the helmet, forearm, elbow, or shoulder, or the initiation of contact with the  helmet.    Full‐pad practice: Full‐pad practice may or may not involve live contact.  Full‐pad practices that  do not involve live contact are intended to provide preparation for a game that is played in a full  uniform, with an emphasis on technique and conditioning versus impact.     Maryland Preseason practice plan:  On days in which two team practices are scheduled, both practices may  contain live contact drills.  A maximum seven (7) live contact practices will occur in a given week, and a maximum  of 17 total may occur in preseason.  Three (3) of these 17 practices will contain live contact for greater than 50%  of that practice schedule (scrimmages).    Maryland Inseason practice plan:  There will be no more than three (3) live contact practices per week. Inseason  is defined as the period between six (6) days prior to the first regular‐season game and the final regular‐season  game or conference championship game.       Bowl practice guidelines (FBS):  There will be no more than three (3) live contact practices per week.     Spring practice guidelines:  Of the 15 allowable sessions that occur during the spring practice season, twelve (12)  practices will involve live contact; three (3) of these live contact practices will include greater than 50 percent live  contact (scrimmages). Live contact practices are limited to three (3) in a given week and will not occur on  consecutive days.     Independent Medical Care:  Maryland sports medicine staff members are empowered to determine management  and return‐to‐play of any ill or injured student‐athlete, as he or she deems appropriate.  Coaches support the  decisions of the Maryland sports medicine staff and do not impose undue pressure or demands that would  impede the medical care of a student‐athlete.      10  UMD Sports Medicine  04/30/15  Athletic Trainer Spotter for Football Games  The University of Maryland will have experienced team physicians and athletic trainers on the sideline  observing for potential injuries, managing health care delivery and return to play decisions.     In addition, the Big Ten Conference will also have an independent neutral Athletic Trainer (AT) Spotter in  the replay booth for home and away football games.   Games:    The AT Spotter will be seated in the replay booth and will have access to their own monitor to  assist him/her in their role.    The AT Spotter will have the ability to directly contact game officials on the field.         11  UMD Sports Medicine  04/30/15  UNIVERSITY OF MARYLAND SPORTS MEDICINE DEPARTMENT Mild Traumatic Brain Injury Sideline Evaluation Guidelines When evaluating a University of Maryland Student-Athlete for a possible MTBI / concussive injury on the field and sideline, sports medicine personnel will use standardized components of the Sport Concussion Assessment Tool (e.g., SAC, SCAT 2, SCAT 3). Student-athletes will be evaluated for emergent conditions and then for possible concussion. If a concussion is suspected, the student-athlete will undergo further evaluation by a medical professional with concussion expertise. The diagnosis of a concussion is a clinical judgment made by a medical professional. The SCAT should not be used solely to make, or exclude, the diagnosis of concussion in the absence of clinical judgement. When evaluating a University of Maryland Student-Athlete post-concussion injury in the clinic, sports medicine personnel may use the symptoms checklist. 12  UMD Sports Medicine  04/30/15  UNIVERSITY D-F MARYLAND EPIDHTS MEDIEIHE DEPARTMENT Marne Bate Time 5port Date of Injury CHECKLIST: ?rcle YE or No to indiEIte ify-ou haye experienced the following 11-IE If ?Yes?, indicate the severity. DaynfTestingSeverity me new? 1. HayeyuuhadaheadacheHave you experienced ?prEsure in your headYejj'l'Have you experienced any nausea orwrnitingHave you had any 1.Iisio-n problems blurred visionE1. Have your eyes been sensitive to lightYejj'l'lo 1 2 3 4 5 111 Have you felt ?slowed {lo-umYesy'hlo 1 2 3 4 5 J3-I-layeyon hadti?imltyoonoenna?rg?? 1 2 3 4 5 14. Have you had dif?culty remembering ?lings1E.l-la1.reycuu fettoonfnsed? Yesy'hlo 1 2 3 4 5 1?-I-layeyou drows'n?s? Yejj'l'lo 1 2 3 4 5 13. Have you had trouble falling asleep and orother sleep disturbance211 Have you been irrit?sle?J-lau-eyoufettsidnE-j? Yesf?o 1 2 3 4 5 1'1. Have you been nervous and or anliousStudent-Athlete Signature Date Athletic Tlainer Signature Date UMD Sports Medicine 04/30/15 MAHWLAIN EPUHTS MEDICINE WHGUSSIDH HUME SHEET Name Date '?au have 5.:Feree a heat: Heat: "juriee ua'gr in fre'n 1-: eeue'e. Tmugh meat severe head in_..rie5 can he reengn a11hetirr'e c-f t"e "jury. Ire eig"5 .5. empterr'e nt:-1 deue a later he Therefe'e. it is rrzue-Iatiire that a1h e1e "a5 susta r'ei: eiren .3 'niner "earl he eheerued elneely'. Itll?h: In: EatagnTrE-J ?'ecity'meyesiuiraght D?l?i?ml-DL Tate mi: .32] Emamgm every- USE Aeetm?in-tthen ITgriend: ta:ieI5 - Eta'g 'r leunFHeFEH. enema: e: Henna eenx DRUG - I-iyl'ci'ateiwier . . WATCH Full TI-IE ?lmed-dim Immedian Elnrhiirg?aeadbaiane Fi'g'rgi'ulheeae Tenn-amine 11115" ?enuisiensar?'nlseial? [Fan]; prebleme tie-Helen. at:- te the eleseet emergency mum and call yeur athletic 13'ainer- A1h elje T'ainer F'hcr'e 'I'nu need be seen for a follow?up examination on at Feetleearnl-hJee Peemae? 4 ea F's-It. MD aim-43235 amen?334::- aim-emis- 14 UMD Sports Medicine 04/30/15 UNIVERSITY OF MARYLAND SPORTS MEDICINE DEPARTMENT  CONCUSSION RECOVERY TRACKING CHECKLIST    Student‐Athlete _________________________________  Athletic Trainer _______________________________    Sport__________________ Date of Injury ____________   Treating Physician  ____________________________                                Date      Initial Injury Evaluation Completed              ____________________              ____________________  a) Serial follow‐up with Concussion Symptom Checklist    b) Physician evaluation and/or consultation                  Date when athlete reports asymptomatic within baseline      ____________________  Axon Test returned to within baseline         ____________________  STAGE ONE: Recovery Period.    Post‐ Concussion Follow‐Up                Balance Testing returned to within baseline        Graduated Return to Play Protocol Completed without Symptoms      STEP 1: Light Aerobic Exercise without resistance training.         ____________________      ____________________    STEP 2: Sports‐Specific, Exertional Functional Activity    STEP 3: Supervised “modified/non‐contact” practice            With Progressive Resistance Training    Step 4: Return to Competitive Team Activities        Date of return to full academics              ____________________          ____________________          ____________________          ____________________    Comments:  __________________________________________________________________________________    _____________________________________________________________________________________________      _________________________________________  Physician Name:        Physician Signature:   __________________________________________  Date:  _______________________ 15  UMD Sports Medicine  04/30/15  THE IVY LEAGUE/BIG TEN CONCUSSION REGISTRY Section 1. Background 1. 2. 3. 4. 5. 6. 7. School Sport Men or Women’s Team Gender of Participant Age in years at concussion diagnosis Number of previous concussions Date of 3 most recent concussions Section 2. Circumstances of Concussion Event 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Sport‐‐‐Related or Not Activity (competition, practice, skill instruction, etc.) Type of play Part of Season (pre‐‐‐season, regular season, second season) Position Implement of injury (ground, ball, person) Where did play occur (midfield, near sideline) Describe the play or event Were others injured Was a rule violated on the play Was a foul or penalty called What protective equipment were you wearing Describe any other injuries sustained Section 3. Impact of Concussion Event 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Date of current concussion Date reported Date when first symptoms appeared How long did symptoms last Did you lose consciousness Did you have amnesia Date of return to exertion Date of return to limited play Date of return to full play Date of return to full academics Describe any other limitations 16  UMD Sports Medicine  04/30/15  CONCUSSION A FACTSHEEF FUR WHAT EA. Acclaim-hail buliniujurr Huh: 1th. Emma-and. inn-Bur. nrhu'ng hit'hf lpi??! aura: dining FICHDE bnmlu-cm HOW CAN Undutu?ngj?ng MWMmab?. andlli'll hath: hadl?cnur mammalian. rill-emf WHAT AFIE CF A. lm die-inch; nfmsiuum?l. -Fh?ingllu?ilh.?nmnramw. mening?mui. Bet-Hun: I DO IF I I I-LWE A 1h Spurn 11m ?ail-Enumde nhl?'m?nn: uni. El?l'liJIIn mt??niffnuhn min-henna. In ?ue-mam rum: I: Illq Amara-Zn Ikcp puritans: pub?h?h?h??mn?m?h?hh?ln?tm?nhm Ecru: MISS CHE THAN THE WHDLE SEASDH. WHEN IN DOUBT, GET CHECKED OUT. Pu: mun: i?mmn and renames. 'riIiJ: mammfZIIan-?C-ancuiun. w-n-u?r-I?u-I lg'brnn lull-mil I-m? il maria-tnqu brain- rm. UMD Sports Medicine 04/30/15 17 Big Ten Injury and Illness Reporting Acknowledgement Form I, acl-tnowledge that I have to be an actiye participant in my own healthcare. As such, I hate the direct responsibility for reporting all of my injurtes and illnesses to the sports medicine statT of my institution team physician, athletic training stafljr- I recognize that my true physical condition is dependent upon my accurate medical history and a full disclosure of any complaints, prior injuries andror disabilities experienced. I hereby af?rrn that I haye fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at my institution- I further understand that there is a possibility that participation in my sport may result in a head injury andtor concussion. I hate been provided with education on head injuries and understand the importance of immediately reporting of a head injuryrconcussion to my sports medicine staff. By signing below, I acknowledge that my institution has provided me with educational materials on what a concussion is and giyen me an opportunity to asI-t questions about areas and issues that are not clear to me on this issue. I, haye read the above and agree that the statements are accurate. Smdentethlete?s name Signature of student-athlete Date Name of person obtaining consent Signature of person consenting 18 UMD Sports Medicine 04/30/15 CONCUSSION A FAGT SHEET FDR GDAGH E5 THE FACTS- WHAT IS A - All mnm?lnmm: scrim 11nd. ?windy will-I "in'Lpqu'e?iwcr - Caucasian: ?n withnul: less at camcinmnus- ar all-ml: the had. Cancun-imam aha-rum: ub'rinLu: ?gm. Jun-d. Inn-Ear: mrJ': a: ?rmmd. in: El: flu-5r. 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Fn: n1nr: Ind 'r'uil Iynhf' GEEK .1. ?w'?f?I?chrm UMD Sports Medicine 04/30/15 20 Big Ten Coaches Concussion Acknowledgement Form I, acknowledge that as a member of the athletic department at, I accept responsibility for supporting our sports medicine department's policy on concussion management. I understand that my may have a risk of head Injury andtor concussion- I also understand the importance of them reporting any such of a head injuryiconcussion to the sports medicine staff ieg, team physician, head athletic trainer}- I also accept responsibility for reporting to the sports medicine staff any signs or that I may witness- By signing below, I acknowledge that my institution has provided me with educational maten'als on what a concussion Is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue- Ir read EDDVE and EQTEIEE that the EIFE: accurate- Signature of coach Date Name of person obtaining acknowledgement Signature of such person UMD Sports Medicine 04/30/15 21 CONCUSSION POLICY POLICY The NCAA has created guidelines stating the course of action to be followed in the event of a sports related concussion to student-athletes. Treatment of sports-related concussions will follow these guidelines, and include additional steps put in place by the UHealth Sports Medicine Concussion Team. Student-athletes will receive concussion education materials and sign an injury reporting acknowledgement stating their understanding of the responsibility they have to inform the Athletic Training Staff of concussion signs or symptoms. Each coaching staff member will sign an injury reporting acknowledgement form, and receive concussion education materials. Return to activity following concussion will follow the steps outlined in the University of Miami Department of Athletics Concussion Guidelines. PURPOSE To allow safe return to play for any student-athlete who has experienced concussion signs or symptoms. To follow the NCAA’s guidelines for safe management and return to activity following concussion related episodes. PROCEDURE See the attached University of Miami Department of Athletics Concussion Guidelines document for all concussion procedures. UNIVERSITY OF MIAMI DEPARTMENT OF ATHLETICS CONCUSSION GUIDELINES (Updated June 1, 2015) I. Baseline Testing and Concussion Education The University of Miami Department of Athletics will follow the below guidelines with regard to concussion and concussion management of student-athletes. A. Baseline testing will include ImPACT, a neurocognitive computerized baseline test, the Balance Error Scoring System (BESS), and the King-Devick remove-from-play sideline concussion screening test. These baseline tests will be conducted prior to the first practice or contact activity of the student-athlete’s first semester of school at UM. 1. Per NCAA Guidelines, institutions should record a baseline assessment for ALL studentathletes prior to the first practice. The same baseline assessment tools should be used postinjury at appropriate time intervals. The baseline assessment should consider one or more of the following areas of assessment. a. The baseline assessment should consist of the use of a symptoms checklist and standardized cognitive and balance assessments (Balance Error Scoring System (BESS)). b. Additionally, neuropsychological testing (ImPact computerized test) has been shown to be effective in the evaluation and management of concussion. The development and implementation of a neuropsychological testing program should be performed in consultation with a neuropsychologist. Ideally, post injury neuropsychological test data should be interpreted by a neuropsychologist. B. All student-athletes will fill out a medical history including brain injury and concussion history which will be reviewed by the medical staff prior to their pre-participation physicals. C. All student-athletes will be examined by a general medical physician as well as an orthopedic physician as a part of their pre-participation examination. The physician will review each student-athlete’s concussion history and will determine their participation clearance. D. During the returning physical examination process each year, student-athletes must read and sign a statement acknowledging that they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. During the review and signing process, student-athletes will be presented with NCAA Concussion educational materials. a. Each student-athlete will repeat the Impact computerized exam and the King-Devick sideline assessment annually with their returning student-athlete physical, and will sign the acknowledgement annually. E. All UM coaches must read and sign the attached coaches’ statement acknowledging that they have read and understand the NCAA Concussion Fact Sheet, will encourage their student-athletes to report any suspected injuries and illnesses related to concussions, and that they accept the responsibility for referring any student-athlete to the medical staff suspected of sustaining a concussion. Furthermore, the coach acknowledges they have read and understand the UM Concussion Guidelines. F. All UM Team Physicians (Primary care and Orthopedic), Athletic Trainers, Graduate Assistant Athletic Trainers and Undergraduate Athletic Training Students must read and sign the attached medical provider statement acknowledging that they will provide the UM student-athletes with the NCAA Concussion Fact Sheet and encourage their student-athletes to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussions. Furthermore, the staff acknowledges they have read and understand the UM Concussion Guidelines. G. The Director of Athletics and all UM administrators must read and sign the attached administrators’ statement acknowledging that they have read and understand the NCAA Concussion Fact Sheet, will encourage their student-athletes to report any suspected injuries and illnesses related to concussions, and that they accept the responsibility for referring any studentathlete to the medical staff suspected of sustaining a concussion. Furthermore, the administrator acknowledges they have read and understand the UM Concussion Guidelines. II. NCAA Recommendations The NCAA Safeguards committee reaffirms its recommendation from December 2009 that an athlete exhibiting an injury that involves significant symptoms, long duration of symptoms or difficulty with memory function should not be allowed to return to play during the same day of competition and expands upon it by stating a student-athlete diagnosed with a concussion should not return to activity for the remainder of that day. Student-athletes that sustain a concussion outside of their sport should be managed in the same manner as those sustained during sport activity. The student-athlete should be monitored for recurrence of symptoms both from physical exertion and also mental exertion, such as reading, phone texting, computer games, working on a computer, classroom work, or taking a test. Healthcare professionals should assume a concussion when unsure and waiting for final diagnosis. When in doubt, sit the athlete out. Institutions should ensure healthcare professionals attain continuing education on concussion evaluation and management annually. Structured and documented education of student-athletes and coaches is also recommended to improve the success of the recognition and referral components of a consistent concussion management program. III. University of Miami Concussion Treatment and Return to Play Guidelines A. Concussions and other brain injuries can be serious and potentially life threatening injuries in sports. Research indicates that these injuries can also have serious consequences later in life if not managed properly. In an effort to combat this injury the following concussion management guidelines will be used for student-athletes suspected of sustaining a concussion. B. In the event a suspected concussion occurs, UM Athletic Trainers will: 1. Rule out cervical spine, skull fracture, intracranial bleed, or any other immediate lifethreatening injuries. a. In the case any of these life-threatening injuries are suspected, the Athletic Trainer will immediately activate the Emergency Action Plan. The Athletic Training Staff will stabilize the student-athlete and monitor vital signs until Emergency Personnel arrives at the scene. b. Emergency Personnel will stabilize the student-athlete will transport the studentathlete to the nearest medical facility for further evaluation and treatment. 2. Perform a symptom assessment. a. If the student-athlete displays any of the following symptoms, the Emergency Action Plan should be activated: i. Glasgow Coma Scale <13 ii. Prolonged loss of consciousness iii. Focal neurological deficit iv. Repetitive emesis v. Persistently diminishing mental status 3. Administer the King-Devick test on the sideline or locker room. 4. The student-athlete shall be withheld from the competition or practice and not return to activity for the remainder of that day. 5. Have the student-athlete see the UM Team Physician for evaluation. 6. The student-athlete will receive serial monitoring for deterioration. Student-athletes will be provided with written instructions upon discharge; preferably with a roommate, guardian, or someone that can follow the instructions. 7. Complete a repeat ImPACT and BESS Test for the student-athlete (within 24-72 hours of suspected concussion), as per the Team Physician’s instructions. 8. Notify UM Department of Athletics Academics Services that the student-athlete has sustained a possible head injury. Academic Services will arrange daily meetings with the studentathlete to assess accommodations that may be necessary. 9. Refer the student-athlete, upon the recommendation by the UM Team Physicians, for further neurological evaluation to Dr. Kester Nedd and Dr. Gillian Hotz Ph.D. at UMH. 10. Follow the recommendations of Dr. Nedd and Dr. Hotz for return-to-play guidelines, along with any academic accommodations that may be necessary. 11. Monitor the student-athlete for recurrence of symptoms both from physical exertion and also mental exertion, such as reading, phone texting, computer games, working on a computer, classroom work, or taking a test. 12. The University of Miami will document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion in the NExtt Solutions Injury Database. 13. Although sports currently have rules in place; athletics staff, student-athletes and officials should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced. C. Return-To-Play Guidelines In order to be considered for return to play, the student-athlete must: 1. Follow the outlined guidelines by the Team Physician for management of his/her injury; 2. Be fully asymptomatic at rest, with exertional testing, and with supervised non-contact and contact sports-specific activities: Exertional guidelines allow for a gradual increase in volume and intensity during the return to play process. The student-athlete will be monitored for any concussion-like signs/symptoms during and after each exertional activity. If at any point during the process the student-athlete becomes symptomatic, the student-athlete should be re-assessed daily until asymptomatic. Once asymptomatic, the student- athlete should then begin the gradual increase in exertional exercise again. Each step should take approximately 24 hours. Graduated Return to Play from ZURICH Consensus Statement: a. No Activity: Complete and cognitive rest until asymptomatic. Objective is rest and recovery. b. Light aerobic exercise: Walking, stationary bike at >70% intensity. Objective is to increase heart rate. Example: 20 minute stationary bike ride – evaluate for symptoms. c. Sport-specific exercise: Running, soccer/football drills etc. Objective is to add movement. Examples: Interval bike ride: 30 sec sprints 30 sec rest x 10 sprints evaluate for symptoms; Bodyweight circuit: Squats, Push Ups, Sit-ups x 20sec x 3 evaluate for symptoms. d. Non-contact training drills: More advance drills like passing drills, etc. May add resistance training. Objective is to add coordination and cognitive load with exercise. Examples: 60 yard shuttle run x 10 (40sec rest) and plyometric workout: 10 yard bounding, 10 medicine ball throws, 10 vertical jumps x 3, non-contact sport specific drills for approximately 15 minutes – evaluate for symptoms. e. Full contact practice: Participate in normal training activities. Objective is to restore confidence and allow assessment of functional skills by coaching staff. Example: Limited, controlled return to full contact practice and monitoring for symptoms. f. Return-To-Play: No student-athlete can return to full practice activity or competitions until the student-athlete is asymptomatic in limited, controlled, and full-contact activities, and cleared by the Team Physician. Example: Full sport participation in a practice. 3. Be within normal baseline limits on all post-exertion assessments as determined by the team physicians; AND 4. Be cleared for participation by a University of Miami Team Physician. D. Return-to-Learn Guidelines 1. Once a student-athlete has sustained a concussion or head injury, the Athletic Trainer will notify the student-athlete’s Academic Advisor in Academic Services, who will be the point person in notifying the student-athlete’s professors 2. The student-athlete will be excused from all classroom activity the same day as the initial concussion, and may remain at home/dorm if light cognitive activity cannot be tolerated. 3. The Team Physicians, along with Dr. Hotz and Dr. Nedd at UMH Sports Medicine will determine what classroom accommodations may be necessary based on their evaluation and the student-athlete’s symptoms. They will provide this information in writing, which will be sent to the Academic Advisor. 4. The Academic Advisor will notify all professors and will contact any other resources that may be necessary (e.g., learning specialists, office of disability services) in a manner that is compliant with ADAAA. 5. The student-athlete will follow-up with Team Physicians to progress the gradual return into classroom/studying. If the student-athlete is continuing to experience symptoms with academic work, the Team Physician will re-evaluate the accommodations necessary. . E. Student-Athlete With Prolonged Symptoms: 1. If a student-athlete is not able to complete the graduated return-to-play criteria, or if they have a recurrence of symptoms during the process, the student-athlete will follow-up with Dr. Hotz and Dr. Nedd at University of Miami Sports Medicine. a. Dr. Hotz and Dr. Nedd will consider other possible diagnosis, including but not limited to post-concussion syndrome, sleep dysfunction, migraines, mood disorders, or ocular or vestibular dysfunction. b. The student-athlete will perform all necessary testing and will follow-up per Dr. Hotz and Dr. Nedd’s orders 2. The Athletic Trainer will notify Academic Services, and if necessary a note will be obtained from the physicians if any accommodations need to be made academically. 3. If a student-athlete has returned-to-play and develops recurrent symptoms or sustains any other head trauma, he/she will follow-up with the Team Physicians. Concussion and Injury Reporting Acknowledgement Student-Athlete Concussion Statement I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet, I am aware of the following information (please initial beside each statement): ______ A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer. ______ A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. ______ You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. ______ If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer. ______ I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms. ______ Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. ______ In rare cases, repeat concussions can cause permanent brain damage, and even death. ____________________________________________ Signature of Student-Athlete _________________________ Date Printed name of Student-Athlete ___________________________ Date of Most Recent Impact Test __________________________ ATC Signature Concussion and Injury Reporting Acknowledgement Coaches Concussion Statement I have read and understand the UM Concussion Guidelines. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet and reviewing the UM Concussion Guidelines, I am aware of the following information (please initial beside each statement): ______ A concussion is a brain injury, which student-athletes should report to the medical staff. ______ A concussion can affect the student-athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. ______ I will not knowingly allow the student-athlete to return to play in a game or practice if he/she has received a blow to the head or body that results in concussion-related symptoms. ______ Student-athletes shall not return to play in a game or practice on the same day that they are suspected of having a concussion. ______ If I suspect one of my student-athletes has a concussion, it is my responsibility to have that student-athlete see the medical staff. ______ I will encourage my student- athletes to report any suspected injuries and illness to the medical staff, including signs and symptoms of concussions. ______ Following concussion the brain needs time to heal. Concussed student-athletes are much more likely to have a repeat concussion if they return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. ______ I am aware that every first-year student-athlete participating on specified UM teams must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition and balance if the student-athlete were to become injured. ______ I am aware that student-athletes diagnosed with a concussion will be assessed by the medical staff. Once symptoms have resolved the student-athlete will begin a graduated return to play guideline, following full recovery of neurocognition and balance. _____________________________________________ Signature of Coach _____________________________________________ Printed name of Coach ______________ Date Concussion and Injury Reporting Acknowledgement Medical Provider Concussion Statement I have read and understand the UM Concussion Guidelines. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet and reviewing the UM Concussion Guidelines, I am aware of the following information (please initial beside each statement): ______ A concussion is a brain injury, which student- athletes should report to the medical staff. ______ A concussion can affect the student-athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. ______ You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. ______ I will not knowingly allow the student-athlete to return to play in a game or practice if he/she has received a blow to the head or body that results in concussion-related symptoms. ______ If I suspect one of my student-athletes has a concussion, it is my responsibility to have that student-athlete see the medical staff. ______ I will encourage my student-athletes to report any suspected injuries and illness to the medical staff, including signs and symptoms of concussions. ______ Following a concussion the brain needs time to heal. Concussed student-athletes are much more likely to have a repeat concussion if they return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. ______ I am aware that every first-year student-athlete participating on specified UM teams must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition and balance if the student-athlete were to become injured. ______ I am aware that student-athletes diagnosed with a concussion will be assessed by the medical staff. Once symptoms have resolved the student-athlete will begin a graduated return to play guideline, following full recovery of neurocognition and balance. _____________________________________________ Signature of Medical Provider _____________________________________________ Printed name of Medical Provider ______________ Date Concussion and Injury Reporting Acknowledgement Administrators Concussion Statement I have read and understand the UM Concussion Guidelines. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet and reviewing the UM Concussion Guidelines, I am aware of the following information (please initial beside each statement): ______ A concussion is a brain injury, which student-athletes should report to the medical staff. ______ A concussion can affect the student-athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. ______ I will not knowingly allow the student-athlete to return to play in a game or practice if he/she has received a blow to the head or body that results in concussion-related symptoms. ______ Student-athletes shall not return to play in a game or practice on the same day that they are suspected of having a concussion. ______ If I suspect a student-athletes has a concussion, it is my responsibility to have that studentathlete see the medical staff. ______ I will encourage student- athletes to report any suspected injuries and illness to the medical staff, including signs and symptoms of concussions. ______ Following a concussion the brain needs time to heal. Concussed student-athletes are much more likely to have a repeat concussion if they return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. ______ I am aware that every first-year student-athlete participating on specified UM teams must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition and balance if the student-athlete were to become injured. ______ I am aware that student-athletes diagnosed with a concussion will be assessed by the medical staff. Once symptoms have resolved the student-athlete will begin a graduated return to play guideline, following full recovery of neurocognition and balance. _____________________________________________ Signature of Administrator _____________________________________________ Printed name of Administrator ______________ Date Balance Error Scoring System (BESS) Procedures• • • • • • • • • • • • • • • • • • • Shoes off Roll pant legs above ankles Feet narrowly together Hands on the iliac crests Eyes closed Athlete Position- Test Procedures / Patient Instructions- Test begins when the patient closes his/her eyes Patient is instructed to make any necessary adjustments in the event that they lost their balance and to return to the testing position as quickly as possible Test #1-Double Leg Stance (feet together) Test #2-Single Leg Stance (non-dominant foot; free leg should be bent to 90 degrees) Test #3-Tandem Stance (non-dominant foot in the rear; weight evenly distributed) 20 seconds per test Each test is performed on a firm surface (grass, turf, court, etc.) and a 10-cm-thick foam / unstable surface Balance Errors- Hands lifted off of iliac crests Opening eyes Step, stumble, or fall Moving hip into more than 30 degrees of flexion or abduction Lifting forefoot or heel Remaining out of testing position for more than five (5) seconds BESS Scoring- The number of balance errors (1 point per error) on each of the six (6) tests are added together for a total BESS Score Athlete Name Examiner Date SCORE CARD # ERRORS Double Leg Stance Feet together Single Leg Stance Non-Dominant foot Tandem Stance Non-Dominant foot in back Sub-Totals FIRM SURFACE Total Score: FOAM SURFACE 118 CO N C U S S I O N A fAct sheet for student-Athletes What is a concussion? A concussion is a brain injury that: • Is caused by a blow to the head or body. – From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. • Can change the way your brain normally works. • Can range from mild to severe. • Presents itself differently for each athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness. hoW can i prevent a concussion? Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport. What are the symptoms of a concussion? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. What should i do if i think i have a concussion? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. it’s better to miss one game than the Whole season. When in doubt, get checked out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. 216 CO N C U S S I O N A fAct sheet for coAches The FacTs • A concussion is a brain injury. • All concussions are serious. • Concussions can occur without loss of consciousness or other obvious signs. • Concussions can occur from blows to the body as well as to the head. • Concussions can occur in any sport. • Recognition and proper response to concussions when they first occur can help prevent further injury or even death. • Athletes may not report their symptoms for fear of losing playing time. • Athletes can still get a concussion even if they are wearing a helmet. • Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries, depending on the sport. WhaT is a concussion? A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Recognizing a possible concussion To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; -AND2. Any change in the student-athlete’s behavior, thinking or physical functioning (see signs and symptoms). signs and sympToms Signs Observed By Coaching Staff • Appears dazed or stunned. • Is confused about assignment or position. • Forgets plays. • Is unsure of game, score or opponent. • Moves clumsily. • Answers questions slowly. • Loses consciousness (even briefly). • Shows behavior or personality changes. • Can’t recall events before hit or fall. • Can’t recall events after hit or fall. Symptoms Reported By Student-Athlete • Headache or “pressure” in head. • Nausea or vomiting. • Balance problems or dizziness. • Double or blurry vision. • Sensitivity to light. • Sensitivity to noise. • Feeling sluggish, hazy, foggy or groggy. • Concentration or memory problems. • Confusion. • Does not “feel right.” 217 pReVenTion and pRepaRaTion As a coach, you play a key role in preventing concussions and responding to them properly when they occur. Here are some steps you can take to ensure the best outcome for your student-athletes: • Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to-play. – Review and practice your emergency action plan for your facility. – Know when you will have sideline medical care and when you will not, both at home and away. – Emphasize that protective equipment should fit properly, be well maintained, and be worn consistently and correctly. – Review the Concussion Fact Sheet for Student-Athletes with your team to help them recognize the signs of a concussion. – Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete. • Insist that safety comes first. – Teach student-athletes safe-play techniques and encourage them to follow the rules of play. – Encourage student-athletes to practice good sportsmanship at all times. – Encourage student-athletes to immediately report symptoms of concussion. • Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death. iF you ThinK youR sTudenT-aThleTe has susTained a concussion: iF a concussion is suspecTed: Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion. 1. Remove the student-athlete from play. Look for the signs and symptoms of concussion if your student-athlete has experienced a blow to the head. Do not allow the student-athlete to just “shake it off.” Each individual athlete will respond to concussions differently. An athlete who exhibits signs, symptoms or behaviors consistent with a concussion, either at rest or during exertion, should be removed immediately from practice or competition and should not return to play until cleared by an appropriate health care professional. Sports have injury timeouts and player substitutions so that student-athletes can get checked out. 2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the studentathlete to the appropriate athletics medical staff, such as a certified athletic trainer, team physician or health care professional experienced in concussion evaluation and management. 3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return-to-play progression should occur in an individualized, step-wise fashion with gradual increments in physical exertion and risk of contact. 4. Develop a game plan. Student-athletes should not return to play until all symptoms have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact, as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change. iT’s beTTeR They miss one game Than The Whole season. When in doubT, siT Them ouT. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. IF YOU THINK YOU OR YOUR TEAMMATE HAS HAD A CNCUSSIN HIDE IT. 0 REPORT IT. 9 TAKE TIME TO RECOVER. - Amnesia - Confusion - Nausea L055 0' CONSCIOUSNESS - Balance problems or dizziness 0 Double or fuzzy vision I - Sensitivity to light or noise I - Headache - Feeling sluggish, foggy or - . 0 Concentration or memory problems 0 Slowed reaction time . BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. 0 Feeling unusually irritable WHEN IN DOUBT, GET CHECKED OUT.   STUDENT-ATHLETE HEALTH & WELFARE    Concussion Safety Protocol    Revision Date:  June 2, 2015  Approval Date:  June 2, 2015      INTRODUCTION/PURPOSE:    Concussion  management  in  sport  is  challenged  by  the  fact  that  concussion  risk  is  both  individualized  and  dynamic.  A blow to the head with the exact same forces will yield different symptoms of differing severity  depending  on  the  individual  concussed.    Add  to  this  the  fact  that  the  brain  is  dynamic,  especially  in  the  developmental years of youth and adolescence, and is influenced by a multitude of other factors (i.e. sleep  deprivation,  dehydration,  fatigue,  depression,  ADD/ADHD,  headache  disorders,  drugs  and  supplements  to  name a few).     International experts have convened at conferences on multiple occasions, most recently in Zurich in 2012, in  attempts to form consensus statements on the management of sports‐related concussion.  What has resulted  is  a  recommendation  to  abandon  the  concept  of  categorizing  concussions  by  “grades”  or  labeling  them  as  “simple”  or  “complex”  based  on  signs,  symptoms,  and  severity  at  presentation  for  the  purpose  of  making  return‐to‐play  decisions.    This  supports  the  realization  that  sports  concussion  diagnosis  and  management  needs to be individualized, and does not lend itself to a “cookbook” approach.      University  of  Michigan  Student‐Athlete  Health  and  Welfare  personnel  recognize  that  concussions  are  potentially  very  serious  injuries  that  require  a  comprehensive  and  carefully  measured  approach  to  management.    This  protocol  was  created  with  the  understanding  that  each  concussion,  as  well  as  each  student‐athlete,  is  unique.    Individualizing  concussion  management,  considering  each  student‐athlete’s  complete  medical  history,  and  close  physician  involvement,  are  the  hallmarks  of  this  protocol,  and  are  essential for the safety of our student athletes.      DEFINITION:  Concussion is defined as a complex pathophysiological process affecting the brain and induced by traumatic  biomechanical forces.  It is most commonly characterized by the rapid onset of a constellation of symptoms or  cognitive impairment that is self‐limited and resolves spontaneously.                U‐M SA Health & Welfare  6/2/2015                      1 PRESEASON EDUCATION:  Education  efforts  around  concussions  are  an  ongoing  process  that  includes  the  education  of  all  parties  involved  in  the  health  and  welfare  of  the  student‐athlete,  including,  but  not  limited  to  coaches,  athletic  administration, medical team personnel, and most importantly student‐athletes.      University  of  Michigan  student‐athletes  will  receive  annual  didactic  education  by  a  certified  athletic  trainer  and/or  Team  Physician  on  a  number  of  topics  including  concussions  during  their  yearly  pre‐participation  physical evaluation process.  Student‐athletes will be provided with applicable online and written education  materials such as the NCAA Concussion Fact Sheet for Student‐Athletes and the NCAA Concussion Video   (https://s3.amazonaws.com/ncaa/web_video/health_and_safety/concussion/concussion.html).     Student‐athletes are required  to  sign  a  Medical  Examination  and  Authorization  Waiver  on  an  annual  basis  acknowledging  that  they  have  disclosed their prior medical history, have received concussion education, and agree to report any problems,  ailments, injuries, and/or complaints.      University  of  Michigan  coaches  and  athletic  administration  will  undergo  annual  education  on  the  topic  of  concussions  and  will  be  provided  with  applicable  online  and  written  education  materials  such  as  the  NCAA  Concussion Fact Sheet for Coaches and the NCAA Concussion Video   (https://s3.amazonaws.com/ncaa/web_video/health_and_safety/concussion/concussion.html).      Within  this  education,  it  will  be noted to all that that Michigan Athletics follows the NCAA guideline that athletics health care providers are  empowered to have the authority to enter the field of play and/or remove a student‐athlete from the field of  play if they feel as though a student‐athlete is at risk and to determine management and return‐to‐play of any  ill  or  injured  student‐athlete  without  risk  of  employment  status  change.    Personnel  will  also  be  required  to  sign  a  Concussion  Acknowledgement  Form  (see  appendix)  acknowledging  the  responsibility  for  supporting  the  department’s  concussion  management  policy,  the  responsibility  to  report  any  signs,  symptoms,  or  behaviors  consistent  with  a  concussive  injury  that  they  may  witness,  and  acknowledging  the  education  and  return‐to‐play decision‐making process.    University of Michigan Medical Team personnel will engage in professional development activities specific to  the  topic  of  concussions  and  will  also  be  required  to  sign  a  Concussion  Acknowledgement  Form  acknowledging  the  responsibility  for  supporting  the  department’s  concussion  management  policy,  the  responsibility to report any signs, symptoms, or behaviors consistent with a concussive injury that they may  witness, and acknowledging the education and return‐to‐play decision‐making process.      BASELINE ASSESSMENT:  A pre‐participation assessment for every student‐athlete will include a detailed history that includes details of  prior concussions suffered before college entry and any history of migraine/headache disorders, ADD/ADHD,  or other learning disabilities, a focused neurological evaluation conducted by a University of Michigan Team  Physician, symptom evaluation, cognitive assessment, and balance evaluation.  Additionally, student‐athletes  will  receive  a  more  detailed  baseline  assessment  of  the  student‐athlete’s  neurological  function  using  more  objective  techniques  such  as  a  baseline  Michigan  Sideline  Assessment  of  Concussion  (MSAC)  and  a  computerized  neurocognitive  test  among  other  things.    A  University  of  Michigan  Team  Physician  will  determine clearance and/or the need for additional consultation or testing.            U‐M SA Health & Welfare  6/2/2015                      2 CONCUSSION RECOGNITION & DIAGNOSIS:  Student‐Athletes  that  exhibit  signs,  symptoms,  or  behaviors  consistent  with  a  concussive  injury  will  be  immediately  removed  from  participation  and  will  undergo  an  assessment  by  Athletic  Medicine  personnel  (Certified  Athletic  Trainer  (ATC)  and/or  Team  Physician)  that  includes  a  focused  assessment  of  the  student‐ athlete’s neurological status, testing to assess neurocognitive function and balance, and a clinical assessment  for  other  head  and  neck  trauma.    An  approximate  timeline  of  the  injury  and  the  presence  and  severity  of  symptoms will be documented.  If the student‐athlete manifests signs and symptoms that are initially severe  or their clinical status is deteriorating (e.g.  Glasgow Coma Scale <13; prolonged loss of consciousness;  focal  neurological  deficit  suggesting  intracranial  trauma;    repetitive  emesis;    persistently  diminished  /  worsening  mental  status  or  other  neurological  signs  /  symptoms;    spine  injury;    other),  that  student‐athlete  will  be  referred to a medical facility for more immediate follow‐up care as per the U‐M Emergency Action Plan.    A  University  of  Michigan  student‐athlete  that  is  diagnosed  with  a  concussion  will  be  withheld  from  participation for the remainder of the day of injury and will be serially evaluated and monitored as necessary  following  the  injury  by  Athletic  Medicine  personnel.    Athletic  Medicine  personnel  will  also  provide  verbal  and/or  written  care  instructions  to  the  student‐athlete  and/or  other  appropriate  personnel  at  the  time  of  discharge.      RETURN TO PLAY:  Any  future  return‐to‐play  decision  is  based  on  both  the  initial  evaluation  and  subsequent  follow‐up  assessments  with  a  U‐M  Team  Physician,  and  is  not  entertained  until  the  student‐athlete  has  successfully  progressed  through  an  individualized  graded  exercise  and  head  injury  progression  without  a  return  of  symptoms. The supervised stepwise progression will include light aerobic exercise without resistance training,  sport‐specific  exercise  and  activity  without  head  impact,  non‐contact  practice  with  progressive  resistance  training, unrestricted training, and return‐to‐competition.  This progression can take anywhere from days to  weeks and the speed with which the athlete moves through this progression and returns‐to‐play is dependent  on  multiple  factors  and  is  guided  by  the  U‐M  Team  Physician.      In  addition,  when  follow‐up  computerized  neurocognitive  testing  is  felt  warranted  by  the  treating  team  physician  and  is  included  as  part  of  the  post‐ concussion  evaluation,  the  testing  results  should  indicate  a  return  to  the  student‐athlete’s  baseline  level  of  function before return to play.  Any student‐athlete with prolonged symptoms or an atypical time course for  recovery  will  continue  to  be  evaluated  and  managed  by  a  University  of  Michigan  Team  Physician  with  consultation  from  our  University  of  Michigan  Team  Neurologist  as  indicated.  In  these  cases,  additional  referrals to relevant specialties will occur expeditiously.    A University of Michigan  Team Physician has the final authority in deciding if and when an injured student‐ athlete may return to practice and/or competition.  Any student‐athlete seen by and/or under the care of a  physician  other  than  a  University  of  Michigan  Team  Physician,  must  submit  copies  of  any  imaging  and/or  testing,  physician’s  notes,  and/or  medical  records,  and  must  return  to  the  University  of  Michigan  Team  Physician  for  a  follow‐up  evaluation  and  final  clearance  prior  to  active  participation  status.    If  a  student‐ athlete is under the care of a private physician for an injury or illness and the physician’s treatment precludes  or alters activity in intercollegiate athletics, the student‐athlete must secure, in writing, a release to reinstate  the  student‐athlete  to  full  participation.    No  student‐athlete  will  be  allowed  to  return  to  participation  until  University of Michigan Student‐Athlete Health and Welfare personnel has received a release from the private  physician  and  the  student‐athlete  is  examined  by  a  University  of  Michigan  Team  Physician  and  cleared  for  participation.            U‐M SA Health & Welfare  6/2/2015                      3 RETURN TO LEARN:  When  a  student‐athlete  is  diagnosed  with  a  concussion  and  evaluated  by  a  team  physician,  the  academic  support  staff  of  the  student‐athlete’s  sport  will  be  notified  and  will  function  as  the  primary  point  person  within  Athletics.    The  student‐athlete  should  not  be  involved  in  classroom  activity  on  the  same  day  as  the  concussion, and an individualized and stepwise progression for returning to academic participation, including  any appropriate academic modifications and/or accommodations, will be developed in collaboration with the  U‐M Team Physician and  other appropriate personnel and will  be communicated  to academic  personnel by  Academic Success Program (ASP) personnel only.      A multi‐disciplinary team of professionals, including, but not limited to the following individuals:   Team Physician   Athletic Trainer   Mental Health professional   Neuropsychology consultant   Faculty Athletics Representative   Academic Counselor   Course Instructor(s)   Administrators   Coach(es)   Office of Disability Services personnel   Other appropriate personnel as deemed necessary    will  be  identified  in  appropriate  circumstances  to  assist  with  the  management  of  more  complex  cases  and  appropriate U‐M campus resources will be engaged as necessary.  Compliance with ADAAA will be maintained  at all times.  The Team Physician will continue to re‐evaluate the student‐athlete as necessary.      REDUCING EXPOSURE TO HEAD TRAUMA:        The  University  of  Michigan  is  committed  to  student‐athlete  health  and  welfare  and  will  emphasize  ways  to  minimize head trauma exposure by:   Adherence to Inter‐Association Consensus:  Independent Medical Care Guidelines;   Adherence to Inter‐Association Consensus:  Year‐Round Football Practice Contact Guidelines;   Taking a “student‐athlete‐centered” approach to health and welfare;  and   Student‐Athlete  and  coach  education  regarding  safe  play,  proper  technique,  and  the  reporting  of  concussive signs, symptoms, and behaviors to appropriate medical personnel.    U‐M SA Health & Welfare  6/2/2015                      4 Michigan State University Department of Intercollegiate Athletics Concussion Management Guidelines June 2, 2015 1. MSU student athletes will undergo baseline neurocognitive testing using instruments and protocols approved by the Head Athletic Trainer and the Director of Sports Medicine and Performance. Current testing includes the computerized IMPACT testing system and BESS testing. Updated testing will be completed every 2 years following the initial baseline testing completed at Pre-Participation Physicals. Symptom evaluation along with additional history of brain injury and management will be included in the PPPE. The Team Physician will determine pre-participation clearance once the above are completed. 2. Prior to each competition season, all student athletes, coaches, appropriate additional administrative staff, including the Director of Intercollegiate Athletics, Staff Athletic Trainers and Team Physicians will be presented information on appropriate reporting of head injuries to medical personnel. As part of this education process, each participant will complete and sign the education forms provided by the Big Ten conference. 3. In the event of a head injury, the designated student athlete shall be held from participation until appropriate medical personnel have been consulted. 4. Any student athlete suspected of incurring a concussion will be immediately evaluated by medical personnel at the site. This evaluation will be completed using an approved standardized tool (for example, SCAT 2 or 3). A thorough musculoskeletal cervical spine examination and neurological evaluation will be completed to assess for cervical spine trauma, skull fracture and intracranial bleeds. The results of the initial and any subsequent evaluation will be entered into the student athlete’s permanent medical record. 5. Any student athlete suspected of incurring a concussion will not be allowed to return to play that day and must be evaluated by: a. The Team Physician for that sport (or designee) b. A staff Athletic Trainer or c. The on-site Athletic Trainer in consultation with the Team Physician or staff Athletic Trainer. 6. Any student athlete held from play will be subsequently evaluated using available clinical tools along with IMPACT and BESS testing until resolution of the injury. Return to practice and play will be governed by current recommendations from the NCAA/Big Ten and the 4th International Conference on Concussion in Sport. These include: a. Restriction of activity until symptoms resolve b. Return to activity when asymptomatic will follow the graduated return to play criteria set forth in the 4th International Conference on Concussion in Sport. This includes beginning with light aerobic activity on day one, sport specific exercise without contact on day two, non-contact training drills on day three, full contact practice on day four and return to play if asymptomatic on day five. If any symptoms occur during the step wise progression, the athlete will revert back to the previous asymptomatic level for 24 hours before progressing further. c. No return to play will occur until asymptomatic with exertion d. Final determination for return to play will be completed by the Team Physician overseeing the case. 7. Activity restriction for a student athlete diagnosed with a concussion will include involvement of the Student Athlete Academic Support Services personnel where appropriate. The student athletes Academic Advisor will work with the medical staff on return-to-learn options. There will be no same day classes on the date of the concussion. The student athlete may remain at home/dorm if they are unable to tolerate light cognitive activity. Return to class and studying will be individualized and progressed to tolerance. Additional academic support to complement athletic restrictions will be included on a case by case basis. In the event concussive symptoms worsen with additional academic progression, a re-evaluation by a Team Physician will be completed. All decisions relative to the student athlete will be in compliance with the ADAAA. Academic accommodations will be managed by the medical staff, academic support staff and additional campus resources consistent with the ADAAA. 8. Post-Concussion management, including implementation of an Emergency Action Plan and potential transportation, will be initiated with a Glasgow Coma scale <13, prolonged loss of consciousness, focal neurological deficits suggesting intracranial trauma, repetitive emesis, persistently diminished or worsening mental status or a suspected cervical spine injury. Serial evaluations by the designated Team Physician and additional appropriate medical staff will occur throughout the initial event and then as determined appropriate by the medical team once recovery is underway. Those athletes with prolonged symptoms will be followed by their designated Team Physician and Neurological consultants when warranted. 9. Any student athlete diagnosed with a concussion will be supplied with written instructions of neurological care for immediate follow-up of the injury. Wherever possible, the athlete will be discharged under the observation of a companion. (See attachment A) 10. A Multi-disciplinary team will be utilized to manage concussions when appropriate. Including, but no limited to are; Team physician, athletic trainer, psychiatrist and neuropsychologist, neurologist, academic advisor, coaches, faculty athletic representatives, course instructors, college administrators and a representative of the office of disability services. 11. Reducing head trauma exposure will be discussed and will include, but not limited to, reducing contact during practice, taking a safety first approach to sport, taking the head out of contact and additional instruction on proper techniques to limit risk and exposure. 12. All Big Ten and NCAA directed mandates will be followed per recommendations by each, including; Neurology sideline coverage, press box spotting, etc. ______________ Director of Intercollegiate Athletics _____________________ _______________ ____________________ Associate Athletic Director for Sports Medicine and Performance _____________________ Head Team Physician _________ Head Athletic Trainer ______________ __________________________ Attachment A Home Instructions WHAT YOU SHOULD KNOW: A minor head injury can cause the brain to have trouble working normally for a short time. Minor head injuries are usually not a serious problem. They are most often caused by a blow to the head. The first 24-48 hours are essential in monitoring symptoms from a head injury. Instructions for home monitoring will assist in caring for the head injured athlete. INSTRUCTIONS: Medicines: • • • Keep a written list of what medicines you take, the amounts, and when and why they are taken. Bring the list of your medicines or the pill bottles when you visit your caregiver. Ask your caregiver for more information about the medicines. Do not take any other medicines without first asking your caregiver. This includes prescriptions, over-the-counter drugs, vitamins, herbs, or food supplements. Always take your medicine as directed by caregivers. Call your caregiver if you think the medicines are not helping. Call if you feel you are having side effects. Do not quit taking the medicines until you discuss it with your caregiver. Take acetaminophen (a-seet-a-MIN-oh-fen) or ibuprofen (i-bu-PRO-fen) for headache or neck pain if your caregiver says it is OK. Keep all appointments: Ask your caregiver when to return for a follow-up visit. Home Care: • • Waking: You will need to have someone wake you at different times during the night. Ask your caregiver how often you need to be woken up and for how long. Also, have them ask you a few questions to see if you are thinking clearly. An example would be to ask your name or your address. Rest: Rest in bed or do quiet activities for the first 24 hours. You may begin normal activities again after you are cleared to do so by a Physician or designated Health Care Provider. CONTACT A CAREGIVER IF: • • • You are vomiting. You seem more sleepy, or are harder to wake up than usual. Your symptoms get worse during the first several days after the injury. You have new headaches that are very bad, or that get worse in the days after the injury. SEEK CARE IMMEDIATELY IF: o o o o o o o • You are vomiting. You have increasing confusion or a change in personality. You have blood or clear fluid coming out of the ears or nose. You do not know where you are, or you do not recognize people that are familiar. You have new problems with vision (blurry or double vision). Your speech becomes slurred or confused. You have arm or leg weakness, loss of feeling, or new problems with coordination (balance and movement). You or someone with you should dial 9-1-1 or 0 (Operator) for an ambulance if: o o o o Your pupils (black part in the center of the eye) are unequal in size, and this is new for you. You have a seizure (convulsion). Someone tries to wake you and cannot do so. You stop responding to others or you pass out (faint). Read more: http://www.drugs.com/cg/minor-head-injury-aftercareinstructions.html#ixzz0qZk5jyhV UNIVERSITY OF MINNESOTA - ATHLETIC MEDICINE CONCUSSION MANAGEMENT PLAN The health and safety of our student-athletes is the first priority of the University of Minnesota. This document establishes (1) the educational procedures for student-athletes, coaches, directors of athletics and medical staff regarding concussions, (2) the diagnosis and medical management plan for concussions, (3) the return to play and return to learn management plans, and (4) the management plan to reduce head trauma exposure. PRE-SEASON EDUCATION The University of Minnesota will make our Concussion Management Plan and other concussion education materials available on GopherSports.com. Student-Athlete Education • All student-athletes will be provided the NCAA Fact Sheet for Student-Athletes or other concussion education material and a copy of the concussion management plan annually. • Each student-athlete will be required to sign an acknowledgement that they have received, read and understand this educational material including the causes, signs and symptoms, and possible consequences of concussion. This education also outlines their responsibility for reporting any suspected concussions or head injuries directly to the medical staff. • The Director of Athletic Medicine will ensure that each student-athlete has completed this education and the signed acknowledgement forms will be retained in the student-athlete’s medical chart. Staff Education • All coaches and directors of athletics will be provided the NCAA Fact Sheet for Coaches or other concussion education material and a copy of the concussion management plan annually. • Each coach and director of athletics will be required to sign an acknowledgement that they have received, read and understand this educational material including the causes, signs and symptoms, and possible consequences of concussion. This education also outlines their responsibility for reporting any suspected concussions or head injuries directly to the medical staff. • The Director of Athletic Medicine will ensure that each coach and director of athletics has completed this education and will retain the signed acknowledgement forms. Medical Staff Education • All athletic trainers and team physicians will receive concussion education material and review the University of Minnesota’s concussion management plan annually. • All athletic trainers and team physicians will sign an acknowledgement that they understand the concussion management plan, their role within the plan and that they have received education about concussions. • The Director of Athletic Medicine will ensure that each athletic trainer and team physician has completed this education and will retain the signed acknowledgement forms. • Review and revision of the written management plan will be conducted annually to reflect best known and/or evidence based management practices. University of Minnesota – Concussion Management Plan – May 2015 Page 1 PRE-PARTICIPATION ASSESSMENT Pre-Participation Management Plan • All student-athletes will undergo a pre-participation history and physical examination by a University of Minnesota Team Physician which includes brain injury and concussion history. • All student-athletes will undergo pre-participation baseline concussion assessment testing – specifically computerized neuropsychological testing using ImPACT and the Sport Concussion Assessment Tool – 3rd Edition (SCAT 3). These assessment tools include symptom evaluation, cognitive assessment and balance evaluation. • Team physician judgment will determine pre-participation clearance and/or the need for additional consultation or testing based upon known individual concussion modifiers. • New baseline concussion assessment will be considered at six months or beyond for any student-athlete with a documented concussion, especially those with complicated or multiple concussion history. This will be determined by the team physician. RECOGNITION AND DIAGNOSIS OF CONCUSSION Recognition and Diagnosis of Concussion Management Plan • A student-athlete who shows any signs, symptoms or behaviors consistent with a concussion must be removed from practice or competition and evaluated by a medical staff member (i.e. Certified Athletic Trainer, team physician or other medical physician designated by the University of Minnesota Athletic Medicine staff). • If a concussion is confirmed, the student-athlete must be removed from practice or competition for the reminder of that calendar day. • A clinical assessment of head injury including skull fracture and/or intracranial bleed as well as assessment for cervical spine trauma will be performed and implementation of emergency action plan, as warranted. • If an athletic trainer or team physician is on site and the student-athlete is medically stable, the SCAT 3 should be used for the evaluation of the injured student-athlete. • If there is no team physician or athletic trainer available and the student-athlete is minimally symptomatic contact the athletic trainer / team physician to determine a plan for evaluation of the student-athlete. University of Minnesota – Concussion Management Plan – May 2015 Page 2 POST-CONCUSSION MANAGEMENT Post-Concussion Management Plan • A student-athlete observed to have a prolonged loss of consciousness or worsening symptoms, especially worsening headache, nausea or vomiting, Glasgow Coma Scale < 13, increased confusion, garbled speech, lethargy or extreme sleepiness, trouble using their arms or legs, convulsions or seizure activity or potential spine injury, will trigger implementation of the emergency action plan including potential transport for further medical care. • The student-athlete will be evaluated serially – including a symptom inventory and monitored for deterioration following injury. • Physician evaluation of all concussed athletes, timing dependent on athletic trainer assessment & clinical judgment. The athletic trainer should contact the team physician to discuss follow up. • Upon discharge from medical care, both oral and/or written instructions for home care will be given to the student-athlete and another responsible adult (e.g., parent, roommate, or teammate). • The concussed student-athlete will be instructed to minimize potential cognitive stressors such as school work, video games, reading, texting, and watching television. • For student-athletes with prolonged concussion symptoms, team physician evaluation will consider additional diagnosis and best management options. Additional diagnoses may include, but are not limited to: post-concussion syndrome, sleep dysfunction, migraine or other headache disorder, mood disorder such as anxiety and depression, or ocular or vestibular dysfunction. Team physician judgment will determine the need for additional consultation, testing or treatment of diagnosed condition. • Student-athletes who sustain a concussion outside of their sport will be managed for return to play/return to learn in the same manner as those sustained during sport activity. RETURN TO PLAY Return to Play Management Plan • A student-athlete diagnosed with a concussion is required to be medically cleared by a physician (i.e., team physician or other medical physician designated by the University of Minnesota Athletic Medicine staff) before returning to practice or competition. • A team physician may allow monitored exertional activity prior to asymptomatic status. • After symptoms return to baseline, follow up ImPACT will be completed and results reviewed by team physician. • Rate of return to play progression shall be determined and supervised by a team physician and an athletic trainer. • Return to play progression involves a gradual, step-wise increase in physical demand, sport specific activities and the risk for contact. a. Light aerobic exercise without resistance training (e.g. exercise bike). HR 100-140/RPE 3-4 b. Sport specific activity without head impact (e.g. lifting, agility drills, skating). HR 120-160/RPE 4-6 c. Non-contact practice or equivalent with progressive resistance training. HR 140-180/RPE 6-8 d. Unrestricted training including contact drills. HR 160-200/RPE 8-10 e. Return to game/competition activity. If symptoms return with activity, the progression should be halted and restarted at the preceding symptom-free step. RPE: Rate of Perceived Exertion=subjective measurement of exercise intensity on a 0-10 scale. University of Minnesota – Concussion Management Plan – May 2015 Page 3 RETURN TO LEARN Return to Learn Management Plan • Following a diagnosis of concussion cognitive rest will be immediately prescribed. No classroom activity on the same day as a concussion injury. • In consultation with the medical staff, the academic counselor specific to the student-athlete’s sport and the Learning Center Coordinator will be considered the point-person(s) to assist the student-athlete in navigating the return to academic and team cognitive activities. This academic counselor will assist with modification of schedule and academic accommodations as appropriate. • The gradual return to cognitive (classroom/studying) activity is based on the return of concussion symptoms following cognitive exposure and involves a step-wise increase in cognitive demand: a. If the student-athlete cannot tolerate light cognitive activity, he/she should remain at home/dorm. b. Gradual return to classroom/studying as tolerated. • Student-athletes with concussion symptoms lasting greater than two weeks should be reevaluated by a team physician as appropriate. • Student-athletes with symptoms that worsen with academic challenges should be re-evaluated by a team physician. • For complex cases of prolonged return-to-learn, the level of academic adjustment needed will be decided by a multi-disciplinary team that may include, but is not limited to: the team physician, athletic trainer, sports/neuro-psychologists, faculty athletics representatives, academic counseling staff, Learning Center Coordinator, course instructors, administrators, disability services, coaches, etc. • A student-athlete with persistent or prolonged concussion symptoms whose academic challenges cannot be managed through schedule modification/academic accommodations will be referred to the Disability Resource Center on campus for consideration of additional academic accommodations consistent with the ADAAA. Documentation of Concussion Management • Team physicians will document their clinical care for each concussion in EPIC. • Athletic trainers will document their clinical care and details about return to play progression for each concussion in Presagia. • Both medical professionals will document that the University of Minnesota Concussion Management Plan has been followed. University of Minnesota – Concussion Management Plan – May 2015 Page 4 REDUCING EXPOSURE TO HEAD TRAUMA Reducing Head Trauma Exposure Management Plan • • • • • The University of Minnesota will take a “safety first” approach to all of our sports. The University of Minnesota will provide education to coaches and student-athletes regarding safe play, proper technique and taking the head out of contact. The University of Minnesota will adhere to the NCAA Inter-Association Consensus: YearRound Football Practice Contact Guidelines. The University of Minnesota will adhere to the NCAA Inter-Association Consensus: Independent Medical Care Guidelines. The University of Minnesota will aim to reduce gratuitous contact during practices in all sports. MEDICAL POLICY REVIEW COMMITTEE: Moira Novak, ATC, Director of Athletic Medicine Robert Johnson, M.D. Sports Medicine Team Physician Dave Olson, M.D. Sports Medicine Team Physician Steve Stovitz, MD, Sports Medicine Team Physician Brad Nelson, M.D. Medical Director Suzanne Hecht, M.D. Sports Medicine Team Physician Chris Ashton, ATC, Assistant Athletic Trainer Jeff Winslow, ATC, Assistant Athletic Trainer DATE EFFECTIVE: August 1, 2010 REVISION DATE: April 23, 2015 DATE REVIEWED: April 22, 2015 APPROVED BY: Brad Nelson, MD Medical Director KEY LITERATURE REVIEWED: NCAA Sports Medicine Handbook, Guideline 2 I Sport-Related Concussion. July 2014. NCAA Concussion: Return-to-Learn Guidelines: http://www.ncaa.org/health-and-safety/medicalconditions/concussion-return-learn-guidelines National Athletic Trainers’ Association Position Statement: Management of Sport Concussion. Journal of Athletic Training, 2014; 49(2): 245-265. Inter-Association Guidelines from the NCAA and College Athletic Trainers’ Society. Concussion Guidelines: Diagnosis and Management of Sport-Related Concussion Guidelines. Available at: http://www.ncaa.org/healthand-safety/concussion-guidelines. Accessed July 8, 2014. Consensus statement on Concussion in Sport-4th International Conference on Concussion in Sport held in Zurich, 2012. BR J Sports Med 2013; 47: 250-258. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Clin J Sport Med 2013; 23(1): 1-18. University of Minnesota – Concussion Management Plan – May 2015 Page 5 Updated 6-9-15 MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUATION & RETURN TO PLAY GUIDELINES The University of Mississippi Sports Medicine staff will serially evaluate student-athletes with suspected mild traumatic brain injury/concussions by the following protocol developed for the use of University of Mississippi Sports Medicine Staff. Pre-Season Education-student athletes will receive a concussion fact sheet and a responsibility to report document with their medical packet which must be signed and dated. Athletic trainers and team physicians will review concussion policies yearly and acknowledge in a signed document. Coaches and directors of athletics will review the concussion policy at the initial yearly coaches meeting. If coaches are not present at that meeting then it is the responsibility of the athletic trainer of the sport to present it to those coaches by sport. There should be a signed document that states they have reviewed the policy. Baseline TestingALL ATHLETES WILL COMPLETE an initial screening as part of their PPE which will include history of prior concussions and symptoms. In addition, the following tests will be performed during/close as possible to the PPE to be used as baseline results: • • • A. ImPACT – Neuropsychological Assessment Balance Error Scoring System (BESS modified for eyes closed on floor only) Once these tests have been completed the team physician will review them and clear the student athlete for participation. Time of Injury- Any student-athlete that exhibits signs, symptoms, or behaviors consistent with a concussive injury (listed below) during practice or competition will be withheld from athletic participation for the remainder of that day. Some possible signs or symptoms may include, but not limited to: a. Altered level and/or loss of consciousness; b. Confusion, as evidenced by disorientation to person, time, or place; inability to respond appropriately to questions; inability to process information correctly and/or respond appropriately to analytical questions; or inability to remember assignments and/or plays; c. Amnesia (antegrade and/or retrograde; immediate or delayed); d. Abnormal neurological examination (ex: abnormal papillary response, persistent dizziness/vertigo, abnormal balance, etc); e. New and persistent headache, particularly if accompanied by photosensitivity or other visual disturbances, tinnitus, nausea, vomiting, or dizziness; f. Any other persistent signs or symptoms of a concussive injury. B. These student athletes that are suspected of suffering a MTBI/concussion will be evaluated by an ATC or a physician that has had experience with assessing concussions: a. SCAT3 Evaluation Sheet (within the first 24 hours if possible) b. Physician evaluation and examination (if applicable) Upon evaluation if any of the following signs/symptoms are present, the Emergency Action Plan must be followed, including transportation for further medical care. Glasgow Coma Scale <13, Prolonged loss of consciousness, focal neurological deficit suggesting intracranial trauma or skull fracture, repetitive vomiting, diminished mental status or neurological signs and symptoms or suspected spinal injury. Post-Concussion Follow-Up (24-hours post-injury)• SCAT3 • Physician evaluation and/or consultation • Contact parent/guardian regarding concussive injury • Home instruction sheet will be provided to athlete and family member/roommate who will help monitor student athlete over the next 24-48 hours. A copy of the completed home care instruction will be kept with the athlete’s medical records. The SCAT3 Symptom Evaluation form should be repeated every day until the student-athlete SelfReport no symptoms (SRA), at which time the student-athlete will begin with Step 1 SRA Procedures. If the student-athlete remains symptomatic at 7 days, he/she will follow-up at that time with the team physician of the team physician’s designee. Step 1 Initial Assessment in Asymptomatic Student-Athlete: • • ImPACT SCAT3 The team physician or his/her designee will review IMPACT and SCAT3 results, and if these results are considered to be back within baseline levels, the student-athlete will begin Step 2 with close monitoring by their ATC. If the IMPACT results are still below baseline levels in any of the tested parameters, the test will be repeated in 24-48 hours, and studentathlete will remain in Step 1 unless otherwise directed by the team physician. It should be noted if the athlete experiences reoccurrence of any symptoms during the IMPACT or SCAT3 testing. Step 2 Graduated Return to Physical Exertion Student-Athlete will begin a graduated return to exertion/activity protocol as recommended by the recent Zurich consensus panel for management of sports-related concussions. This will be done under the close observation of the sport ATC and the student-athlete will be instructed to report any reoccur ant symptoms or concerns during these stages. If during any of these stages, the athlete develops symptoms, they will rest for 24 hours and re-start at that step after this time. It is felt that each one of these stages should take around 24 hours to complete, but it is recognized there may be some variability in this based on student-athlete’s injury and prior history. 1. Light aerobic exercise. This may include walking, swimming or stationary cycling keeping Increase heart rate intensity less than 70 percent maximum permitted heart rate. No resistance training. 2. Sport-specific exercise. This may include running drills and routes in football, Skating drills in ice hockey, running drills in soccer, dribbling/shooting drills in basketball . No head-impact activities. May consider light resistance training, weight-lifting without “maxing out” at this stage 3. Non-contact Training Drills. This may include full passing routes in football, passing drills in soccer, more intense running, and may increase resistance activity. Step 3 Return to Full Sport ParticipationIf the student-athlete progresses through all 3 stages of Step 2 and continues to be completely asymptomatic, the student-athlete will be referred to the team physician or his/her designee for evaluation and consideration for return to full sport activity. Once team physician has cleared the student-athlete to return to full sport activity, they will have at least one session of activity in a practice setting before returning to full game activity. If student-athlete completes full practice session, including contact activity if applicable, they will be considered cleared to return to full game and sport participation. It will be noted that student-athlete will still need to be cognizant of any symptoms and report those to their ATC going forward. Return to Learn It is recognized that during the initial period of recovery, the student-athlete should engage in physical AND cognitive rest until such time that he/she is asymptomatic. No student-athlete will engage in classroom activity as the same day as a concussion, and may remain at home/dorm as needed. It shall be at the discretion of the University of Mississippi Sports Medicine Staff to recommend removal of student-athlete from any activities that increase concussive symptoms (ie: reading, classroom work, taking tests, sport-specific meetings, etc) as per Inter-Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines. The student athlete’s academic counselor will be the liaison between the medical staff and academics and will help with any modifications that are needed to the student athlete’s academic schedule. Student disability services, other physicians/specialists (included but not limited to, psychologist, neuropsychologist or, college administrators) will be utilized if needed in the transition back to the class room in a manner that is ADAAA compliant. Students athletes with symptoms lasting longer than 2 weeks such as sleep dysfunction, migraines, ocular or vestibular dysfunction or any other mood disorders will be evaluated by the team physician and referred to other specialists as needed. Reducing Head Trauma Exposure Coaches will be educated to the fact that minimizing head trauma exposure during practices could potentially decrease the amount of MTBI/Concussions. Information from the Year Round Football Practice Contact Guidelines will be recommended as well as coaching proper technique will be emphasized in order to prevent MTBI/Concussion. MODIFIED BESS BASELINE ATHLETE’S NAME:_________________________ DATE OF BASELINE: _______________ This balance testing is based on a modified version of the Balance Error Scoring System (BESS). Balance Testing “I am now going to test your balance. Please take your shoes off, roll up your pants legs above ankle. This test will consist of 3- twenty second tests with different stances.” (a) Double Leg Stance: “Please stand with your feet together, hands on your hips, and with your eyes closed. You should try to maintain stability in that position for 20 seconds. I will be counting the number of times you move out of this position. I will start timing when you are set and have closed your eyes.” (b) Single Leg Stance: “Stand on your Non-Dominant foot. 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Symptom-limited physical and cognitive rest. Recovery. 2. Light aerobic exercise. Walking, swimming or stationary cycling keeping Increase heart rate. intensity less than 70 percent maximum permitted heart rate. No resistance training. 3. Sport-specific exercise. Skating drills in ice hockey, running drills in soccer. Add movement. No head-impact activities. 4. Noncontact training drills. Progression to more complex training drills, Exercise, coordination e.g. passing drills in football and ice hockey. and cognitive load. May start progressive resistance training. 5. Full-contact practice. Following medical clearance, participate in normal Restore confidence training activities. and assess functional skills by coaching staff. 6. Return to play. Normal game play * 2013 International Conference on Concussion in Sport. Zurich, Switzerland. CONCUSSION FLOW CHART Head Injury Evaluate: Concussion Remove from Competition • • Evaluate: No Concussion Return to Competition Within 1st 24 hours SCAT 3 Eval by Physician if available 24 hours post-incident • SCAT 3 Symptom Evaluation • Eval/Consult by Physician Self Report Symptomatic • Cont SCAT3 Symptom Evaluation every 24 hours until Self-Report Asymptomatic (SRA) If symptoms recur while performing one of the SRA steps, wait 24 hours, then proceed with the same level as before. Once asymptomatic, proceed to the next step • • Step 1 SRA ImPACT SCAT 3 • • Step 2 SRA ImPACT Gradual Return to Physical Exertion • Step 3 SRA Return to full sport participation Reevaluation by Team Physician and/or designee for full return to activity CONCUSSION: HOME INSTRUCTION SHEET Name: ________________________________ Date___________ You have had a head injury or concussion and need to be watched closely for the next 24-48 hours. IT IS OK TO: - Use Tylenol (acetaminophen) Apply ice to head/neck for comfort Eat a light meal Go to sleep DO NOT: - Drink ALCOHOL Eat spicy foods Use aspirin, Aleve, Advil (Ibuprofen), or any other NSAID products WATCH FOR ANY OF THE FOLLOWING PROBLEMS: Worsening headache Stumbling/loss of balance Vomiting Weakness in one arm/leg Decreased level of consciousness Blurred Vision Dilated (large) pupils Increased irritability Increased confusion If any of these problems develop, call your athletic trainer immediately. Athletic Trainer: ____________________ Phone: ____________ Recommendations provided to: __________________________ Recommendations provided by: __________________________ STUDENT-ATHLETE RESPONSIBILITY TO REPORT SIGNS AND SYMPTOMS OF CONCUSSION Signs and Symptoms of Concussions - Amnesia Confusion Headache Loss of consciousness Balance problems Dizziness Memory Problems - Sensitivity to light Sensitivity to noise Nausea Feeling sluggish, foggy, or groggy Feeling unusually irritable Concentration problems Slowed reaction time I accept responsibility for reporting any injuries or illnesses to the Ole Miss Sports Medicine staff, including signs and symptoms of concussions. My signature below shows that I acknowledge and have been presented with educational material regarding concussions, and understand that it is my responsibility to report any signs and symptoms. _________________________ Print Name _________________________ Student-Athlete Signature _______________ Sport _______________ Date CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A CONCUSSION? A concussion is a brain injury that: • • • • • • Is caused by a blow to the head or body from contact with another player, hitting a hard surface such as the ground, floor, or being hit by a piece of equipment such as a bat, or ball, etc. Can change the way your brain normally works. Can range from mild to severe. Presents itself differently for each athlete. Can occur during practice or competition in ANY sport. Can happen even if you do not lose consciousness. HOW CAN I PREVENT A CONCUSSION? Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, and stepping on a head are all ways to cause concussion. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport. WHAT ARE THE SYMPTOMS OF A CONCUSSION? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting plays, facts, meeting times). • Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as a headache or tiredness) to reappear or get worse. WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. For more information visit www.NCAA.org/health-safety Get checked out. Your Sports Medicine Staff can tell you if you have had a concussion, and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reactions time, balance, sleep, and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. WHEN IN DOUBT, GET CHECKED OUT. August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 MISSISSIPPI STATE UNIVERSITY SPORTS MEDICINE CONCUSSION MANAGEMENT PLAN OVERVIEW In compliance with NCAA rules, Mississippi State University has instituted the following protocol for concussion management in student-athletes. NCAA legislation states that institutions shall have a management plan on file such that a student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. Student-athletes that sustain a concussion outside of their sport will be managed in the same manner as those sustained during sport activity. Student-athletes diagnosed with a concussion will not return to activity for the remainder of that day. Medical clearance will be determined by the team physician or their designee. The student-athlete will be monitored for recurrence of symptoms both from physical exertion and also mental exertion, such as reading, phone texting, computer games, working on a computer, classroom work, or taking a test. Neuropsychological testing (i.e. ImPACT testing) has proven to be an effective tool in assessing neurocognitive changes following concussion and will serve as an important component of MSU’s concussion management plan. However, neuropsychological tests will not be used as a standalone measure to diagnose the presence or absence of a concussion and will not be used in lieu of a comprehensive assessment by qualified healthcare providers. Healthcare professionals will assume a concussion when unsure and waiting for final diagnosis. When in doubt, sit the athlete out. MSU will ensure healthcare professionals attain continuing education on concussion evaluation and management annually. Structured and documented education of student-athletes and coaches will be done to improve the success of the recognition and referral components of this program. CONCUSSION STATEMENT As part of NCAA legislation, student-athletes must annually sign a statement in which they accept the responsibility for reporting their injuries and illnesses to MSU medical staff, including signs and symptoms of concussions. During the review and signing process, student-athletes will be presented with educational material on concussions. The statement can be found in Appendix A and has been approved by university counsel. The signed statement will be kept in the student-athlete’s compliance or medical file. The signature of a parent or legal guardian of the student-athlete is required if he or she is a minor. In this case, a minor has been defined as anyone less than 18 years of age. August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 BEST PRACTICES FOR CONCUSSION MANAGEMENT 1. Require student-athletes to sign a statement (see Appendix A) in which student-athletes accept the responsibility for reporting their injuries and illnesses to MSU medical staff, including signs and symptoms of concussions. During the review and signing process, student-athletes will be presented with educational material on concussions and access to the MSU Concussion Management Plan. 2. Have on file and annually update an emergency action plan for each athletics venue to respond to studentathlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses. 3. MSU’s healthcare plan includes equitable access to athletics healthcare providers and care for each NCAA sport. 4. MSU medical staff will be empowered to have the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. 5. This concussion management plan will be team physician-directed and includes the following components: a. Provide applicable NCAA concussion fact sheets or other applicable educational material annually to student-athletes, coaches, team physicians, athletic trainers, and athletics directors. There will be a signed acknowledgement that all parties have read and understand these concussion facts and MSU’s Concussion Management Plan. Additionally, ensure coaches have acknowledged they understand their role within the plan. b. MSU Athletics healthcare providers will practice within the standards as established for their professional practice (e.g., physician, certified athletic trainer, nurse practitioner, neurosurgeon). c. Record a brain injury/ concussion history, baseline ImPACT (including a symptom check list and symptom evaluation), and modified Balance Error Scoring System (BESS) assessment (or similar functional/ balance testing) for each student-athlete prior to participation their initial year. Team physicians have the ultimate authority to determine pre-participation clearance and/or the need for additional consultation or testing. A new ImPACT baseline will be taken during the student-athlete’s third year in the program in high risk sports such as baseball, basketball, football, pole vaulting, soccer, and softball. If a studentathlete in any sport receives a severe concussion, a new baseline will also be established a minimum of six months post-injury. A new baseline may be considered if a student-athlete begins medicine to treat ADHD or depression. ImPACT will be used post-injury after the student-athlete is asymptomatic and prior to returning to full speed drills. Additional ImPACT tests will be continued at appropriate intervals. As requested by the team physician or certified athletic trainer, post injury neuropsychological test data will be interpreted by the team neurosurgeon and/or a neuropsychologist. d. When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, at rest or with exertion, the athlete will be removed from practice or competition and evaluated by an athletics healthcare provider (ATC or team physician) with experience in the evaluation and management of concussion. e. A student-athlete diagnosed with a concussion will be withheld from the competition or practice and not return to activity for the remainder of that day. Disposition decisions for more serious August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 injuries such as cervical spine trauma, skull fracture or intracranial bleed, will be made at the time of presentation. f. MSU Athletics healthcare providers, who have the experience to diagnose and manage concussions, will conduct and document serial clinical evaluation inclusive of symptom inventory and evaluation of cognition and balance. g. The student-athlete will be evaluated by a team physician as outlined within this concussion management plan. Once asymptomatic and post-exertion assessments are within normal baseline limits, return-to-play will follow a medically supervised stepwise process. h. Final authority for Return-to-Play will reside with the team physician or the physician's designee. 6. Document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion. 7. Although sports currently have rules in place; athletics staff, student-athletes, and officials will continue to emphasize that purposeful or flagrant head or neck contact in any sport is not permitted and current rules of play will be strictly enforced. 8. Modifying factors and co-morbidities -- such as attention deficit hyperactivity disorder, migraine and other headache disorders, learning disabilities and mood disorders -- will be considered in making the diagnosis, in providing a management plan, and in making both return-to-play and return-to-learn recommendations. 9. Academic accommodations and cognitive rest will be considered after a concussion and done in cooperation with the Athletics Academics staff. ROLES OF ATHLETICS HEALTHCARE STAFF Team Physician and/or Team Neurosurgeon- Evaluation, return-to-play clearance, directs the overall concussion management plan Certified Athletic Trainer- Evaluation and return-to-play clearance at the designation of the team physician Nurse Practitioner- Evaluation and return-to-play clearance at the designation of the team physician WHEN TO REFER MSU team physicians have specified that student-athletes be referred when they present with the following signs and symptoms, and these signs and symptoms are not associated with other, previously diagnosed, medical conditions: Headache, confusion, fogginess, blurred vision, dizziness, phonophobia, photophobia, difficulty concentrating, irritability, memory loss, exertional headache, nausea/vomiting, emotionality, nervousness/anxiety POST-CONCUSSION MANAGEMENT The foundation of sport-related concussion management is initial physical and relative cognitive rest as part of an individualized treatment plan. Initial management of sport-related concussion is based on individual serial clinical assessments, taking a concussion history, modifying factors, and taking specific needs of the student-athlete into consideration. Such management includes, but is not limited to: August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 1. Clinical evaluation at the time of injury. When the rapid assessment of concussion is necessary (e.g., during competition), symptom assessment, physical and neurological exam, and balance exam will be performed. 2. Assessment for skull fracture, intracranial bleed, and cervical spine trauma at time of injury and implementation of the emergency action plan, as warranted. 3. Implementation of the emergency action plan and transportation for further medical care if any of following signs and symptoms are present: Glasgow Coma score less than 13; prolonged period of loss of consciousness (longer than 1 minute); focal neurological deficit suggesting intracranial trauma; repetitive emesis; persistently diminished or worsening mental status or other neurological signs or symptoms; and potential spine injury. 4. Serial evaluation and monitoring for deterioration following injury will be ongoing and provided by either the team physician or their designee. 5. Upon discharge from medical care, both oral and written instructions (Appendix B) for home care will be given to the student-athlete and to a responsible adult (e.g., parent or roommate) who should continue to monitor and supervise the student-athlete during the acute phase of sport-related concussion. RETURN TO ACTIVITY Sport-related concussion is a challenging injury for student-athletes and, unlike other injuries, the timeline for return to full activity (including return-to-play and return-to-learn) is often difficult to project. The psychological response to injury is also unpredictable. Sometimes, student-athletes who are kept out of their sport for a prolonged period of time experience emotional distress related to being unable to participate in sport. It is important that health care providers remain alert to the signs and symptoms of depression and other emotional responses to injury that can be particularly challenging following concussive injury. These symptoms may represent, but are not limited to, post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, co-morbid mood disorders such as anxiety and depression, or ocular or vestibular dysfunction. An evaluation by a physician will be conducted for student-athletes with a prolonged recovery in order to consider these additional diagnoses and best management options. A diagnosis will be verified instead of assuming that the student-athlete has prolonged concussion symptoms. Passive management, such as prolonged physical and cognitive rest, may be counter-productive in these scenarios. RETURN TO PLAY Once a student-athlete has returned to his/her baseline, the return-to-play decision is based on a protocol of a stepwise increase in physical activity that includes both an incremental increase in physical demands and contact risk supervised by a physician or physician-designee. It is important to stress an individualized approach for return-to-play. Some student-athletes may have minimal concussive symptomatology with minimal symptom duration and no modifiers (conditions that may prolong recovery such as prior concussion, migraine, ADHD, depression/anxiety). In scenarios of this nature, and with experienced clinicians in a highly select setting, the return-to-play protocol may be modified. August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 In contrast, if a student-athlete has a concussion history, increased symptom burden or duration, or has symptoms for three to four weeks with other concussion modifiers, then the return-to-play progression should proceed more cautiously and each stage may take more than a day. Distinctive neurological deficits, such as vestibular or oculo-motor dysfunction, should be specifically addressed to avoid prolonged return-to-play. For example, if a student-athlete suffers from vestibular dysfunction as a manifestation of sport-related concussion, and is unable to progress in the return-to-play protocol, it is important to address the specific vestibular dysfunction rather than to simply return the student-athlete to the previous level of return-to-play progression. In other words, ‘rest’ can sometimes lead to adverse outcomes if an accurate diagnosis based on neurological dysfunction is not made. PROCESS FOR RETURN-TO-PLAY When the symptom score returns to baseline with relative physical and cognitive rest, the student-athlete will begin a gradual return to play and proceed at a pace determined by symptomatology. A return to baseline includes symptom score, cognitive function, and balance. MSU team physicians have specified the following step-wise progression be used for return-to-play and this process will be supervised by a health care provider with expertise in concussion. 1. Relative physical and cognitive rest 2. Cognitive exertion/ no physical activity 3. Light aerobic exercise (such as walking, swimming, or riding a stationary)/ stationary cardiovascular activity/ no resistance training 4. Functional testing (mode, duration, and intensity-dependent exercise based upon sport) 5. Sport-specific exercise (no head impact) 6. Noncontact sport drills/ resumption of progressive resistance training 7. Full-contact practice 8. Return to play At any point, if the student-athlete becomes symptomatic (i.e., more symptomatic than baseline), or scores on clinical/ cognitive measures decline, the team physician will be notified and the student-athlete will be returned to the previous level of activity once symptoms resolve. Final determination of return-to-play ultimately resides with the team physician or a medically qualified physician designee. RETURN TO ACADEMICS Return-to-learn guidelines assume that both physical and cognitive activities require brain energy utilization, and that after a sport-related concussion, brain energy may not be available for physical and cognitive exertion because of a brain energy crisis. Return-to-learn will be managed in a stepwise program that fits the needs of the individual, within the context of a multi-disciplinary team that includes physicians, athletic trainers, coaches, psychologists/ counselors, neuropsychologists, administrators as well as academic (e.g. professors, deans, academic advisors) and the MSU Office of Student Support Services and Disability Support Services representatives as warranted. Like return-to-play, it is difficult to provide prescriptive recommendations for return-to-learn. The studentathlete may appear physically normal but may be unable to perform as expected due to concussive symptomatology. August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 PROCESS FOR RETURN-TO-LEARN 1. Relative physical and cognitive rest (minimizing potential cognitive stressors, such as school work, video games, reading, texting and watching television). Consideration will be given to avoiding the classroom for at least the same day as the sport-related concussion. The period of time needed to avoid class or homework will be individualized. 2. Gradual return to academics based on the absence of concussion symptoms following cognitive exposure. a. If the student-athlete cannot tolerate light cognitive activity, he or she should remain at home or in the residence hall. b. Once the student-athlete can tolerate cognitive activity without return of symptoms, he/she will return to the classroom in graduated increments. At any point, if the student-athlete becomes symptomatic (i.e., more symptomatic than baseline), or scores on clinical/cognitive measures decline, the team physician will be notified and the student-athlete’s cognitive activity reassessed. The extent of academic adjustments needed will be decided by a multi-disciplinary team that may include the team physician, athletic trainer, team athletic academic counselor, faculty athletics representative or other faculty representative, coach, individual teachers, neuropsychologist, college administrators, office of disability services representative, and psychologist/ counselor. The level of multi-disciplinary involvement will vary on a case-by-case basis. The majority of student-athletes who are concussed will not need a detailed return-to-learn program because full recovery typically occurs within two weeks. For the student-athlete whose academic schedule requires some minor modification in the first one to two weeks following a sport-related concussion, adjustments can often be made without requiring meaningful curriculum or testing alterations. Any modifications needed will be implemented with help from the student-athlete’s point person, usually their athletic academic advisor. For those student-athletes whose symptoms persist for longer than two weeks, academic adjustment or accommodations may be considered, such as a change in his or her class schedule and special arrangements for extended absences, tests, term papers, and projects. Other accommodations may be considered in coordination with Athletic Academics and/or the MSU Office of Student Support Services and Disability Support Services and in compliance with the Americans with Disabilities Act. Re-evaluation by the team physician and member of the multi-disciplinary team will occur, as appropriate, in these cases of prolonged recovery. A more difficult scenario occurs when the student-athlete experiences prolonged cognitive difficulties. In this case, considerations may include neuropsychological evaluation to: (a) determine the nature and severity of cognitive impairment, and (b) identify the extent to which psychological issues may be present and may be interacting with the cognitive processes. The student-athlete may choose to disclose the documentation to the MSU Office of Student Support Services and Disability Support Services in order to seek long-term accommodations or academic adjustments. That office will verify if the impairment is limiting a major life activity per the Americans with Disabilities Act. Accommodations or academic adjustments may be considered in order to ‘level the playing field’ for the student-athlete with prolonged cognitive difficulties resulting from a concussion. August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 The successful implementation of return-to-learn depends on several variables: - Recognition that concussion symptoms vary widely among student-athletes, and even within the same individual who may be suffering a repeat concussion. Identification of a point person or case manager for the student-athlete who can navigate the dual obligations of academics and athletics. In most cases, this will be the student-athlete’s athletics academic advisor who will work closely with the student-athlete’s athletic trainer. Identification of co-morbid conditions that may impair recovery, such as migraine or other headache conditions, attention-deficit hyperactivity disorder, anxiety and depression, or other mood disorders. Identification of campus resources that can help assure that student-athletes are provided their full rights during this transition period. EDUCATIONAL OPPORTUNITIES: STUDENT-ATHLETES - Student-Athlete Handbook - NCAA Fact Sheet for Student-Athletes - New student-athlete orientation - SEC and/or NCAA educational posters displayed in all locker rooms EDUCATIONAL OPPORTUNITIES: COACHES AND STAFF - Annual education at a Compliance meeting - Department-wide e-mail including NCAA Fact Sheet for Coaches, NCAA video link, and information on where to access MSU Concussion Management plan - SEC and/or NCAA educational posters displayed in all locker rooms - All members of the athletic training staff (staff, graduate assistants, students) will annually review concussion evaluation and management REDUCING EXPOSURE TO HEAD TRAUMA While reducing head trauma is difficult to quantify, we recognize the importance of emphasizing ways to minimize head trauma exposure and will continue an ongoing evaluation of strategies to minimize/reduce exposure to contact. Minimizing head trauma exposure can be improved through: - Adherence to the Inter-Association Consensus: Year-Round Football Practice Contact Guidelines - Adherence to the Inter-Association Consensus: Independent Medical Care Guidelines - Reducing gratuitous contact during practice - Taking a “safety first” approach to sport - Taking the head out of contact - Coaching and student-athlete education regarding safe play and proper techniques August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 APPENDICES Appendix A- Statement Appendix B- Home Instructions for Concussions Appendix C- NCAA Fact Sheet for Student-Athletes Appendix D- NCAA Fact Sheet for Coaches Appendix E- NATA Position Statement Appendix F- Sport Concussion Assessment Tool 2 (SCAT2 and SCAT3) and modified Balance Error Scoring System (BESS) Appendix G- Inter-Association Consensus: Year-Round Football Practice Contact Guidelines Appendix H- Inter-Association Consensus: Independent Medical Care Guidelines August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 APPENDIX A- STATEMENT August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 MSU SPORTS MEDICINE STUDENT-ATHLETE CONCUSSION STATEMENT (To be signed annually) I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet, I am aware of the following information: _____ A concussion is a brain injury, which I am responsible for reporting to my Initial physician or athletic trainer. _____ Initial A concussion can affect my ability to perform everyday activities and affect reaction time, balance, sleep, and classroom performance. _____ Initial You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. _____ Initial Common signs and symptoms of a concussion include: - Amnesia - Confusion - Headache - Loss of consciousness - Nausea - Double or fuzzy vision - Sensitivity to light or noise - Balance problems or dizziness - Feeling unusually irritable - Feeling sluggish, foggy, or groggy - Slowed reaction time - Concentration or memory problems If I experience any of these signs or symptoms or in any way suspect I have suffered a concussion, I am responsible for reporting this to my team physician or athletic trainer. _____ Initial If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer. _____ Initial I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms. _____ Initial Following a concussion, the brain needs time to heal. I understand I am much more likely to have a repeat concussion if I return to play before my symptoms resolve. _____ Initial I understand repeat concussions can cause permanent brain damage and even death. ___________________________________ PRINT NAME _________________________________ DATE ___________________________________ SIGNATURE ___________________________________ SIGNATURE OF PARENT OR GUARDIAN IF UNDER 18 August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 APPENDIX B- HOME INSTRUCTIONS FOR CONCUSSIONS August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 MSU SPORTS MEDICINE HOME INSTRUCTIONS FOR CONCUSSIONS Name _______________________________ Date _____________________ You have had a head injury and/or concussion and need to be watched closely for the next 24-48 hours. It is ok to: - Use Tylenol (acetaminophen) - Use an ice pack on your head/neck for comfort - Eat a light meal - Go to sleep There is no need to: - Check eyes with a light - Wake up every hour - Stay in bed DO NOT: - Drink alcohol or eat spicy foods - Drive a car - Use aspirin, Aleve (naproxen sodium), Advil (ibuprofen), or other NSAID products - Participate in any strenuous activity until cleared by your athletic trainer and/or team physician Special Recommendations: ____________________________________________ __________________________________________________________________ Watch for any of the following problems and contact your athletic trainer immediately: - Worsening headache - Stumbling/ loss of balance - Vomiting - Weakness in arms/ legs - Decreased level of consciousness - Increased irritability - Dilated (enlarged) pupils - Increased confusion - Seizure - Neck pain - Abnormal respiration, pulse, and/ or blood pressure - Difficulty with facial expressions, numbness of the face, and/or decreased hearing, vision, or balance - Increase in severity or number of symptoms You need to be seen for a follow-up examination tomorrow at ________AM/PM at _______________________________. 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PVU PG QMBZ JNNFEJBUFMZ BOE BMMPX BEFRVBUF UJNF GPS FWBMVBUJPO CZ B IFBMUI DBSF QSPGFTTJPOBM FYQFSJFODFE JO FWBMVBUJOH GPS DPODVTTJPO Remove the student-athlete from play. -PPL GPS UIF TJHOT BOE TZNQUPNT PG DPODVTTJPO JG ZPVS TUVEFOU BUIMFUF IBT FYQFSJFODFE B CMPX UP UIF IFBE %P OPU BMMPX UIF TUVEFOU BUIMFUF UP KVTU iTIBLF JU PČ w &BDI JOEJWJEVBM BUIMFUF XJMM SFTQPOE UP DPODVTTJPOT EJČFSFOUMZ "O BUIMFUF XIP FYIJCJUT TJHOT TZNQUPNT PS CFIBWJPST DPOTJTUFOU XJUI B DPODVTTJPO FJUIFS BU SFTU PS EVSJOH FYFSUJPO TIPVME CF removed immediately from practice or competition BOE TIPVME OPU SFUVSO UP QMBZ VOUJM DMFBSFE CZ BO BQQSPQSJBUF IFBMUI DBSF QSPGFTTJPOBM 4QPSUT IBWF JOKVSZ UJNFPVUT BOE QMBZFS TVCTUJUVUJPOT TP UIBU TUVEFOU BUIMFUFT DBO HFU DIFDLFE PVU Ensure that the student-athlete is evaluated right away by an appropriate health care professional. %P OPU USZ UP KVEHF UIF TFWFSJUZ PG UIF JOKVSZ ZPVSTFMG *NNFEJBUFMZ SFGFS UIF TUVEFOU BUIMFUF UP UIF BQQSPQSJBUF BUIMFUJDT NFEJDBM TUBČ TVDI BT B DFSUJĕFE BUIMFUJD USBJOFS UFBN QIZTJDJBO PS IFBMUI DBSF QSPGFTTJPOBM FYQFSJFODFE JO DPODVTTJPO FWBMVBUJPO BOE NBOBHFNFOU Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. "MMPX BUIMFUJDT NFEJDBM TUBČ UP SFMZ PO UIFJS DMJOJDBM TLJMMT BOE QSPUPDPMT JO FWBMVBUJOH UIF BUIMFUF UP FTUBCMJTI UIF BQQSPQSJBUF UJNF UP SFUVSO UP QMBZ " SFUVSO UP QMBZ QSPHSFTTJPO TIPVME PDDVS JO BO JOEJWJEVBMJ[FE TUFQ XJTF GBTIJPO XJUI HSBEVBM JODSFNFOUT JO QIZTJDBM FYFSUJPO BOE SJTL PG DPOUBDU Develop a game plan. 4UVEFOU BUIMFUFT TIPVME OPU SFUVSO UP QMBZ VOUJM BMM TZNQUPNT IBWF SFTPMWFE CPUI BU SFTU BOE EVSJOH FYFSUJPO .BOZ UJNFT UIBU NFBOT UIFZ XJMM CF PVU GPS UIF SFNBJOEFS PG UIBU EBZ *O GBDU BT DPODVTTJPO NBOBHFNFOU DPOUJOVFT UP FWPMWF XJUI OFX TDJFODF UIF DBSF JT CFDPNJOH NPSF DPOTFSWBUJWF BOE SFUVSO UP QMBZ UJNF GSBNFT BSF HFUUJOH MPOHFS $PBDIFT TIPVME IBWF B HBNF QMBO UIBU BDDPVOUT GPS UIJT DIBOHF IT’S BETTER THEY MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, SIT THEM OUT. 'PS NPSF JOGPSNBUJPO BOE SFTPVSDFT WJTJU XXX /$"" PSH IFBMUI TBGFUZ BOE XXX $%$ HPW $PODVTTJPO Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 APPENDIX E- NATA POSITION STATEMENT Journal of Athletic Training 2014;49(2):245–265 doi: 10.4085/1062-6050-49.1.07 Ó by the National Athletic Trainers’ Association, Inc www.natajournals.org position statement National Athletic Trainers’ Association Position Statement: Management of Sport Concussion Steven P. Broglio, PhD, ATC*; Robert C. Cantu, MD†; Gerard A. Gioia, PhD‡; Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM§; Jeffrey Kutcher, MD*; Michael Palm, MBA, ATC ; Tamara C. Valovich McLeod, PhD, ATC, FNATA¶ *University of Michigan, Ann Arbor; †Department of Surgery, Emerson Hospital, Concord, MA; ‡Division of Pediatric Neuropsychology, Children’s National Medical Center, Washington, DC; §Department of Exercise and Sport Science, University of North Carolina, Chapel Hill; Athletico Physical Therapy, Oak Brook, IL; ¶Athletic Training Program, A.T. Still University, Mesa, AZ Objective: To provide athletic trainers, physicians, and other health care professionals with best-practice guidelines for the management of sport-related concussions. Background: An estimated 3.8 million concussions occur each year in the United States as a result of sport and physical activity. Athletic trainers are commonly the first medical providers available onsite to identify and evaluate these injuries. Recommendations: The recommendations for concussion management provided here are based on the most current research and divided into sections on education and prevention, documentation and legal aspects, evaluation and return to play, and other considerations. Key Words: mild traumatic brain injuries, pediatric concussions, education, assessment, evaluation, documentation D concussion management. They are typically the first providers to identify and evaluate injured persons and are integral in the postinjury management and return-to-play (RTP) decision-making process. Without exception, ATs should be present at all organized sporting events at all levels of play and should work closely with a physician or designate who has specific training and experience in concussion management to develop and implement a concussion-management plan based on the recommendations outlined here. An update to the initial 2004 National Athletic Trainers’ Association position statement on the management of sport-related concussion,5 this document contains recommendations on concussion management for practicing ATs based on the most recent scientific evidence. A review of the literature supporting these recommendations has also been included. The document covers the topics of ‘‘Education and Prevention,’’ ‘‘Documentation and Legal Aspects,’’ ‘‘Evaluation and RTP,’’ and ‘‘Other Considerations.’’ espite a significant increase in research dedicated to identifying and managing sport-related concussion, it remains one of the most complex injuries sports medicine professionals face. Concussions occur from forces applied directly or indirectly to the skull that result in the rapid acceleration and deceleration of the brain. The sudden change in cerebral velocity elicits neuronal shearing, which produces changes in ionic balance1 and metabolism.2 When accompanied by clinical signs and symptoms, changes at the cellular level are commonly referred to as mild traumatic brain injury, or concussion. Concussions occur in males and females of all ages and in all sports, but are most common in contact and collision activities. Data collected from emergency department visits show a 62% increase (153 375 to 248 418) in nonfatal traumatic brain injuries between 2001 and 2009,3 with as many as 3.8 million reported and unreported sport- and recreation-related concussions occurring each year in the United States.4 As licensed medical professionals, athletic trainers (ATs) receive comprehensive didactic and clinical training in Journal of Athletic Training 245 Table 1. Strength of Recommendation Taxonomy (SORT)a Strength of Recommendations A Recommendation based on consistent and good quality experimental evidence (morbidity, mortality, exercise and cognitive performance, physiologic responses) Recommendation based on inconsistent or limited quality experimental evidence Recommendation based on consensus; usual practice; opinion; disease-oriented evidenceb; case series or studies of diagnosis, treatment, prevention, or screening; or extrapolations from quasi-experimental research B C a b Definition Reprinted with permission from ‘‘Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading Evidence in the Medical Literature,’’ February 1, 2004, American Family Physician. Copyright Ó 2004 American Academy of Family Physicians. All Rights Reserved. Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptoms improvement, cost reduction, and quality of life. Disease-oriented evidence measures are intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes (eg, blood pressure, blood chemistry, physiologic function, pathologic findings). INJURY DEFINITION To best assemble the available concussion research and remain consistent with other medical groups, we sought to evaluate literature that defined concussion as a ‘‘traumainduced alteration in mental status that may or may not involve loss of consciousness.’’6 This definition was selected based on its broad application by medical organizations and widespread use within the literature from the time of the first National Athletic Trainers’ Association position statement. We recognize the strength of the definition provided by the International Concussion in Sport Group and its subpoints as valid features that further define concussion.7 In evaluating and writing this document, we also included research defining concussive injuries in these terms. Notably absent from the literature and consistent with previous recommendations were the terms ‘‘ding,’’ ‘‘getting one’s bell rung,’’ ‘‘clearing the cobwebs,’’ and other such phrases in reference to concussive injuries.5 These colloquial terms are antiquated, minimize injury severity, and should not be used to refer to concussion or mild traumatic brain injury. 4. The AT should work to educate coaches, athletes, and parents about the limitations of protective equipment for concussion prevention. Strength of Recommendation: C 5. As part of educational efforts, ATs, athletes, coaches, and parents should read all warning labels associated with protective equipment. Strength of Recommendation: C Documentation and Legal Aspects 6. The AT should be aware of any and all relevant governing bodies (eg, state, athletic conference) and their policies and procedures regarding concussion management. Strength of Recommendation: C 7. The AT should document the athlete’s (and when appropriate, the parent’s) understanding of concussive signs and symptoms and his or her responsibility to report a concussion. Strength of Recommendation: C 8. The AT should communicate the status of concussed athletes to the managing physician on a regular basis. Strength of Recommendation: C 9. The AT should ensure proper documentation of the concussion evaluation, management, treatment, return-to- RECOMMENDATIONS FOR CLINICAL PRACTICE Education and Prevention The clinical practice recommendations for each topic have been graded based on the Strength of Recommendation Taxonomy (SORT; Table 1).8 1. The AT should use, and educate others in using, the proper terminology of concussion and mild traumatic brain injury as opposed to such colloquial terms as ‘‘ding’’ and ‘‘bell ringer.’’9 Strength of Recommendation: B 2. The AT should work with the appropriate administrators to ensure that parents and coaches are educated on the following aspects of concussion: prevention, mechanism, recognition and referral, appropriate return to participation, physical and cognitive restrictions for concussed athletes, and ramifications of improper concussion management.10–12 Strength of Recommendation: B 3. The AT should be aware of and document potential modifying factors that could delay the RTP, and patients should be educated on the implications of these conditions as they affect recovery (Table 2).7 Strength of Recommendation: C 246 Volume 49 Number 2 April 2014 Table 2. Factors That May Modify the Risk of Concussion and Duration of Recovery7 Risk Symptoms Modifiers Number Duration (.10 d) Severity Signs Prolonged loss of consciousness (.1 min), amnesia Sequelae Concussive convulsions Temporal Frequency: repeated concussions over time Time: injuries close together in time Recency: recent concussion or traumatic brain injury Threshold Repeated concussions occurring with progressively less impact, force, or slower recovery after each successive event Age Child or adolescent (,18 y) Comorbidities and Migraine, depressions, or other mental health premorbidities disorders; attention-deficit hyperactivity disorder; learning disabilities; sleep disorders Medication Psychoactive drugs, anticoagulants Behavior Dangerous style of play Sport High-risk activity, contact or collision sport, high sporting level participation progression, and physician communications. Strength of Recommendation: C Evaluation and RTP 10. Athletes at high risk of concussion (eg, those in contact or collision sports) should undergo baseline examinations before the competitive season.5,13,14 Strength of Recommendation: B 11. A new baseline examination should be completed annually for adolescent athletes, those with a recent concussion, and, when feasible, all athletes.15–17 Strength of Recommendation: B 12. The baseline examination should consist of a clinical history (including any symptoms), physical and neurologic evaluations, measures of motor control (eg, balance), and neurocognitive function.5,7,18–20 Strength of Recommendation: B 13. The baseline and postinjury examinations should be administered in similar environments that maximize the patient’s abilities, and all baseline examinations should be reviewed for suboptimal performance.21 Strength of Recommendation: C 14. Any athlete suspected of sustaining a concussion should be immediately removed from participation and evaluated by a physician or designate (eg, AT). Strength of Recommendation: C 15. The concussion diagnosis is made through the clinical evaluation and supported by assessment tools.19 Strength of Recommendation: B 16. When the rapid assessment of concussion is necessary (eg, during competition), a brief concussion-evaluation tool (eg, Standardized Assessment of Concussion [SAC]20,22,23) should be used in conjunction with a motor-control evaluation and symptom assessment to support the physical and neurologic clinical evaluation. Strength of Recommendation: B 17. Once a concussion diagnosis has been made, the patient should undergo a daily focused examination to monitor the course of recovery. Strength of Recommendation: C 18. During the acute postconcussion recovery stage, daily testing of neurocognitive function and motor control is typically not needed until the patient is asymptomatic.24 Strength of Recommendation: C 19. A concussed athlete should not be returned to athletic participation on the day of injury.9 Strength of Recommendation: C 20. No concussed athlete should return to physical activity without being evaluated and cleared by a physician or designate (eg, AT) specifically trained and experienced in concussion evaluation and management. Strength of Recommendation: C 21. Young athletes with a past medical history that includes multiple concussions, a developmental disorder (eg, learning disabilities, attention-deficit hyperactivity disorder), or a psychiatric disorder (eg, anxiety, depression) may benefit from referral to a neuropsychologist to administer and interpret neurocognitive assessments and determine readiness to return to scholastic and athletic activities.7,25 Strength of Recommendation: C 22. A physical-exertion progression should begin only after the concussed athlete demonstrates a normal clinical examination, the resolution of concussion-related symp- toms, and a return to preinjury scores on tests of motor control and neurocognitive function.7,26 Strength of Recommendation: C 23. Concussed athletes who do not show a typical progressive return to normal functioning after injury may benefit from other treatments or therapies. Strength of Recommendation: C 24. Concussion-grading scales should not be used to manage the injury. Instead, each patient should be evaluated and treated on an individual basis.7,9 Strength of Recommendation: B 25. After the injury has resolved, the concussion may be retrospectively graded for the purpose of medical record documentation. Strength of Recommendation: C Other Considerations Equipment. 26. The AT should enforce the standard use of certified helmets while educating athletes, coaches, and parents that although such helmets help to prevent catastrophic head injuries (eg, skull fractures), they do not significantly reduce the risk of concussions.7,27–29 Strength of Recommendation: B 27. Helmet use in high-velocity sports (eg, alpine sports,30–32 cycling33–35) has been shown to protect against traumatic head and facial injury. Strength of Recommendation: A 28. Consistent evidence to support the use of mouthguards for concussion mitigation is not available. However, substantial evidence demonstrates that a properly fitted mouthguard reduces dental injuries.29 Strength of Recommendation: B 29. Research on the effectiveness of headgear in soccer players to reduce concussion is limited. The use of headgear is neither encouraged nor discouraged at this time. Strength of Recommendation: C Pediatric Concussion. 30. When working with children and adolescents, ATs should be aware that recovery may take longer than in adults and require a more prolonged RTP progression.7,36,37 Strength of Recommendation: B 31. Age-appropriate, validated concussion-assessment tools should be used in younger populations.7,25 Strength of Recommendation: C 32. Assessment of postconcussion symptoms in pediatric patients should include age-validated, standardized symptom scales and the formal input of a parent, teacher, or responsible adult.38–40 Strength of Recommendation: B 33. Pediatric athletes are undergoing continual brain and cognitive development and likely need more frequent updates to baseline assessments.16,41 Strength of Recommendation: B 34. Athletic trainers should work with school administrators and teachers to include appropriate academic accommodations in the concussion-management plan. 7,39,42 Strength of Recommendation: C Home Care. 35. The AT and physician should agree on a standard concussion home-instruction form (eg, Appendix A) that is consistently used for all concussed patients, and a copy should be maintained in the medical record. Both oral and written instructions for home care should be given to the Journal of Athletic Training 247 36. 37. 38. 39. 40. 41. 42. concussed athlete and to a responsible adult (eg, parent or roommate) who will observe and supervise the patient during the acute phase of the concussion.5,43 Strength of Recommendation: C After a concussion diagnosis, the patient should be instructed to avoid medications other than acetaminophen. All current medications should be reviewed by the physician. 5,44,45 Strength of Recommendation: C After a concussion diagnosis, the patient should be instructed to avoid ingesting alcohol, illicit drugs, or other substances that might interfere with cognitive function and neurologic recovery.5 Strength of Recommendation: C After the initial monitoring period, rest is currently the best practice for concussion recovery. As such, there is typically no need to wake the patient during the night unless instructed by a physician.5 Strength of Recommendation: C During the acute stage of injury, the patient should be instructed to avoid any physical or mental exertion that exacerbates symptoms.5,7,28,39,42 Strength of Recommendation: C In addition to exclusion from physical activity related to team activities, concussed student-athletes should be excused from any activity requiring physical exertion (eg, physical education classes). Strength of Recommendation: C School administrators, counselors, and instructors should be made aware of the patient’s injury with a recommendation for academic accommodation during the recovery period.7,28,39,42 Strength of Recommendation: C A patient with a concussion should be instructed to eat a well-balanced diet that is nutritious in quality and quantity and should drink fluids to stay hydrated.5 Strength of Recommendation: C Multiple Concussions. 43. For an athlete with a concussion history, the AT should adopt a more conservative RTP strategy.7,46,47 Strength of Recommendation: B 44. Referral to a physician or designate with concussion training and experience should be considered when an athlete with a history of multiple concussions sustains concussions with lessening forces, demonstrates increasing severity with each injury, or demonstrates objective or subjective changes in baseline brain function. Strength of Recommendation: C 45. The AT should recognize the potential for second-impact syndrome in young patients who sustain a second trauma to the brain prior to complete resolution of the first injury.1,48–50 Strength of Recommendation: C 46. The AT should be aware of the potential for long-term consequences of multiple subconcussive and concussive impacts.51–53 Strength of Recommendation: C SUPPORTING LITERATURE REVIEW Education and Prevention When athletes, parents, coaches, administrators, and others discuss concussive injuries, they should use the appropriate medical terminology: concussion or mild traumatic brain injury. Use of such colloquial terms as 248 Volume 49 Number 2 April 2014 ‘‘ding,’’ ‘‘bell ringer,’’ and ‘‘getting your bell rung’’ has a connotation that mitigates injury severity and should thus be avoided. For example, a noted decline in neurocognitive ability at 36 hours after injury was reported in patients labeled as ‘‘dinged’’ whose symptoms appeared to resolve within 15 minutes.9 This finding demonstrates a more serious effect of what was initially considered a minor injury. Before the competitive season, the AT should review all concussion policies and procedures that outline injury definition, signs and symptoms, and the institution’s policy on concussion management (see ‘‘Documentation and Legal Aspects’’ below regarding how state laws and organizational body regulations may influence institutional concussion policy). In many instances, the AT has access to the most up-to-date information on concussion diagnosis and management. This information should be disseminated to all of those involved in athlete health care as rapidly as possible and in an appropriate manner. These individuals include but are not limited to coaches, athletes, parents, administrators, and other medical professionals. In addition to these documents, agencies have developed educational information specific to coaches, athletes, and parents that has been shown to effectively educate the target audience.54–56 Athletes themselves have demonstrated limited knowledge regarding concussion symptoms; more than 50% of high school athletes57 and 70% of collegiate athletes58 did not report concussions sustained during football. One reason for nonreporting was that athletes were not aware of the signs and symptoms of concussion. Another study59 of high school rugby players demonstrated more knowledge of concussion signs and symptoms (61%); however, the athletes had limited knowledge of postinjury concussionmanagement guidelines. For example, 25% of the athletes believed loss of consciousness was required for the injury to be considered a concussion.59 Educational methods are effective in increasing athletes’ awareness of concussion symptoms. Goodman et al60 found that exposure to a concussion-symptom video game improved symptom identification among youth ice hockey players.60 Similarly, Bramley et al61 noted that high school soccer players who received concussion education were more likely to report concussion symptoms to their coach. Researchers57 have documented athletes’ lack of willingness to report concussions to medical personnel, so parents of youth athletes should also be educated to recognize signs and symptoms of concussion. Parents (or guardians) typically have the most contact with young athletes and so are well positioned to report atypical behavior, but many parents are not properly educated on the topic of concussion.62 Sullivan et al63 reported that parents of male high school rugby athletes were knowledgeable about the signs and symptoms (83%) and the risks associated with continuing to play while injured (96%), yet only half were aware of the appropriate RTP guidelines after injury. Even in the presence of an AT, coaches have the responsibility for recognizing the signs and symptoms of concussion in athletes. Several studies, however, have shown that coaches have limited knowledge and many misconceptions related to concussions. In a survey of youth sports coaches, 45% of respondents believed a concussion did not require immediate removal from a game or practice, and only 62% could correctly identify proper postconcussion management.10 In another investigation,64 high school coaches demonstrated greater overall knowledge of sport concussion (84%); they knew the most about injury recognition (92%) and the least about injury management (79%). Concussion-specific training is effective in improving injury knowledge: those attending a coaching education program10 or a coaches’ workshop64 scored higher than nonattendees on their respective surveys. Sarmiento et al11 reported that 34% of high school coaches using the Centers for Disease Control and Prevention’s ‘‘Heads Up’’ tool kit for concussion improved their concussion knowledge; specifically, they gained knowledge related to injury signs and symptoms. The coaches also noted that the tool kit changed their attitudes and behaviors related to concussion.11 Similarly, a short (15–20 minute), interactive, online, concussion-education program aimed at youth sports coaches resulted in improvements in symptom knowledge, general knowledge, injury misconceptions, self-efficacy, and behavioral intention.12 Collectively, these findings suggest that a brief training session on sportconcussion signs, symptoms, and injury management targeted at coaching staff can improve injury recognition. This type of training may ultimately benefit the AT by encouraging coaches to help identify concussed athletes and follow treatment plans. After a concussive event, the AT should also educate the patient and any additional stakeholders (eg, parents and administrators) about the typical injury recovery. Although injury severity and a precise time to recover cannot be predicted immediately after injury, most concussed athletes return to their preinjury level of functioning within 2 weeks.65 However, several factors, including specific symptom patterns,7,66 age, and sex,67 may influence injury recovery and delay the return to participation (Table 2). Informing the patient about expected outcomes after injury may reduce anxiety about the injury and associated symptoms.7,68 Documentation and Legal Aspects Certified ATs, team physicians, and other health care providers responsible for the management of patients with sport-related concussion should be aware of potential liabilities involved with delivering medical coverage and making RTP decisions for patients. Concussion management has medical and legal implications, and the threat of lawsuits is increasing for sports medicine professionals. Previous lawsuits against ATs and team physicians have addressed the premature clearing of patients and, surprisingly, withholding patients from play after concussion.69–73 Therefore, it is imperative for clinicians to manage these injuries in a systematic manner, using objective assessments, while documenting their daily findings. Certain legal principles are common to the laws of each state, but material differences exist in the decisions of the higher courts for each state and in state statutes.74 It is, however, the responsibility of the AT to follow the best-practice guidelines, recommendations, and practice limitations adopted by their respective work setting or oversight organization (eg, National Federation of State High School Associations, National Collegiate Athletic Association, National Football League) and the best practices for licensed ATs established, in part, by the position statements of the National Athletic Trainers’ Association. In addition, ATs working in states with concussion-management legislation are bound to follow those laws in the event of a discrepancy with organizational guidelines or position statements. To avoid litigation, ATs should understand the general elements of negligence and malpractice that typically govern claims for injury or death caused by improper treatment. A tort is a private wrong or injury suffered by a person as the result of another person’s conduct. The law gives injured persons the right to be compensated through the recovery of damages. Torts may be intentional, meaning that the person intended to act, or unintentional, in that the person did not mentally intend to cause harm. A tort is committed when an AT fails to act as an ordinary and reasonably prudent person under similar circumstances and causes injury to another person.74,75 Negligence is an unintentional tort. Negligence law was founded on the principle that those who are harmed as the result of others’ carelessness or failure to properly carry out responsibilities must be compensated. The person who was harmed has the burden of proving that the 4 legal elements of negligence are satisfied: a duty of care was owed as a result of a relationship that existed between the parties; the defendant breached the duty owed to the injured party; the breach of the duty is proved to be the cause of the harm to the plaintiff; and actual harm, not just the potential for harm, must have occurred. All 4 elements of negligence must be proven in order for the plaintiff to be compensated by the defendant for damages.75,76 Athletic trainers employed to treat and manage athletic injuries such as concussion owe a duty of reasonable care to their patients and have been the target of lawsuits alleging failures to meet the standard of care after sport-related injury, especially concussion. Allegations against ATs in cases of negligence after concussion most often include improper evaluation and testing of the patient, improper documentation, misunderstood communications with the patient, and a lack of education of the patient or the patient’s family.77 For ATs to minimize the risk of becoming defendants and to better defend themselves should a case be filed, they must understand the standard of care for managing specific injuries based on the most recent scientific literature. The standard of care in athletic training is defined as a person’s ‘‘legal duty to provide health care services consistent with what other health care practitioners of the same training, education, and credentialing would provide under the circumstances.’’78 Athletic trainers can learn how the standard of care is applied to legal cases by examining specific cases and the firsthand experiences of those who have defended ATs during the litigation process.77 The athletic training profession must identify and adopt standard practice limitations and guidelines to establish the standard of care for managing concussions and other brain injuries. Ambiguity and the lack of a clear standard make it easier for plaintiffs’ lawyers to construct theories of liability for lawsuits against ATs, alleging they breached the standard of care after a suspected concussion.77 Lawsuits against ATs often involve the evaluation or testing of the patient (or lack thereof), documentation of an Journal of Athletic Training 249 injury, communications with the patient or with a physician about a patient, and education of the patient. In a 2008 California case, an AT was found liable for failing to properly and promptly evaluate a patient who apparently had sustained a concussion only to later pass out, fall, and suffer a variety of physical injuries as a result of the AT’s alleged failures.79 The court ordered the defendants to pay substantial damages to the injured patient. In another case, a University of Tennessee football player recovered hundreds of thousands of dollars when an AT allegedly failed to promptly report a patient’s initial and ongoing symptoms to a physician. The patient subsequently sustained an acute subdural hematoma in connection with an injury incurred 1 month later.80 In another case, a high school football player alleged that his AT failed to properly evaluate him or take seriously his reported headaches and dizziness after a concussion and then prematurely returned him to play, which allegedly caused the patient to suffer second-impact syndrome after a second concussion 2 weeks later.81 In this case, although the jury awarded no damages to the injured player, the cost to the defendants was 3 years of litigation, substantial legal fees and expenses, and a month-long, stressful, high-profile trial. Another possible allegation in the cases against ATs involves the lack of documentation in managing a sportrelated concussion. For several years, ATs have been advised to document ‘‘all pertinent information’’ surrounding concussions.5 The documentation of information surrounding the evaluation and management of any suspected concussion should include but not be limited to (1) mechanism of injury; (2) initial signs and symptoms; (3) state of consciousness; (4) findings of the physical and neurologic examinations, symptoms, neurocognitive function, and motor control (noting any deficits compared with baseline); (5) instructions given to the patient or parent (or both); (6) recommendations provided by the physician; (7) graduated RTP progression, including dates and specific activities; and (8) relevant information on the patient’s history of prior concussion and associated recovery pattern(s). Though lengthy, this level of detail can help prevent a premature return to participation, catastrophic brain injury such as second-impact syndrome, and legal liability. The expression ‘‘if it’s not written, it didn’t happen’’ is often used in legal situations. The question in these cases sometimes becomes whether certain information is or is not ‘‘pertinent.’’ For example, at some point during a concussed athlete’s RTP progression, he or she will begin performing graduated exertional exercises (see ‘‘Evaluation and RTP’’ below). Daily documentation of the details surrounding this progression will help to avoid potential litigation in the event that the recovery or return to participation does not proceed as expected. For example, the dates on which the testing was performed, the witnesses to the testing, the actual maneuvers the patient performed, and the patient’s description of any symptoms during or after activity should be documented. The value of this documentation may not be realized for some time, as legal trials generally occur years after the alleged improper conduct, when it is unlikely that anyone can accurately recall the details if they were not recorded at the time. At the time of writing, all 50 states have enacted concussion laws. Nearly all of these laws include the components of (1) educating athletes, parents, and coaches; 250 Volume 49 Number 2 April 2014 (2) instituting a concussion policy and emergency action plan; (3) removing the athlete from practice or play at the time of the suspected concussion; and (4) having a health care provider with training in concussion management perform medical evaluation and RTP clearance. The AT must know the laws of the state and recognize that failure to warn or educate the athlete can be the basis for another possible allegation. One simple way to educate athletes about the dangers of concussion and continuing to play while still symptomatic is to require them to read and sign a standard acknowledgment form indicating that they understand the signs and symptoms of concussion and their responsibility to report a concussion (Appendix B). Some legal experts even suggest that athletes should sign an acknowledgment that they understand the warning a manufacturer has placed on a helmet. For example, some football helmets carry warnings such as this: Contact in football may result in concussion/brain injury, which no helmet can prevent. Symptoms include loss of consciousness or memory, dizziness, headache, nausea, or confusion. If you have symptoms, immediately stop and report them to your coach, [athletic] trainer, and parents. Do not return to a game or contact until all symptoms are gone and you receive medical clearance. Ignoring this warning may lead to another and more serious or fatal brain injury. No helmet system can protect you from serious brain and/or neck injuries, including paralysis or death. To avoid these risks, do not engage in the sport of football. (Reprinted with permission of Schutt Sports.) In catastrophic cases where such an acknowledgment of understanding has not been secured by the AT, a ‘‘failure to warn’’ claim almost certainly will be made against the AT, especially when the plaintiff alleges that the patient never recovered from an earlier injury. Thus, before each season, at a minimum, the AT should require that each athlete read a concussion fact sheet, read the aforementioned warning on the helmet, and sign an acknowledgment that he or she read and understood both. Not only do these acknowledgments serve as a possible defense to a failure-to-warn claim, but under certain circumstances, they may also be used to establish that the patient is legally responsible for his or her own injuries (if, for example, the athlete reports symptoms to teammates but withholds the information from team personnel and continues to play). When a defendant asserts and can show that the plaintiff’s injuries are a result of the plaintiff’s own negligence, the defendant may prevail on a theory of contributory negligence or comparative negligence, which could bar the plaintiff from recovering any damages whatsoever. The more education the AT provides to the patient (and parents of a patient who is a minor) concerning the risks of RTP before a complete recovery after a concussion (eg, the risk of playing while still symptomatic), the greater the likelihood of success the AT will have in defending against a failure-to-warn or failure-to-educate claim. More importantly, enhanced education to athletes should translate into more informed participants, which should lead to fewer catastrophic injuries.77 Finally, it is imperative that practicing ATs understand their individual state laws on concussion management because some states have made Table 3. Suggested Domains of the Clinical History and Examination for Concussion Management Domain Previous concussions Concussion-related personal history Family history Symptoms Mental status Eye examination Muscle strength Motor control Cognitive function a b How to Assess?a Features or Examples Date(s) and circumstances; presence and duration of loss of consciousness, amnesia, and symptoms with each injury Mood disorder, learning disability, attention-deficit hyperactivity disorder, epilepsy or seizures, sleep apnea, skull fracture, migraine headaches Mood disorder, learning disability, attention-deficit hyperactivity disorder, dementia (eg, Alzheimer disease), migraine headaches, complications from concussions Current and recurrent Level of consciousness, attention and concentration, orientation, memory Eye movements with smooth pursuit (cranial nerves III, IV, VI), nystagmus (VIII), pupillary reflex (CN II, III) Strength evaluation of deltoids, biceps, triceps, wrist and finger flexors and extensorsb; pronator drift Balance assessment Reaction time, working memory, delayed recall Preparticipation examination Preparticipation examination Preparticipation examination Symptom checklist or scale Standardized Assessment of Concussion Clinical examination Clinical examination Balance Error Scoring System Neurocognitive testing Assessment tools are indicated where available. Notable deficits may be associated with nerve root injury or concussion. provisions for ATs to clear a concussed athlete to RTP. However, a physician with specific training and experience in concussion management should still be involved in the comprehensive approach to concussion management outlined in this position statement. A concussion-management policy outlining the roles and responsibilities of each member of the sports medicine team should be adopted. Evaluation and RTP Approach to Concussion Evaluation. The clinical presentation of concussion varies considerably both between individuals and between injuries in 1 individual. Additionally, the degree of brain dysfunction manifested by concussion often produces signs and symptoms that fall within the range of normal experiences in the population (eg, dehydration, fatigue, anxiety). For these reasons, a concussion-assessment model that uses objective baseline testing and careful postinjury testing is recommended. Although all athletes should ideally undergo a preseason baseline assessment, at a minimum, athletes who are at a high risk of concussion based on their sport67,82 should be included in any baseline testing program. Furthermore, athletes with a significant concussion history or other relevant comorbidity, such as attention-deficit hyperactivity disorder, should be considered for testing on an individual basis. The intent of baseline testing is to aid the clinician in the postinjury management process by providing data that represent an athlete’s brain function in an uninjured state. Objective baseline and postinjury information can be highly sensitive to concussive injuries,19 but the concussion diagnosis is made by clinically evaluating the injured athlete. In this way, postinjury retesting should not be considered a diagnostic tool for concussion, nor should it be used as a sole determinant of when it is safe to return to participation; rather, it is a supplement to support the clinical examination. These data are then best used as part of a comprehensive concussion- management approach that is communicated to the directing physician and other members of the sports medicine team with concussion training and experience. Baseline Testing. The baseline evaluation of an athlete for the purpose of concussion management should include a documented neurologic history with symptoms and physical examination (Table 3). Baseline testing should also involve the objective evaluation of multiple spheres of brain function and, at minimum, assess neurocognitive performance and motor control. Obtaining premorbid selfreport symptoms is also recommended for comparison with postinjury symptom presentations and for improved interpretation of other test data. Additionally, medication use should be carefully documented and made available for postinjury review. Numerous testing methods are available for concussion management. When selecting specific tests and procedures for the concussion-assessment and concussion-management protocol, the AT should consult with members of the sports medicine team regarding the best tools for the clinical setting and secure written approval from the administration. When selecting specific assessment tools, the AT must also be aware of the limitations and requirements of the particular baseline test being considered. For example, the reliability of computer-based cognitive tests varies with the test-retest interval,83–87 and additional costs may be incurred to interpret test results.88,89 Once the tests are selected, care should be taken to provide each athlete with an environment that is designed to maximize test performance and be easily reproduced in the postinjury setting. Large-group administration of baseline tests is discouraged; small-group administration is preferable. Having a sufficient number of proctors and using standardized procedures are important.21 The AT should avoid conducting tests at unusual times of the day to ensure that athletes are reasonably rested and not physically or mentally fatigued after a practice or workout. Whenever possible, athletes should not undergo baseline testing when they are ill or injured in a manner that could influence test results. Lastly, if appropriate resources are available, the AT should conduct annual baseline tests on athletes. This is most crucial in adolescents, whose brains are continuing to develop,15–17 and in those who have sustained a concussion since their previous test. Self-Report Symptom Assessment. Collecting subjective symptom information from a patient is a dynamic and complex process. Using symptom checklists (ie, yes/no) or scales (ie, graded and summed responses) Journal of Athletic Training 251 that assess symptom duration or severity (or both) in a standardized manner90 is recommended. In general, symptom reports provide good sensitivity to concussive injuries,19,20 but the degree to which symptom reports can be a useful part of the neurologic history and examination in concussion management is potentially minimized by their limitations. Because of the nature and physical demands of athletics, an evaluation of concussion-related symptoms can yield low specificity compared with the reference standard of clinician-diagnosed concussion. That is, concussion-like symptoms are also commonly reported in athletes who are dehydrated91 and those who have performed strenuous activity92; the presence of these symptoms does not mean the athlete will demonstrate balance or neurocognitive impairments.93 In addition, for a variety of reasons, athletes may be motivated to underreport symptoms so they can continue activity after injury.57 Numerous concussion inventories are available for clinical use, including the Head Injury Scale,94 Graded Symptom Checklist,5 Concussion Symptom Inventory,7,95 and Sport Concussion Assessment Tool 3 (SCAT-3).7 The AT should choose a symptom-evaluation protocol that best suits his or her clinical practice and be consistent in its administration. Motor Control. The diffuse effects of concussive injuries on brain function can often lead to deficits in motor control. Changes in motor control after injury have been documented in several areas, including gait,96,97 postural control,65,98–100 and hand movement101. As such, the assessment of 1 or more motor-control systems can provide useful information for concussion diagnosis and management. Perhaps the most common concussion-assessment tool is the evaluation of postural control. Overall balance deficits after injury have been attributed to failure to integrate sensory information arising from the vestibular and visual components of the balance mechanism.98–100 The Sensory Organization Test, although used successfully to quantify changes to the balance mechanism,19,102 is limited by cost and portability. In the initial days of injury, the Balance Error Scoring System (BESS) demonstrates similar injury sensitivity,20,65 is highly portable, and can be administered with minimal cost and training. As with other concussion-assessment tools, the AT should select the tools that best suit the clinical setting, be trained in their proper administration,103,104 understand their limitations,105–110 and use consistent methods in baseline and postinjury evaluations. Mental-Status Testing. A change in mental status is the hallmark of concussion,6 yet concussed athletes rarely present with easily identifiable signs of injury. In fact, loss of consciousness is present in fewer than 10% of patients and posttraumatic amnesia in 25% of patients.46 In the absence of easily identifiable signs after concussion, an objective measure of mental status can significantly aid the AT in making the sideline diagnosis. Traditional questions of mental status involving questions of orientation about time (eg, what time is it?), location (eg, where are we?), and the person (eg, when is your birthday?) are ineffective in the sporting environment.111 The SAC was developed as a brief mental-status screening tool and is recommended for sideline use when comprehensive neurocognitive testing (see the next section) is not available or applicable. The SAC is a 5-minute test that evaluates the domains of orientation, immediate memory, concentration, and delayed 252 Volume 49 Number 2 April 2014 recall.23 As a stand-alone measure used immediately after concussion, the SAC is highly sensitive to injury; its sensitivity is further increased when used with a symptom inventory and motor-control test.20 Sensitivity of the SAC to concussion declines 24 hours after injury; thus, use of the test to evaluate cognitive functioning is not recommended beyond this point.20 Neurocognitive Testing. Neurocognitive testing has historically been viewed as the cornerstone of the concussion-assessment process,112 yet when used in isolation, this technique does not provide clinically adequate sensitivity to concussion.19,20,113 Therefore, neurocognitive testing should never be used in isolation but rather in conjunction with symptom and motor-control assessments to support the clinical examination. Historically, pencil-and-paper tests, such as the Digit Span, Controlled Oral Word Association Test, and Hopkins Verbal Learning tests, have been used to evaluate concussive injuries. Several computer-based platforms are now available, including the Automated Neuropsychological Assessment Metrics (ANAM), Cogstate Axon, Concussion Vital Signs, Headminder Concussion Resolution Index (CRI), and Immediate PostConcussion Assessment and Cognitive Testing (ImPACT). The testing protocol should evaluate those domains known to be affected by concussion: information processing, planning memory, and switching mental set.112 Similar to other assessment methods, neurocognitive testing has limitations,114 and the AT should become familiar with the benefits and limitations of the testing methods selected.19,113,115,116 Regardless of the instrumentation, the emphasis should be on maximizing performance on the baseline and postinjury assessments. The test should be explained to the athlete before the assessment begins, and a distractionfree testing environment should be provided.21 After the baseline assessment, test scores should be reviewed using the manufacturer’s validity criteria to ensure that the athletes gave maximal effort; those demonstrating suboptimal effort should retake the test.117 Once an athlete is injured, the AT and medical staff should limit the number of tests to time points that are critical to injury management to avoid performance improvements resulting from practice effects.118,119 Also, although some tests provide automated pass or fail scoring, these outputs may not accurately reflect the patient’s injury status and are not recommended for clinical use.86 A neuropsychologist or physician with specific concussion training should interpret the postinjury data.89 Diagnosing Concussion. Concussion diagnosis in the athletic environment can be difficult given the pressures and time restrictions of competition. Some sports allow for unlimited injury- evaluation time, but others do not. Regardless of the time allotment, the AT and the medical staff should never feel pressured to complete a concussion assessment. At the time of suspected injury, the initial evaluation should assess acute trauma. If the athlete is unable to leave the field under his or her own power, the AT should perform a primary survey, including evaluation of airway, breathing, and circulation (ie, the ABCs). Whether the patient is conscious or not, the AT should suspect and, if possible, rule out a cervical spine injury and other more severe injuries. Once no life-threatening injuries are determined to be present, the concussion examination should begin. Any athlete suspected of having a concussion should immediately be removed from participation and a systematic injury evaluation conducted. The intent of the concussion examination is to establish if the athlete should be removed from further participation. Regardless of the assessment measures used as part of the concussionmanagement protocol, the concussion diagnosis is made after a thorough clinical examination (Table 3). The clinical examination should include an injury history (including symptoms), observation of the patient, palpation for more severe orthopaedic or neurologic injury, and special tests for mental status and motor control (described earlier).120,121 Brief assessments that rely on the patient’s response to such simple questions such ‘‘Are you OK?’’ or ‘‘Can you go?’’ are not supported and should not be used. The concussion assessment conducted by the AT should be implemented in a consistent fashion as part of a comprehensive neurologic evaluation. When a physician is not readily available, the AT should be more conservative when interpreting the clinical-examination results and making the injury diagnosis. Transport to a medical facility for a concussion is not typically required but may be necessary if the patient is unconscious for a prolonged period of time (.1 minute), shows declining mental status during or after the injury evaluation, or demonstrates signs and symptoms of an injury more severe than a concussion. For a patient who is transported, the attending physician may recommend imaging to rule out injuries more severe than concussion, but computed tomography and magnetic resonance imaging add little to the concussion-evaluation process.7 Although other diagnostic techniques, such as functional magnetic resonance imaging,122 diffusion tensor imaging, magnetic resonance spectroscopy,2,123 serum biomarkers,124 and biomechanical techniques125,126 may be helpful in identifying and diagnosing concussion, their exclusive use as diagnostic tools has not been validated. Postinjury Management. Once an athlete has been diagnosed with a concussion, he or she should be removed from the sport and not allowed to return to physical activity until cleared by a physician or designate, no sooner than the next day. The patient should not be left unattended on the sideline, and mental status should be regularly monitored. A notable decline in mental status may reflect more severe trauma and indicate that transport to a medical facility is necessary. In most instances, however, the patient can be sent home with appropriate postinjury instructions (see the ‘‘Home Care’’ section). Once the concussion diagnosis has been made, a focused examination of the patient should be conducted daily to ensure a normal course of recovery. The magnitude of impact127,128 or postinjury decrements relative to preinjury testing should not be interpreted as a measure of injury severity or a predictor of how long the patient should be withheld from sport.129 Indeed, although the concept of grading injury severity based on such factors as the presence or absence of consciousness, symptom duration, and mental status has previously been supported,5 this is no longer the case. Each patient and each injury should be treated uniquely, focusing on cessation of symptoms and restoration of motor control, and neurocognitive test results should revert to preinjury levels before an RTP progression is implemented. During the acute recovery period, the patient should be instructed to avoid physical activity (eg, workouts, conditioning, physical education) and limit cognitive activity (eg, academic work, video games, computer use) so as to not exacerbate concussion symptoms. Physical activity during the acute phase can have a detrimental effect on recovery,130 but the effect of cognitive stress on concussion recovery is less clear. As such, limiting cognitive activities to avoid worsening concussion symptoms is favored over complete isolation of the patient, which may result in the exacerbation of concussion-like symptoms unrelated to the injury.131 Once the patient no longer reports concussion-related symptoms and the clinical examination is normal, then objective assessments should be repeated and compared with baseline performance. The patient’s reports of concussion-related symptoms are used as the primary measure to advance to the next stage in postconcussion management, so careful attention should be paid to steady resolution over time. In most instances, patients who no longer report concussion-related symptoms demonstrate preinjury performance levels on cognitive and motor control tests, but up to 40% of asymptomatic patients have continued cognitive declines.118,119 Therefore, the return-toactivity decision-making process should not begin until the patient no longer reports concussion-related symptoms, has a normal clinical examination, and performs at or above preinjury levels on measures of neurocognitive function and motor control. Although the duration of recovery demonstrated by individual patients on neurocognitive and motor-control tests varies, young adult males typically return to preinjury levels of functioning within 2 weeks.65 Female patients and younger patients may suffer from postinjury declines for 14 days or longer.36,132 Those reporting dizziness at the time of injury may have a protracted recovery,66 and those suffering from concussion symptoms beyond 30 days may be diagnosed with postconcussive syndrome.133 Some evidence suggests that normative data can be used for postinjury evaluations when baseline testing is not available.13 This scenario, however, is not ideal, and a more conservative injury-management strategy is warranted in these instances. During the recovery process, the AT should maintain regular contact with the directing physician to track the recovery and ensure that appropriate medical care is provided if recovery does not proceed normally. Return-to-Play Decision Making After an athlete is diagnosed with a concussion, the RTP progression should not start until he or she no longer reports concussion-related symptoms, has a normal clinical examination, and performs at or above preinjury levels of functioning on all objective concussion assessments. The exertion progression should follow the pattern outlined in Table 4; the typical time frame consists of 24 hours between levels.7 However, if activity at any stage results in a return of symptoms or a decline in test performance,134 then the activity should be immediately halted and restarted 24 hours later. The RTP timing is case dependent, but most patients diagnosed with a concussion can expect to be Journal of Athletic Training 253 Table 4. Return-to-Play Progression a Physical Activity Stage 1 2 3 4 5 6 a No activity Light exercise: ,70% age-predicted maximal heart rate Sport-specific activities without the threat of contact from others Noncontact training involving others, resistance training Unrestricted training Return to play Stages should be separated by at least 24 hours.7 withheld from competition for at least 1 week. The AT can lengthen the sequence if symptoms return during recovery or the patient has other comorbidities that may affect recovery. The directing physician can shorten the timeline when appropriate. Regardless, no patient diagnosed with concussion should return to physical activity on the day of injury. An extended RTP progression may be necessary if the patient is held out for an extended amount of time and requires reconditioning for sport participation. Other Considerations Equipment. It would seem natural that preventing concussion would include the appropriate use of protective equipment or other mechanisms. However, the literature to date does not support equipment as a means of concussion prevention. In a 2009 systematic review, Benson et al 29 evaluated 51 studies of protective equipment (helmets, headgear, mouthguards, face shields) to determine if any form of protective equipment was useful in preventing sport-related concussion. Their results suggest that helmet use can reduce the risk of more serious head (eg, skull fracture) and brain (eg, subdural hematoma) injuries in recreational sports such as skiing, snowboarding, and bicycling. Yet the ability of these devices to prevent concussion was inconclusive.29 The authors also assessed the use of mouthguards and face shields and found no strong evidence to suggest that either device decreases concussion risk.29 Nonetheless, some published evidence in ice hockey indicates that, compared with a half-face shield, a full face shield offers a better fit and protection that may decrease the time lost from competition after a concussion.29 More specifically, no differences were noted in the incidence of concussion between American football players135,136 or Australian rules footballers137 wearing custom or noncustom mouthguards. No differences in concussion incidence were seen in rugby, 138,139 ice hockey,140 or basketball141 players who did or did not wear mouthguards. In addition, researchers142 found no differences in neurocognitive impairment at the day-3 follow-up between athletes who reported wearing or not wearing a mouthguard at the time of concussion. The use of protective headgear to decrease the risk of concussion in rugby is inconclusive. One group143 found a decrease in the risk of concussion among English premier rugby athletes who wore headgear; however, in 3 studies139,144,145 of youth or college rugby athletes, no association was noted between wearing headgear and decreased risk of concussion. Studies of headgear use in soccer have largely been laboratory based and focused on biomechanical variables.146–148 In 1 investigation,149 a small decrease in self-reported concussions was demon254 Volume 49 Number 2 April 2014 strated in youth athletes wearing soccer headgear, but these results have not been replicated. Pediatric Concussion. Sport-related concussion is a significant concern in the pediatric population. Data from the National Electronic Injury Surveillance System (NEISS) estimated that concussions in 8- to 19-year-olds resulted in more than 500 000 visits to the emergency department, with close to half (252 807 visits) resulting from a sport-related mechanism. 150 Sport-related concussions –accounted for 58% of all emergency department visits in children (8–13 years old) and 46% of all concussions in adolescents (14–19 years old).150 Similarly, data from the National Hospital Ambulatory Medical Care Survey 43 showed 144 000 emergency department visits for concussion in youth and adolescents (0–19 years old) over a 5-year period (2002–2006). Sportrelated concussion was the most common mechanism, accounting for 30% of all concussions in persons between 5 and 19 years old.45 In high school athletes, Powell and Barber-Foss151 reported that AT-diagnosed concussions accounted for 5.5% of all sports injuries. More recently, data from High School Reporting Information Online (RIO) indicated that concussions in interscholastic athletes were responsible for 8.9% of all athletic injuries67 and that the overall concussion incidence rate according to RIO was 0.23 concussions per 1000 athlete exposures, with a game rate of 0.53 and a practice rate of 0.11 per 1000 athlete exposures. Structural brain development occurs during childhood and adolescence with increased brain volume and connectivity, as reflected by increased white matter volume, which is apparent on magnetic resonance imaging.152,153 Younger athletes may be more vulnerable to concussion because of this structural immaturity, coupled with less myelination, thinner frontal and temporal bones, a greater head-to-body ratio, and weaker neck musculature.154–157 Furthermore, functional brain immaturity is present through early adulthood; the brain continues to mature in areas responsible for cognitive processing, such as attention and concentration, learning and memory, reasoning, and executive function.16,158 Thus, neurocognitive performance would be expected to change at least until the age of 20 years, requiring baseline levels of cognitive performance to be reassessed periodically, so that they can be compared with postinjury results. The susceptibility of a child or adolescent to prolonged recovery after concussion may result from the fact that the developing functions of the immature brain are more vulnerable than established functions. Some have also postulated that injury to the brain might interfere with the complex biological processes needed for brain development.1,159–162 Concussed high school players took longer to recover from memory dysfunction than did concussed college players.36 Prolonged neurocognitive recovery has also been reported in other studies of high school athletes.163,164 Additionally, high school athletes with a history of 2 or more concussions demonstrated poorer cognitive recovery.163 However, to date, little evidence is available regarding postconcussion recovery in patients younger than high school age. A primary concern of premature RTP among pediatric athletes is diffuse cerebral swelling with delayed catastrophic deterioration, commonly referred to as second- impact syndrome or malignant cerebral edema. The presence of second-impact syndrome has been debated,165,166 but in rare circumstances, cerebral swelling or edema can occur after injury to an immature brain.162,167,168 Although there may be controversy regarding the need for a second insult to cause the cerebral swelling, there is agreement that this diffuse cerebral swelling occurs more often in patients with immature brains. The 2012 Zurich consensus statement on management of concussion in sport7 and the 2010 American Academy of Pediatrics’ clinical report on sport-related concussion in children and adolescents169 recommended a multifaceted approach to concussion management in pediatric athletes. Yet, some special concerns are relevant to younger athletes. When assessing a concussed child or adolescent, it is important to obtain input from not only the patient but also from parents, health care providers, and teachers, as they may have additional information about the patient’s preinjury and postinjury behavior that can be useful in the clinical evaluation and management plan.38 Assessing the patient’s symptoms is advocated as a key aspect of concussion management. Numerous symptom checklists and scales have been developed for use in athletic populations,170 and children and adolescents can reliably report concussion-related symptoms.171–173 However, the Zurich consensus panel7 suggested that children younger than 10 years may report concussion symptoms differently from adults; therefore, age-appropriate symptom checklists may be needed to track symptoms after a suspected concussion. In light of this, the Health and Behavior Inventory –Child Version,174 was developed by the National Institutes of Health–National Institute of Neurological Disorders and Stroke to evaluate younger persons. The use of concussion-symptom scales is more appropriate for adolescents (ages 13–22 years) than for children (ages 5–12 years), and research has addressed validity as opposed to reliability.38 The addition of reliable and valid parental reports of postconcussion symptoms is an important adjunct to the report of the child or adolescent. However, in high school athletes, neurocognitive deficits may exist despite the resolution of self-report symptoms,36 suggesting that self-report symptoms should not be the only means of assessment. Assessment of motor control and neurocognitive function is also important and may be useful in pediatric athletes.16,164,175 The method and timing of baseline assessments in children and adolescents require careful consideration because of the cognitive and neuromuscular maturation that occurs during this time.176–179 Hunt and Ferrara16 found that neurocognitive test scores differed between 9th- and 10th-grade students. Therefore, they recommended at least 2 baseline tests for high school athletes: the first as an incoming freshman and the second before sophomore year. A similar trend was noted with the Sport Concussion Assessment Tool-2 (SCAT-2): scores among 9th graders were lower than those among 11th and 12th graders.180 Lastly, improvements in neurocognitive performance were seen between the ages of 9 and 15 years, suggesting that baseline testing should be done every 6 months, or at least annually, until the age of 15.176 Although a person’s own baseline measurements are the best values for postinjury comparisons, repeated baseline assessments may not be feasible because of administration time, cost, and effort. In these cases, using age-matched norms to supplement the clinical examination plus the patient’s self-report and parental report of symptoms may be more cost effective.13 Despite the challenges of obtaining baseline neurocognitive or balance assessments in this younger age group, having baseline and postinjury neurocognitive scores can be valuable for managing potential school-related difficulties, such as focusing attention, learning and retaining new information, and managing multiple academic learning demands. The results of specific domain tests (eg, working memory, concentration, new learning and memory retention, and processing speed) can be useful in working with teachers and guidance counselors to develop strategies for successful academic outcomes. For example, temporary accommodations, including the use of written instructions, shorter assignments, and extended time for assignments, might be considered for students recovering from concussion. Home Care. After a concussion diagnosis, a comprehensive medical management plan should be implemented that follows the institution’s concussion policy and includes communication among all those involved. This plan should include the family (ie, patient and parents), school personnel (ie, teachers, administrators, counselors, coaches), school medical personnel (ie, AT, school nurse), and community referral sources (ie, team physician, other health care referral sources). Communication among all these groups is essential for appropriate management of a concussed athlete. The home care plan should include frequent follow-up assessments and continued monitoring of concussion signs and symptoms.5,7 Patients and their parents or roommates should be provided with a list of signs and symptoms that would indicate a deteriorating condition and warrant immediate referral to the emergency department (Table 5). The patient, or a responsible person, should also be provided with a concussion instruction form (Appendix A) and instructed to follow up with the AT the next day he or she is at school. Medications and Diet. Limited evidence suggests that any medication is beneficial in accelerating the concussionrecovery process. All current medications should be reviewed by the physician, and concussed patients should avoid taking medications containing aspirin or nonsteroidal anti-inflammatory drugs. These medications are known to decrease platelet function and may increase intracranial bleeding, mask the severity and duration of symptoms, and possibly lead to a more severe injury. Acetaminophen may be used sparingly to ease headaches after concussion. During the acute stage of injury, the patient should avoid ingesting other substances that can affect central nervous system function, including alcohol and narcotics, and should be instructed to eat a well-balanced, nutritious diet. During the subacute stage of recovery, the physician may prescribe medications to reduce specific symptoms, such as headache, sleep disturbances, or anxiety, or to improve symptom resolution.7,45 Additionally, medication may be prescribed if the symptoms are affecting broader aspects of the person’s life such that the potential benefit of the medication is greater than the possible risks.45 Pharmacologic management of sport-related concussion should be directed only by those physicians with experience treating Journal of Athletic Training 255 Table 5. Observable Red-Flag Items That Warrant Immediate Referral to the Emergency Department via Emergency Medical Transport Decreasing level of consciousness Increasing confusion Increasing irritability Loss of or fluctuating level of consciousness Numbness in the arms or legs Pupils becoming unequal in size Repeated vomiting Seizures Slurred speech or inability to speak Inability to recognize people or places Worsening headache concussive injuries who are able to justify the benefit-torisk ratio. One important consideration with respect to postconcussion medication use is that the patient should be asymptomatic when not on the medication before beginning an RTP progression.7 Rest. A concussed patient who returns home after the sport event should be monitored by a responsible adult and should have a good night’s rest. In general, the patient does not need to be awakened during the night unless he or she experienced loss of consciousness, prolonged periods of amnesia, or significant symptoms before going to bed.5 Should the AT or physician prescribe nighttime waking, the responsible adult should be provided with instructions on when to wake the patient and what to observe during periods of waking. During the acute recovery period, physical rest and cognitive rest are indicated while the patient is symptomatic.7,28,39,42 While symptomatic, the patient should avoid physical exertion, including physical education classes and recreational activities. Activities of daily living that do not exacerbate symptoms may be beneficial to the patient’s recovery and should be allowed.130 When mental activities exacerbate symptoms, cognitive rest, including temporary academic accommodations (see the next paragraph), should be part of the concussion-management plan.7,28,39,42 Alterations in the amount of cognitive and physical rest should be made on an individual basis as the patient’s symptom reports and adjunct assessment scores (ie, cognitive test scores) change during recovery. The concept of cognitive rest was initially presented in the Prague consensus document181 and was reiterated in the Zurich consensus statement7 and the American Academy of Pediatrics Clinical Report.169 Cognitive rest refers to limiting academic and cognitive stressors in activities of daily living and school activities while the patient recovers from the concussion. Cognitive rest is part of a spectrum that ranges from very limited cognitive activity (ie, absent from school) to full cognitive activity (ie, full school attendance). The goal of cognitive rest is to keep the brain from engaging in mental challenges that will increase symptoms during the postconcussion stage.7,42,179 Most concussed patients require some amount of cognitive rest to ensure resolution of symptoms and recovery from the concussion. The type and amount of cognitive rest are individualized but may take the form of limiting mental exertion, including reading, writing, mathematical computation, and computer work. Limiting social activities requiring concentrated cognitive activity should also be 256 Volume 49 Number 2 April 2014 considered, such as watching television, text messaging, playing video games, and listening to loud music. Communication among the medical providers, parents and patient, and school personnel (such as the school nurse, counselors, administrators, and teachers) is crucial to providing temporary accommodations that allow cognitive rest.42 To date, however, little empirical evidence supports the utility and efficacy of cognitive rest on recovery outcomes after concussion. Moderate levels of supervised exertion (eg, participating in school and light physical activity) during recovery were associated with better visual memory and reaction time outcomes and may be beneficial to recovery.130 Multiple Concussions. Similar to other types of injuries, the best predictor of subsequent concussion is a history of at least 1 concussion. Among collegiate football players, patients who self-reported 3 or more concussions were 3.5 times more likely to sustain a subsequent injury than players with no concussion history, whereas those with 2 concussions were 2.8 times more likely.46 An increased risk for subsequent concussions in high school athletes with a history of concussion has also been reported. In a prospective investigation,182 football players with a concussion history were nearly 3 times more likely to sustain another injury, whereas nonfootball players were 1.2 times more likely. Therefore, current recommendations7,47 suggest that modifying factors, including repeated concussions over time, multiple concussions within a short time frame, sustaining concussions with lessening force, or increasing severity of injury, should result in a more conservative management approach. Proper management of a concussion will reduce the risk of a repeat injury.183 Second-Impact Syndrome. A primary concern of premature RTP by pediatric athletes is second-impact syndrome, or malignant cerebral edema, which occurs after a second impact while the patient is still symptomatic from a previous injury to the head or body. The condition is characterized by diffuse cerebral swelling with catastrophic deterioration.1,48–50 Long-Term Consequences. The relationship between concussion and long-term cognitive health is not clear. A number of cross-sectional investigations184–186 have shown no chronic changes in neurocognitive functioning after concussion in a young adult population. Others, however, have shown changes to neurocognitive functioning,187,188 brain function,189–191 neuroelectrical activity,192–195 and motor control.196,197 Yet none of these authors reported an association between the declines and clinical impairment. Results of surveys51–53,198 of former professional athletes, however, have suggested the potential for cumulative concussive and subconcussive impacts over an athlete’s playing career to be associated with late-life cognitive impairment, depression, and chronic traumatic encephalopathy. Indeed, retired professional football players with a self-reported history of 3 or more concussions were 3 times more likely and those with a history of 1 or 2 concussions were 1.5 times more likely to be diagnosed with depression than their peers who did not report concussions.51 Similarly, a preliminary report52 has associated retired professional football players who sustained 3 or more concussions with mild cognitive impairment and self-reported significant memory impairments. Others53,199,200 have speculated that exposure to concussive and subconcussive impacts may lead to chronic traumatic encephalopathy, a progressive neurodegenerative disorder that results in a buildup of tau proteins in the brain. In large part, persons reporting clinical impairments thought to be associated with concussion are former professional athletes with a uniquely high level of exposure to contact and collision sports that may have been moderated by a number of other intrinsic (eg, genetic profile) and extrinsic (eg, lifestyle) factors.201 In addition, longitudinal research that can directly associate concussive and subconcussive impacts with cognitive health, while controlling for normal age-related declines and other factors, has not been completed. As such, the relationship among concussion, subconcussive impacts, and long-term brain health is not clear. These studies are viewed as preliminary; additional research is needed to adequately address this association. SUMMARY This document is intended to provide clinical ATs with best-practice guidelines for concussion management based on recommendations derived from the most recent research. The best approach to concussion management involves the entire sports medicine team. The AT should spearhead the development of a detailed written plan outlining the concussion-management strategy and share it with administrators and coaches. The plan should include a baseline evaluation of athletes, including a neurologic history with symptoms and physical examination and objective measures of neurocognitive performance and motor control. Once the concussion diagnosis has been made, the patient should be immediately removed from further participation for at least 24 hours. Follow-up testing, using the same protocol as the baseline examination, can aid in determining when to start the return to physical activity after the patient is cleared by a physician or designate. Lastly, although most concussions resolve in a relatively short time frame, patients who are young, who have had multiple concussions, or who have premorbid factors may require additional attention. The AT should be familiar with these concerns, as well as the potential for long-term consequences, and account for them in the concussion-management plan. ACKNOWLEDGMENTS We gratefully acknowledge the efforts of Barry P. Boden, MD; Randall Cohen, DPT, ATC; Michael W. Collins, PhD; Ruben Echemendia, PhD: Michael S. Ferrara, PhD, ATC, FNATA; James S. Galloway, ATC; Margot Putukian, MD; and the Pronouncements Committee in the review of this document. DISCLAIMER The NATA and NATA Foundation publish position statements as a service to promote the awareness of certain issues to their members. The information contained in the position statement is neither exhaustive nor exclusive to all circumstances or individuals. Variables such as institutional human resource guidelines, state or federal statutes, rules, or regulations, as well as regional environmental conditions, may impact the relevance and implementation of these recommendations. The NATA and NATA Foundation advise members and others to carefully and independently consider each of the recommendations (including the applicability of same to any particular circumstance or individual). The position statement should not be relied upon as an independent basis for care but rather as a resource available to NATA members or others. Moreover, no opinion is expressed herein regarding the quality of care that adheres to or differs from the NATA and NATA Foundation position statements. The NATA and NATA Foundation reserve the right to rescind or modify its position statements at any time. REFERENCES 1. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36(3):228–235. 2. Vagnozzi R, Signoretti S, Cristofori L, et al. 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Representative baseline values on the Sport Concussion Assessment Tool 2 (SCAT2) in adolescent athletes vary by gender, grade, and concussion history. Am J Sports Med. 2012;40(4):927–933. 181. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Journal of Athletic Training 261 182. 183. 184. 185. 186. 187. 188. 189. 190. 262 Concussion in Sport, Prague 2004. Br J Sports Med. 2005;39(4):196–204. Schulz MR, Marshall SW, Mueller FO, et al. Incidence and risk factors for concussion in high school athletes, North Carolina, 1996–1999. Am J Epidemiol. 2004;160(10):937–944. Cantu RC, Register-Mihalik JK. Considerations for return-to-play and retirement decisions after concussion. PM R. 2011;3(10 suppl 2):S440–S444. Broglio SP, Ferrara MS, Piland SG, Anderson RB, Collie A. Concussion history is not a predictor of computerized neurocognitive performance. Br J Sports Med. 2006;40(9):802–805. Collie A, McCrory P, Makdissi M. Does history of concussion affect current cognitive status? Br J Sports Med. 2006;40(6):550– 551. Iverson GL, Brooks BL, Lovell MR, Collins MW. No cumulative effects for one or two previous concussions. Br J Sports Med. 2006;40(1):72–75. De Beaumont L, Theoret H, Mongeon D, et al. Brain function decline in healthy retired athletes who sustained their last sports concussion in early adulthood. Brain. 2009;132(pt 3):695–708. Ellemberg D, Leclerc S, Couture S, Daigle C. Prolonged neuropsychological impairments following a first concussion in female university soccer athletes. Clin J Sport Med. 2007;17(5):369–374. Breedlove EL, Robinson M, Talavage TM, et al. Biomechanical correlates of symptomatic and asymptomatic neurophysiological impairment in high school football. J Biomech. 2012;45(7):1265– 1272. Talavage TM, Nauman E, Breedlove EL, et al. Functionallydetected cognitive impairment in high school football players without clinically-diagnosed concussion. J Neurotrauma. http:// online.liebertpub.com/doi/full/10.1089/neu.2010.1512. Published online ahead of print April 11, 2013. Accessed August 30, 2013. Volume 49 Number 2 April 2014 191. Bazarian JJ, Zhu T, Blyth B, Borrino A, Zhong J. Subject-specific changes in brain white matter on diffusion tensor imaging after sports-related concussion. Magn Reson Imaging. 2012;30(2):171– 180. 192. Broglio SP, Pontifex MB, O’Connor P, Hillman CH. The persistent effects of concussion on neuroelectic indices of attention. J Neurotrauma. 2009;26(9):1463–1470. 193. Pontifex MB, O’Connor PM, Broglio SP, Hillman CH. The association between mild traumatic brain injury history and cognitive control. Neuropsychologia. 2009;47(14):3210–3216. 194. Gaetz M, Goodman D, Weinberg H. Electrophysiological evidence for the cumulative effects of concussion. Brain Inj. 2000;14(12):1077–1088. 195. Dupuis F, Johnston KM, Lavoie M, Lepore F, Lassonde M. Concussion in athletes produce brain dysfunction as revealed by event-related potentials. Neuroreport. 2000;11(18):4087–4092. 196. Sosnoff JJ, Broglio SP, Shin S, Ferrara MS. Previous mild traumatic brain injury and postural control dynamics. J Athl Train. 2011;46(1):85–91. 197. Martini DN, Sabin MJ, DePesa SA, et al. The chronic effects of concussion on gait. Arch Phys Med Rehabil. 2011;92(4):585–589. 198. Gavett BE, Stern RA, McKee AC. Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. Clin Sports Med. 2011;30(1):179– 188. 199. Omalu BI, DeKosky ST, Hamilton RL, et al. Chronic traumatic encephalopathy in a National Football League player, part II. Neurosurgery. 2006;59(5):1086––1092. 200. Omalu BI, DeKosky ST, Minster RL, Kamboh MI, Hamilton RL, Wecht CH. Chronic traumatic encephalopathy in a National Football League player. Neurosurgery. 2005;57(1):128–134. 201. Broglio SP, Eckner JT, Paulson H, Kutcher JS. Cognitive decline and aging: the role of concussive and sub-concussive impacts. Exerc Sport Sci Rev. 2012;40(3):138–144. Appendix A. Sample Postconcussion Home Care Instructions I believe that sustained a concussion on To make sure he or she recovers, please follow the following important recommendations: 1. must report to the athletic training facility on at for a follow-up evaluation. 2. If any of the problems below develop before the follow?up Visit, please call at or contact the local emergency medical system or your family physician. Decreasing level of consciousness Increasing confusion Increasing irritability Loss of or ?uctuating level of consciousness Numbness in the arms or legs Pupils becoming unequal in size Repeated vomiting Seizures Slurred speech or inability to speak Inability to recognize people or places Worsening headache Otherwise, you can follow the instructions outlined below. It is OK to Use acetaminophen (Tylenol) for headaches Use ice pack on head and neck as needed for comfort Eat a carbohydrate-rich diet Go to sleep Rest (no strenuous activity or sports) There is 0 need to Check eyes with ?ashlight Wake up frequently (unless otherwise instructed) Test re?exes Stay in bed Do NOT Drink alcohol Drive a car or operate machinery Engage in physical activity (eg, exercise, weight lifting, physical education, sport participation) that makes worse Engage in mental activity (eg, school, job, homework, computer games) that makes worse Other recommendations: Recommendations provided to: Please feel free to contact me if you have any questions. I can be reached at Please follow up in the athletic training facility on Recommendations provided by: Signature: (date). Date: Journal of Athletic Training 263 Appendix B. 264 Sample Information for Patients, Parents, and Legal Custodians About Concussion Volume 49 Number 2 April 2014 Concussion Information Sheet for the Patient and Parent or Legal Custodian *If there is anything on this sheet that you do not understand, please ask an adult to explain or read it to you. Patient Name: his form must be completed for each patient, even if there are multiple patients in the household. Parent or Legal Custodian Name(s): I: We have read the ?Patient and Parent or Legal Custodian Concussion Information Sheet. If true, please check box. After reading the information sheet, I am aware of the following information: Patient Parent or Legal Initials Custodian Initials A concussion is a brain injury, which should be reported to my parents, my coach(es), or a medical professional if one is available. A concussion can affect the ability to perform everyday activities such as the ability to think, balance, and perform in the classroom. A concussion cannot be ?seen.? Some might be present right away. Other can show up hours or days after an injury. I will tell my parents, my coach, or a medical professional about my injuries Not applicable and illnesses. If I think a teammate has a concussion, I should tell my coach(es), parents, or a Not applicable medical professional. I will not return to play in a game or practice if a hit to my head or body causes Not applicable any concussion-related I will/my child will need written permission from a medical professional trained in concussion management to return to play or practice after a concussion. According to the latest data, most concussions take days or weeks to get better. A concussion may not go away right away. I realize that resolution from this injury is a process and may require more than 1 medical evaluation. I realize that emergency department or urgent care physicians will not provide clearance if the patient is seen right away after the injury. After a concussion, the brain needs time to heal. I understand that I am/my child is much more likely to have another concussion or more serious brain injury if return to play or practice occurs before concussion go away. Sometimes, repeat concussions can cause serious and long-lasting problems. I have read and understand the concussion on the Concussion lnforrnation Sheet. Signature of Patient Date Signature of Parent or Legal Custodian Date Journal of Athletic Training 265 August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 APPENDIX F- SCAT2, SCAT3, AND MODIFIED BESS Downloaded from bjsm.bmj.com on 13 May 2009 SCAT2 Sport Concussion Assessment Tool 2 Symptom Evaluation name How do you feel? You should score yourself on the following symptoms, based on how you feel now. Sport / team none Date / time of injury Date / time of assessment Age Gender n M n F Years of education completed examiner What is the SCAT2?1 This tool represents a standardized method of evaluating injured athletes for concussion and can be used in athletes aged from 10 years and older. It supersedes the original SCAT published in 20052. This tool also enables the calculation of the Standardized Assessment of Concussion (SAC)3, 4 score and the Maddocks questions5 for sideline concussion assessment. Instructions for using the SCAT2 The SCAT2 is designed for the use of medical and health professionals. Preseason baseline testing with the SCAT2 can be helpful for interpreting post-injury test scores. Words in Italics throughout the SCAT2 are the instructions given to the athlete by the tester. This tool may be freely copied for distribtion to individuals, teams, groups and organizations. What is a concussion? A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of nonspecific symptoms (like those listed below) and often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following: • Symptoms (such as headache), or • Physical signs (such as unsteadiness), or • Impaired brain function (e.g. confusion) or • Abnormal behaviour. Any athlete with a suspected concussion should be REMOVED FROM PLAY, medically assessed, monitored for deterioration (i.e., should not be left alone) and should not drive a motor vehicle. mild moderate severe Headache 0 1 2 3 4 5 6 “Pressure in head” 0 1 2 3 4 5 6 neck Pain 0 1 2 3 4 5 6 nausea or vomiting 0 1 2 3 4 5 6 Dizziness 0 1 2 3 4 5 6 Blurred vision 0 1 2 3 4 5 6 Balance problems 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 Feeling slowed down 0 1 2 3 4 5 6 Feeling like “in a fog“ 0 1 2 3 4 5 6 “Don’t feel right” 0 1 2 3 4 5 6 Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6 Fatigue or low energy 0 1 2 3 4 5 6 Confusion 0 1 2 3 4 5 6 Drowsiness 0 1 2 3 4 5 6 Trouble falling asleep (if applicable) 0 1 2 3 4 5 6 More emotional 0 1 2 3 4 5 6 Irritability 0 1 2 3 4 5 6 Sadness 0 1 2 3 4 5 6 nervous or Anxious 0 1 2 3 4 5 6 Total number of symptoms (Maximum possible 22) Symptom severity score (Add all scores in table, maximum possible: 22 x 6 = 132) Do the symptoms get worse with physical activity? Do the symptoms get worse with mental activity? n n Y Y Overall rating If you know the athlete well prior to the injury, how different is the athlete acting compared to his / her usual self? Please circle one response. no different SCAT2 SPorT ConCuSSIon ASSeSMenT Tool 2 PAgE 1 very different unsure i85 Downloaded from bjsm.bmj.com on 13 May 2009 Cognitive & Physical Evaluation 1 Symptom score (from page 1) 5 of 22 22 minus number of symptoms Cognitive assessment Standardized Assessment of Concussion (SAC) Orientation (1 point for each correct answer) 2 Physical signs score Was there loss of consciousness or unresponsiveness? minutes If yes, how long? Was there a balance problem / unsteadiness? Y n Y n of 2 Physical signs score (1 point for each negative response) 3 glasgow coma scale (gCS) Best eye response (E) no eye opening eye opening in response to pain eye opening to speech eyes opening spontaneously 1 2 3 4 Best verbal response (V) no verbal response Incomprehensible sounds Inappropriate words Confused oriented 1 2 3 4 5 Best motor response (M) no motor response extension to pain Abnormal flexion to pain Flexion / Withdrawal to pain localizes to pain obeys commands 1 2 3 4 5 6 Trials 2 & 3: “I am going to repeat the same list again. Repeat back as many words as you can remember in any order, even if you said the word before.“ Complete all 3 trials regardless of score on trial 1 & 2. read the words at a rate of one per second. Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the athlete that delayed recall will be tested. list elbow apple carpet saddle bubble Total Modified Maddocks questions (1 point for each correct answer) 1 1 1 1 1 of 5 Maddocks score Maddocks score is validated for sideline diagnosis of concussion only and is not included in SCAT 2 summary score for serial testing. 2 This tool has been developed by a group of international experts at the 3rd International Consensus meeting on Concussion in Sport held in Zurich, Switzerland in november 2008. The full details of the conference outcomes and the authors of the tool are published in British Journal of Sports Medicine, 2009, volume 43, supplement 1. The outcome paper will also be simultaneously co-published in the May 2009 issues of Clinical Journal of Sports Medicine, Physical Medicine & rehabilitation, Journal of Athletic Training, Journal of Clinical neuroscience, Journal of Science & Medicine in Sport, neurosurgery, Scandinavian Journal of Science & Medicine in Sport and the Journal of Clinical Sports Medicine. McCrory P et al. Summary and agreement statement of the 2 International Conference on Concussion in Sport, Prague 2004. British Journal of Sports Medicine. 2005; 39: 196-204 i86 nd Trial 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Alternative word list candle paper sugar sandwich wagon baby monkey perfume sunset iron finger penny blanket lemon insect of 15 Concentration Digits Backward: “I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.” Alternative digit lists “I am going to ask you a few questions, please listen carefully and give your best effort.” 0 0 0 0 0 Trial 2 If correct, go to next string length. If incorrect, read trial 2. one point possible for each string length. Stop after incorrect on both trials. The digits should be read at the rate of one per second. Sideline Assessment – Maddocks Score At what venue are we at today? Which half is it now? Who scored last in this match? What team did you play last week / game? Did your team win the last game? Trial 1 Immediate memory score of 15 glasgow Coma score (E + V + M) 1 of 5 Orientation score Immediate memory “I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order.” GCS should be recorded for all athletes in case of subsequent deterioration. 4 1 1 1 1 1 0 0 0 0 0 What month is it? What is the date today? What is the day of the week? What year is it? What time is it right now? (within 1 hour) 4-9-3 3-8-1-4 6-2-9-7-1 7-1-8-4-6-2 0 0 0 0 1 1 1 1 6-2-9 3-2-7-9 1-5-2-8-6 5-3-9-1-4-8 5-2-6 1-7-9-5 3-8-5-2-7 8-3-1-9-6-4 4-1-5 4-9-6-8 6-1-8-4-3 7-2-4-8-5-6 Months in Reverse Order: “Now tell me the months of the year in reverse order. Start with the last month and go backward. So you’ll say December, November ... Go ahead” 1 pt. for entire sequence correct Dec-nov-oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan 0 Concentration score 1 of 5 3 McCrea M. Standardized mental status testing of acute concussion. Clinical Journal of Sports Medicine. 2001; 11: 176-181 4 McCrea M, randolph C, Kelly J. Standardized Assessment of Concussion: Manual for administration, scoring and interpretation. Waukesha, Wisconsin, uSA. 5 Maddocks, Dl; Dicker, GD; Saling, MM. The assessment of orientation following concussion in athletes. Clin J Sport Med. 1995;5(1):32–3 6 Guskiewicz KM. Assessment of postural stability following sport-related concussion. Current Sports Medicine reports. 2003; 2: 24-30 SCAT2 SPorT ConCuSSIon ASSeSMenT Tool 2 PAgE 2 Downloaded from bjsm.bmj.com on 13 May 2009 6 7 Balance examination This balance testing is based on a modified version of the Balance error Scoring System (BeSS)6. A stopwatch or watch with a second hand is required for this testing. Upper limb coordination Finger-to-nose (FTn) task: “I am going to test your coordination now. Please sit comfortably on the chair with your eyes open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow and fingers extended). When I give a start signal, I would like you to perform five successive finger to nose repetitions using your index finger to touch the tip of the nose as quickly and as accurately as possible.” Balance testing “I am now going to test your balance. Please take your shoes off, roll up your pant legs above ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of three twenty second tests with different stances.“ (c) Tandem stance: “Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly distributed across both feet. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.” Balance testing – types of errors 1. Hands lifted off iliac crest 2. opening eyes 3. Step, stumble, or fall 4. Moving hip into > 30 degrees abduction 5. lifting forefoot or heel 6. remaining out of test position > 5 sec left Scoring: right 5 correct repetitions in < 4 seconds = 1 note for testers: Athletes fail the test if they do not touch their nose, do not fully extend their elbow or do not perform five repetitions. Failure should be scored as 0. of 1 Coordination score 8 Cognitive assessment Standardized Assessment of Concussion (SAC) Delayed recall “Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order.“ Circle each word correctly recalled. Total score equals number of words recalled. list elbow apple carpet saddle bubble Alternative word list candle paper sugar sandwich wagon baby monkey perfume sunset iron finger penny blanket lemon insect of 5 Delayed recall score Overall score Test domain each of the 20-second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the athlete. The examiner will begin counting errors only after the individual has assumed the proper start position. The modified BESS is calculated by adding one error point for each error during the three 20-second tests. The maximum total number of errors for any single condition is 10. If a athlete commits multiple errors simultaneously, only one error is recorded but the athlete should quickly return to the testing position, and counting should resume once subject is set. Subjects that are unable to maintain the testing procedure for a minimum of five seconds at the start are assigned the highest possible score, ten, for that testing condition. Which foot was tested: left Which arm was tested: (a) Double leg stance: “The first stance is standing with your feet together with your hands on your hips and with your eyes closed. You should try to maintain stability in that position for 20 seconds. I will be counting the number of times you move out of this position. I will start timing when you are set and have closed your eyes.“ (b) Single leg stance: “If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now stand on your non-dominant foot. The dominant leg should be held in approximately 30 degrees of hip flexion and 45 degrees of knee flexion. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.“ Coordination examination right (i.e. which is the non-dominant foot) Condition Total errors Double leg Stance (feet together) Single leg stance (non-dominant foot) Tandem stance (non-dominant foot at back) of 10 of 10 of 10 Balance examination score (30 minus total errors) of 30 Score Symptom score Physical signs score Glasgow Coma score (e + V + M) Balance examination score Coordination score Subtotal of 22 of 2 of 15 of 30 of 1 of 70 orientation score Immediate memory score Concentration score Delayed recall score SAC subtotal of 5 of 5 of 15 of 5 of 30 SCAT2 total of 100 Maddocks Score of 5 Definitive normative data for a SCAT2 “cut-off” score is not available at this time and will be developed in prospective studies. embedded within the SCAT2 is the SAC score that can be utilized separately in concussion management. The scoring system also takes on particular clinical significance during serial assessment where it can be used to document either a decline or an improvement in neurological functioning. Scoring data from the SCAT2 or SAC should not be used as a stand alone method to diagnose concussion, measure recovery or make decisions about an athlete’s readiness to return to competition after concussion. SCAT2 SPorT ConCuSSIon ASSeSMenT Tool 2 PAgE 3 i87 Downloaded from bjsm.bmj.com on 13 May 2009 Athlete Information Any athlete suspected of having a concussion should be removed from play, and then seek medical evaluation. Signs to watch for Return to play Problems could arise over the first 24-48 hours. You should not be left alone and must go to a hospital at once if you: • Have a headache that gets worse • Are very drowsy or can’t be awakened (woken up) • Can’t recognize people or places • Have repeated vomiting • Behave unusually or seem confused; are very irritable • Have seizures (arms and legs jerk uncontrollably) • Have weak or numb arms or legs • Are unsteady on your feet; have slurred speech Athletes should not be returned to play the same day of injury. When returning athletes to play, they should follow a stepwise symptom-limited program, with stages of progression. For example: 1. rest until asymptomatic (physical and mental rest) 2. light aerobic exercise (e.g. stationary cycle) 3. sport-specific exercise 4. non-contact training drills (start light resistance training) 5. full contact training after medical clearance 6. return to competition (game play) There should be approximately 24 hours (or longer) for each stage and the athlete should return to stage 1 if symptoms recur. resistance training should only be added in the later stages. Medical clearance should be given before return to play. Remember, it is better to be safe. Consult your doctor after a suspected concussion. Tool Test domain Time Score Date tested Days post injury SCAT2 SAC Total Symptom score Physical signs score Glasgow Coma score (e + V + M) Balance examination score Coordination score orientation score Immediate memory score Concentration score Delayed recall score SAC Score SCAT2 Symptom severity score (max possible 132) Return to play n Y n n n Y n n n Y n n n Y n n Additional comments Concussion injury advice (To be given to concussed athlete) This patient has received an injury to the head. A careful medical examination has been carried out and no sign of any serious complications has been found. It is expected that recovery will be rapid, but the patient will need monitoring for a further period by a responsible adult. Your treating physician will provide guidance as to this timeframe. If you notice any change in behaviour, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please telephone the clinic or the nearest hospital emergency department immediately. Patient’s name Date / time of injury Date / time of medical review Treating physician Other important points: • • • • Rest and avoid strenuous activity for at least 24 hours No alcohol No sleeping tablets Use paracetamol or codeine for headache. Do not use aspirin or anti-inflammatory medication • Do not drive until medically cleared • Do not train or play sport until medically cleared Contact details or stamp Clinic phone number i88 SCAT2 SPorT ConCuSSIon ASSeSMenT Tool 2 PAgE 4 Downloaded from bjsm.bmj.com on March 11, 2013 - Published by group.bmj.com SCAT3 ™ Sport Concussion Assessment Tool – 3rd Edition For use by medical professionals only Name Date Time of Injury: Date of Assessment: What is the SCAT3?1 The SCAT3 is a standardized tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older. It supersedes the original SCAT and the SCAT2 published in 2005 and 2009, respectively 2. For younger persons, ages 12 and under, please use the Child SCAT3. The SCAT3 is designed for use by medical professionals. If you are not SualiƂed, please use the Sport Concussion Recognition Tool1. Preseason baseline testing with the SCAT3 can be helpful for interpreting post-injury test scores. SpeciƂc instructions for use of the SCAT3 are provided on page 3. If you are not familiar with the SCAT3, please read through these instructions carefully. This tool may be freely copied in its current form for distribution to individuals, teams, groups and organizations. Any revision or any reproduction in a digital form requires approval by the Concussion in Sport Group. NOTE: The diagnosis of a concussion is a clinical judgment, ideally made by a medical professional. The SCAT3 should not be used solely to make, or exclude, the diagnosis of concussion in the absence of clinical judgement. An athlete may have a concussion even if their SCAT3 is “normal”. What is a concussion? A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-speciƂc signs and or symptoms some examples listed below) and most often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following: - Examiner: 1 Glasgow coma scale (GCS) Best eye response (E) No eye opening 1 Eye opening in response to pain 2 Eye opening to speech 3 Eyes opening spontaneously 4 Best verbal response (V) 1 No verbal response Incomprehensible sounds 2 Inappropriate words 3 Confused 4 Oriented 5 Best motor response (M) No motor response 1 Extension to pain 2 Abnormal ƃexion to pain 3 Flexion 9ithdrawal to pain 4 Localizes to pain 5 Obeys commands 6 Glasgow Coma score (E + V + M) Symptoms e.g., headache), or Physical signs e.g., unsteadiness), or Impaired brain function e.g. confusion) or Abnormal behaviour e.g., change in personality). of 15 GCS should be recorded for all athletes in case of subsequent deterioration. 2 Maddocks Score3 SIDELINE ASSESSMENT “I am going to ask you a few questions, please listen carefully and give your best effort.” /odiƂ ed /addocMs questions (1 point for each correct answer) Indications for Emergency Management NOTE: A hit to the head can sometimes be associated with a more serious brain injury. Any of the following warrants consideration of activating emergency procedures and urgent transportation to the nearest hospital: - Glasgow Coma score less than 15 Deteriorating mental status Potential spinal injury Progressive, worsening symptoms or new neurologic signs 9hat venue are we at today? 0 1 9hich half is it now? 0 1 9ho scored last in this match? 0 1 9hat team did you play last week game? 0 1 Did your team win the last game? 0 1 Maddocks score of 5 /addocMs score is validated for sideline diaInosis of concussion only and is not used for serial testinI. Potential signs of concussion? If any of the following signs are observed after a direct or indirect blow to the head, the athlete should stop participation, be evaluated by a medical professional and should not be permitted to return to sport the same day if a concussion is suspected. Y N Balance or motor incoordination (stumbles, slow / laboured movements, etc.)? Y N Disorientation or confusion (inability to respond appropriately to questions)? Y N Loss of memory: Y N Blank or vacant look: Y N Visible facial injury in combination with any of the above: Y N Any loss of consciousness? Notes: Mechanism of Injury (“tell me what happened”?): “If so, how long?“ “If so, how long?“ “Before or after the injury?" Any athlete with a suspected concussion should be REMOVED FROM PLAY, medically assessed, monitored for deterioration (i e , should not be left alone) and should not drive a motor vehicle until cleared to do so by a medical professional. No athlete diagnosed with concussion should be returned to sports participation on the day of Injury. SCAT3 SPORT CONCUSSION ASSESMENT TOOL 3 PAGE 1 © 2013 Concussion in Sport Group 259 Downloaded from bjsm.bmj.com on March 11, 2013 - Published by group.bmj.com BACKGROUND COGNITIVE & PHYSICAL EVALUATION Name: 4 Cognitive assessment Date: Examiner: Standardized Assessment of Concussion (SAC) 4 Sport team school: Date time of injury: Age: Gender: M F Years of education completed: Dominant hand: right left neither Orientation (1 point for each correct answer) 9hat month is it? 0 1 9hat is the date today? 0 1 How many concussions do you think you have had in the past? 9hat is the day of the week? 0 1 9hen was the most recent concussion? 9hat year is it? 0 1 How long was your recovery from the most recent concussion? 9hat time is it right now? (within 1 hour) 0 1 Have you ever been hospitalized or had medical imaging done for a head injury? Y N Orientation score Have you ever been diagnosed with headaches or migraines? Y N Immediate memory Do you have a learning disability, dyslexia, ADD ADHD? Y N Have you ever been diagnosed with depression, anxiety or other psychiatric disorder? Y N Has anyone in your family ever been diagnosed with any of these problems? Y N Are you on any medications? If yes, please list: Y N List of 5 Trial 1 Trial 2 Trial 3 Alternative word list elbow 0 1 0 1 0 1 candle baby Ƃnger apple 0 1 0 1 0 1 paper monkey penny carpet 0 1 0 1 0 1 sugar perfume blanket saddle 0 1 0 1 0 1 sandwich sunset lemon bubble 0 1 0 1 0 1 wagon iron insect Total SCAT3 to be done in resting state. Best done 10 or more minutes post excercise. SYMPTOM EVALUATION Concentration: Digits Backward List 3 How do you feel? “You should score yourself on the following symptoms, based on how you feel now”. none mild of 15 Immediate memory score total moderate severe Headache 0 1 2 3 4 5 6 “Pressure in head” 0 1 2 3 4 5 6 Neck Pain 0 1 2 3 4 5 6 Nausea or vomiting 0 1 2 3 4 5 6 Dizziness 0 1 2 3 4 5 6 Trial 1 Alternative diIit list 4-9-3 0 1 6-2-9 5-2-6 4-1-5 3-8-1-4 0 1 3-2-7-9 1-7-9-5 4-9-6-8 6-2-9-7-1 0 1 1-5-2-8-6 3-8-5-2-7 6-1-8-4-3 7-1-8-4-6-2 0 1 5-3-9-1-4-8 8-3-1-9-6-4 7-2-4-8-5-6 Total of 4 Concentration: Month in Reverse Order (1 pt. for entire sequence correct) 0 Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan of 5 Blurred vision 0 1 2 3 4 5 6 Balance problems 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 Feeling slowed down 0 1 2 3 4 5 6 Feeling like “in a fog“ 0 1 2 3 4 5 6 “Don’t feel right” 0 1 2 3 4 5 6 DifƂculty concentrating 0 1 2 3 4 5 6 DifƂculty remembering 0 1 2 3 4 5 6 Fatigue or low energy 0 1 2 3 4 5 6 Confusion 0 1 2 3 4 5 6 Drowsiness 0 1 2 3 4 5 6 Trouble falling asleep 0 1 2 3 4 5 6 ModiƂed Balance Error Scoring System (BESS) testing5 More emotional 0 1 2 3 4 5 6 9hich foot was tested (i.e. which is the non-dominant foot) 5 Neck Examination: Range of motion Tenderness Upper and lower limb sensation & strength Findings: 6 Balance examination &o one or both of the followinI tests. Footwear shoes, barefoot, braces, tape, etc.) Irritability 0 1 2 3 4 5 6 Testing surface hard ƃoor, Ƃeld, etc.) Sadness 0 1 2 3 4 5 6 Condition Nervous or Anxious 0 1 2 3 4 5 6 Double leg stance: Total number of symptoms (Maximum possible 22) Symptom severity score (Maximum possible 132) Errors And / Or Tandem gait6,7 Do the symptoms get worse with mental activity? Y N Time (best of 4 trials): self rated self rated and clinician monitored clinician interview self rated with parent input Overall rating: If you know the athlete well prior to the injury, how different is the athlete acting compared to his her usual self? Please circle one response: seconds 7 Coordination examination Upper limb coordination 9hich arm was tested: N A Scoring on the SCAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete’s readiness to return to competition after concussion. Since signs and symptoms may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion. 260 Errors Errors N unsure Right Tandem stance (non-dominant foot at bacM): Y very different Left Single leg stance (non-dominant foot): Do the symptoms get worse with physical activity? no different 1 Concentration score Coordination score Left Right of 1 8 SAC Delayed Recall4 Delayed recall score SCAT3 SPORT CONCUSSION ASSESMENT TOOL 3 PAGE 2 of 5 © 2013 Concussion in Sport Group Downloaded from bjsm.bmj.com on March 11, 2013 - Published by group.bmj.com Balance testing – types of errors INSTRUCTIONS 9ords in Italics throughout the SCAT3 are the instructions given to the athlete by the tester. Symptom Scale “You should score yourself on the following symptoms, based on how you feel now”. To be completed by the athlete. In situations where the symptom scale is being completed after exercise, it should still be done in a resting state, at least 10 minutes post exercise. For total number of symptoms, maximum possible is 22. For Symptom severity score, add all scores in table, maximum possible is 22 x 6 = 132. SAC 4 Immediate Memory “I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order.” 1. Hands lifted off iliac crest 2. Opening eyes 3. Step, stumble, or fall 4. Moving hip into > 30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of test position > 5 sec Each of the 20-second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the athlete. The examiner will begin counting errors only after the individual has assumed the proper start position. The modiƂed BESS is calculated by adding one error point for each error during the three 20-second tests. The maximum total number of errors for any single condition is 10. If a athlete commits multiple errors simultaneously, only one error is recorded but the athlete should quickly return to the testing position, and counting should resume once subject is set. Subjects that are unable to maintain the testing procedure for a minimum of Ƃve seconds at the start are assigned the highest possible score, ten, for that testing condition. Trials 2 & 3: OPTION: For further assessment, the same 3 stances can be performed on a surface of medium density foam e.g., approximately 50 cm x 40 cm x 6 cm). “I am going to repeat the same list again. Repeat back as many words as you can remember in any order, even if you said the word before.“ Tandem Gait6,7 Complete all 3 trials reIardless of score on trial 1 2. 4ead the words at a rate of one per second. Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the athlete that delayed recall will be tested. Concentration Digits backward “I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.” Participants are instructed to stand with their feet together behind a starting line (the test is best done with footwear removed). Then, they walk in a forward direction as quickly and as accurately as possible along a 38mm wide (sports tape), 3 meter line with an alternate foot heel-to-toe gait ensuring that they approximate their heel and toe on each step. Once they cross the end of the 3m line, they turn 180 degrees and return to the starting point using the same gait. # total of trials are done and the best time is retained. #thletes should complete the test in 1 seconds. #thletes fail the test if they step off the line, have a separation between their heel and toe, or if they touch or grab the examiner or an object. In this case, the time is not recorded and the trial repeated, if appropriate. +f correct, Io to next strinI lenIth. +f incorrect, read trial 2. One point possible for each string length. Stop after incorrect on both trials. The diIits should be read at the rate of one per second. Coordination Examination Months in reverse order Upper limb coordination Finger-to-nose FTN) task: “Now tell me the months of the year in reverse order. Start with the last month and go backward. So you’ll say December, November … Go ahead” 1 pt. for entire sequence correct Delayed Recall The delayed recall should be performed after completion of the Balance and Coordination Examination. “Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order.“ Score 1 pt. for each correct response Scoring: 5 correct repetitions in < 4 seconds = 1 Note for testers: Athletes fail the test if they do not touch their nose, do not fully extend their elbow or do not perform Ƃve repetitions. Failure should be scored as 0. References & Footnotes Balance Examination ModiƂed Balance Error Scoring System (BESS) testing “I am going to test your coordination now. Please sit comfortably on the chair with your eyes open and your arm (either right or left) outstretched (shoulder ƃexed to 90 degrees and elbow and Ƃngers extended), pointing in front of you. 9hen I give a start signal, I would like you to perform Ƃve successive Ƃnger to nose repetitions using your index Ƃnger to touch the tip of the nose, and then return to the starting position, as quickly and as accurately as possible.” 5 This balance testing is based on a modiƂed version of the Balance Error Scoring System BESS)5. A stopwatch or watch with a second hand is required for this testing. “I am now going to test your balance. Please take your shoes off, roll up your pant legs above ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of three twenty second tests with different stances.“ (a) Double leg stance: “The Ƃrst stance is standing with your feet together with your hands on your hips and with your eyes closed. You should try to maintain stability in that position for 20 seconds. I will be counting the number of times you move out of this position. I will start timing when you are set and have closed your eyes.“ (b) Single leg stance: “If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now stand on your non-dominant foot. The dominant leg should be held in approximately 30 degrees of hip ƃexion and degrees of knee ƃexion. #gain, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.“ (c) Tandem stance: “Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly distributed across both feet. #gain, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.” 1. This tool has been developed by a group of international experts at the 4th International Consensus meeting on Concussion in Sport held in Zurich, Switzerland in November 2012. The full details of the conference outcomes and the authors of the tool are published in The BJSM Injury Prevention and Health Protection, 2013, Volume 47, Issue 5. The outcome paper will also be simultaneously co-published in other leading biomedical journals with the copyright held by the Concussion in Sport Group, to allow unrestricted distribution, providing no alterations are made. 2. McCrory P et al., Consensus Statement on Concussion in Sport – the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. British Journal of Sports Medicine 2009; 43: i76-89. 3. Maddocks, DL; Dicker, GD; Saling, MM. The assessment of orientation following concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5 1): 32 – 3. 4. McCrea M. Standardized mental status testing of acute concussion. Clinical Journal of Sport Medicine. 2001; 11: 176 – 181. 5. Guskiewicz KM. Assessment of postural stability following sport-related concussion. Current Sports Medicine Reports. 2003; 2: 24 – 30. 6. Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond-Tooke, G. & McCrory, P. Normative values for 16-37 year old subjects for three clinical measures of motor performance used in the assessment of sports concussions. Journal of Science and Medicine in Sport. 2010; 13 2): 196 – 201. 7. Schneiders, A.G., Sullivan, S.J., Kvarnstrom. J.K., Olsson, M., Yden. T. & Marshall, S.9. The effect of footwear and sports-surface on dynamic neurological screening in sport-related concussion. Journal of Science and Medicine in Sport. 2010; 13 4): 382 – 386 SCAT3 SPORT CONCUSSION ASSESMENT TOOL 3 PAGE 3 © 2013 Concussion in Sport Group 261 Downloaded from bjsm.bmj.com on March 11, 2013 - Published by group.bmj.com ATHLETE INFORMATION Scoring Summary: Any athlete suspected of having a concussion should be removed from play, and then seek medical evaluation. Test Domain Score Date: Signs to watch for Number of Symptoms of 22 Problems could arise over the Ƃrst 24 – 48 hours. The athlete should not be left alone and must go to a hospital at once if they: Symptom Severity Score of 132 - Have a headache that gets worse Are very drowsy or can’t be awakened Can’t recognize people or places Have repeated vomiting Behave unusually or seem confused; are very irritable Have seizures arms and legs jerk uncontrollably) Have weak or numb arms or legs Are unsteady on their feet; have slurred speech Date: Date: Orientation of 5 Immediate Memory of 15 Concentration of 5 Delayed Recall of 5 SAC Total BESS total errors) Tandem Gait seconds) Coordination of 1 Remember, it is better to be safe. Consult your doctor after a suspected concussion. Return to play Athletes should not be returned to play the same day of injury. 9hen returning athletes to play, they should be medically cleared and then follow a stepwise supervised program, with stages of progression. Notes: For example: Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage No activity Physical and cognitive rest Recovery Light aerobic exercise 9alking, swimming or stationary cycling keeping intensity, 70 % maximum predicted heart rate. No resistance training Increase heart rate Sport-speciƂc exercise Skating drills in ice hockey, running drills in soccer. No head impact activities Add movement Non-contact training drills Progression to more complex training drills, eg passing drills in football and ice hockey. May start progressive resistance training Exercise, coordination, and cognitive load Full contact practice Following medical clearance participate in normal training activities Restore conƂdence and assess functional skills by coaching staff Return to play Normal game play There should be at least 24 hours or longer) for each stage and if symptoms recur the athlete should rest until they resolve once again and then resume the program at the previous asymptomatic stage. Resistance training should only be added in the later stages. If the athlete is symptomatic for more than 10 days, then consultation by a medical practitioner who is expert in the management of concussion, is recommended. Medical clearance should be given before return to play. CONCUSSION INJURY ADVICE Patient’s name To be given to the person monitoring the concussed athlete) Date time of injury This patient has received an injury to the head. A careful medical examination has been carried out and no sign of any serious complications has been found. Recovery time is variable across individuals and the patient will need monitoring for a further period by a responsible adult. Your treating physician will provide guidance as to this timeframe. Date time of medical review Treating physician If you notice any change in behaviour, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please contact your doctor or the nearest hospital emergency department immediately. Other important points: - Rest physically and mentally), including training or playing sports until symptoms resolve and you are medically cleared - No alcohol - No prescription or non-prescription drugs without medical supervision. SpeciƂcally: · No sleeping tablets · Do not use aspirin, anti-inƃammatory medication or sedating pain killers - Do not drive until medically cleared - Do not train or play sport until medically cleared Contact details or stamp Clinic phone number 262 SCAT3 SPORT CONCUSSION ASSESMENT TOOL 3 PAGE 4 © 2013 Concussion in Sport Group August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 APPENDIX G- INTER-ASSOCIATION CONSENSUS: YEAR-ROUND FOOTBALL PRACTICE CONTACT GUIDELINES 2014-15 NCAA Sports Medicine Handbook INTER-ASSOCIATION CONSENSUS: YEAR-ROUND FOOTBALL PRACTICE CONTACT GUIDELINES September 2014 PURPOSE is unknown. Likewise, there are no conclusive data for understanding the short- or long-term clinical impact of sub-concussive impacts. However, there are emerging data that football players are more frequently diagnosed with sport-related concussion on days with increased frequency and higher magnitude of head impact (greater than 100g linear acceleration).9-11 This document addresses year-round football practice contact. Traditionally, the literature addressing differing levels of contact in football practice correlated with the protective equipment (uniform) worn. This means that fullpad practice correlated with full-contact and both halfpad (shell) and helmet-only practice correlated with less contact. However, coaches, administrators and athletics health care providers who helped to shape these guidelines have noted that contact during football practice is not determined primarily by the uniform, but rather by whether the intent of practice is centered on live contact versus teaching and conditioning. There are limited data that address this issue, and such data do not differentiate whether the intent of the practice is live tackling or teaching/conditioning. Within these limitations, non-published data from a single institution reveal the following:10 • The total number of non-concussive head impacts sustained in helmets-only and full-pad practices is higher than those sustained in games/scrimmages. • Mild- and moderate-intensity head impacts occur at an essentially equal rate during full-pad and half-pad practices when the intent of practice is not noted. • Severe-intensity head impacts are much more likely to occur during a game, followed by fullpad practices and half-pad practices. • There is a 14-fold increase in concussive impacts in full-pad practices when compared to half-pad or helmets-only practices. • Offensive linemen and defensive linemen experience more head impacts during both full-pad and half-pad practices relative to all other positions. The Safety in College Football Summit (see appendix) resulted in inter-association consensus guidelines for three paramount safety issues in collegiate athletics: 1. Independent medical care in the collegiate setting; 2. Concussion diagnosis and management; and 3. Football practice contact. BACKGROUND Enhancing a culture of safety in collegiate sport is foundational. Football is an aggressive, rugged, contact sport,1 yet the rules clearly state that there is no place for maneuvers deliberately designed to inflict injury on another player.1 Historically, rules changes and behavior modification have reduced catastrophic injury and death. Enforcement of these rules is critical for improving player safety.2 Despite sound data on reducing catastrophic football injuries, there are limited data that provide a strong foothold for decreasing injury risk by reducing contact in football practice.3-8 Regardless of such scientific shortcomings, there is a growing consensus that we must analyze existing data in a consensus-based manner to develop guidelines that promote safety. “Safe” football means “good” football. NCAA regulations currently do not address inseason, fullcontact practices. The Ivy League and Pac-12 Conference have limited inseason, full-contact practices to two per week and have established policies for full-contact practices in spring and preseason practices through their Football Practice Standards and Football Practice Policy, respectively. Neither address full-pad practice that does not involve live contact practice, as defined below. Both conferences cite safety concerns as the primary rationale for reducing full-contact practices; neither conference has published or announced data analysis based on their new policies. In keeping with the intent of both conferences and other football organizations, the rationale for defining and reducing live contact practice is to improve safety, including possibly decreasing student-athlete exposure for concussion and sub-concussive impacts. Reduced frequency of live contact practice may also allow even more time for teaching of proper tackling technique. The biomechanical threshold (acceleration/deceleration/rotation) at which sport-related concussion occurs The guidelines below are based on: expert consensus from the two day summit referenced above; comments and recommendations from a broad constituency of the organizations listed; and internal NCAA staff members. Importantly, the emphasis is on limiting contact, regardless of whether the student-athlete is in full-pad, half-pad, or is participating in a helmet-only Appendixes practice. Equally importantly, the principles of sound and safe conditioning are an essential aspect of all practice and competition exposures. These guidelines must be differentiated from legislation. For each section below that addresses a particular part of the football calendar, any legislation for that calendar period is referenced. As these guidelines are based on consensus and limited science, they are best viewed as a “living, breathing” document that will be updated, as we have with other health and safety guidelines, based on emerging science or sound observations that result from application of these guidelines. The intent is to reduce injury risk, but we must also be attentive to unintended consequences of shifting a practice paradigm based on consensus. For example, football preseason must prepare the student-athlete for the rigors of an aggressive, contact, rugged sport. Without adequate preparation, which includes live tackling, the student-athlete could be at risk of unforeseen injury during the inseason because of inadequate preparation. We plan to reanalyze these football practice contact guidelines at least annually. Additionally, we recognize that NCAA input for these guidelines came primarily from Division I Football Bowl Subdivision schools. Although we believe the guidelines can also be utilized for football programs in all NCAA divisions, we will be more inclusive in the development of future football contact practice guidelines. DEFINITIONS Live contact practice: Any practice that involves live tackling to the ground and/or full-speed blocking. Live contact practice may occur in full-pad or half-pad (also known as “shell,” in which the player wears shoulder pads and shorts, with or without thigh pads). Live contact does not include: (1) “thud” sessions, or (2) drills that involve “wrapping up;” in these scenarios players are not taken to the ground and contact is not aggressive in nature. Live contact practices are to be conducted in a manner consistent with existing rules that prohibit targeting to the head or neck area with the helmet, forearm, elbow, or shoulder, or the initiation of contact with the helmet. Full-pad practice: Full-pad practice may or may not involve live contact. Full-pad practices that do not involve live contact are intended to provide preparation for a game that is played in a full uniform, with an emphasis on technique and conditioning versus impact. Legislation versus guidelines: There exists relevant NCAA legislation for the following: 1. 2. 3. 4. 5. Preseason practice a. DI FBS/FCS – NCAA Bylaws 17.9.2.3 and 17.9.2.4 b. DII – NCAA Bylaws 17.9.2.2 and 17.9.2.3 c. DIII – NCAA Bylaws 17.9.2.2 and 17.9.2.3 Inseason practice: No current NCAA legislation addresses contact during inseason practices. Postseason practice: No current NCAA legislation addresses contact during postseason practices. Bowl practice: No current NCAA legislation addresses contact during bowl practice. Spring practice: a. DI FBS/FCS – NCAA Bylaw 17.9.6.4 b. DII – NCAA Bylaw 17.9.8 c. DIII – NCAA Bylaw 17.9.6 – not referenced to as spring practice, but allows five (5) week period outside playing season. The guidelines that follow do not represent legislation or rules. As noted in the appendix, the intent of providing consensus guidelines in year one of the inaugural Safety in College Football Summit is to provide consensus-based guidance that will be evaluated “realtime” as a “living and breathing” document that will become solidified over time through evidence-based observations and experience. Preseason practice guidelines: For days in which institutions schedule a two-a-day practice, live contact practices are only allowed in one practice. A maximum four (4) live contact practices may occur in a given week, and a maximum of 12 total may occur in preseason. Only three practices (scrimmages) would allow for live contact in greater than 50 percent of the practice schedule. Inseason practice guidelines: Inseason is defined as the period between six (6) days prior to the first regular-season game and the final regular-season game or conference championship game (for participating institutions). There may be no more than two (2) live contact practices per week. Postseason guidelines: (FCS/DII/DIII) There may be no more than two (2) live contact practices per week. Bowl practice guidelines: (FBS) There may be no more than two (2) live contact practices per week. Spring practice guidelines: Of the 15 allowable sessions that may occur during the spring practice season, eight (8) practices may involve live contact; three (3) of these live contact practices may include 2014-15 NCAA Sports Medicine Handbook greater than 50 percent live contact (scrimmages). Live contact practices are limited to two (2) in a given week and may not occur on consecutive days. REFERENCES 1. NCAA Football: 2013 and 2014 Rules and Interpretations. 2. Cantu RC, Mueller FO. Brain injury-related fatalities in American football, 1945-1999. Neurosurgery 2003; 52:846-852. 3. McAllister TW et al. Effect of head impacts on diffusivity measures in a cohort of collegiate contact sport athletes. Neurology 2014; 82:1-7. 4. Bailes JE et al. Role of subconcussion in repetitive mild traumatic brain injury. J Neurosurg 2013: 1-11. 5. McAllister TW et al. Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes. Neurology 2012; 78:1777-1784. 6. Beckwith JG et al. Head impact exposure sustained by football players on days of diagnosed concussion. Med Sci Sports Exerc 2013; 45:737-746. 7. Talavage TM et al. Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion. J Neurotrauma 2014; 31:327-338 8. Miller JR et al. Comparison of preseason, midseason, and postseason neurocognitive scores in uninjured collegiate football players. Am J Sports Med 2007; 35:1284-1288. 9. Mihalik JP, Bell DR, Marshall SW, Guskiewicz KM. Measurement of head impacts in collegiate football players: an investigation of positional and event-type differences. Neurosurgery 2007; 61:12291235. 10. Trulock S, Oliaro S. Practice contact. Safety in College Football Summit. Presented January 22, 2014, Atlanta, GA. 11. Crison JJ et al. Frequency and location of head impact exposures in individual collegiate football players. J Athl Train 2010; 45:549-559. ENDORSEMENTS This Inter-Association Consensus: Year-Round Football Practice Contact Guidelines, has been endorsed by: • American Academy of Neurology • American College of Sports Medicine • American Association of Neurological Surgeons • American Football Coaches Association • American Medical Society for Sports Medicine • American Osteopathic Academy for Sports Medicine • College Athletic Trainers’ Society • Congress of Neurological Surgeons • Football Championship Subdivision Executive Committee • National Association of Collegiate Directors of Athletics • National Athletic Trainers’ Association • National Football Foundation • NCAA Concussion Task Force • Sports Neuropsychological Society August 1st, 2010 Revised August 2011 Revised September 2013 Revised September 2014 Revised April 2015 APPENDIX H- INTER-ASSOCIATION CONSENSUS: INDEPENDENT MEDICAL CARE GUIDELINES 2014-15 NCAA Sports Medicine Handbook INTER-ASSOCIATION CONSENSUS: INDEPENDENT MEDICAL CARE GUIDELINES September 2014 PURPOSE The Safety in College Football Summit resulted in inter-association consensus guidelines for three paramount safety issues in collegiate athletics: 1. Independent medical care in the collegiate setting; 2. Concussion diagnosis and management; and 3. Football practice contact. This document addresses independent medical care for college student-athletes in all sports. BACKGROUND Diagnosis, management, and return to play determinations for the college student-athlete are the responsibility of the institution’s athletic trainer (working under the supervision of a physician) and the team physician. Even though some have cited a potential tension between health and safety in athletics,1,2 collegiate athletics endeavor to conduct programs in a manner designed to address the physical well-being of college student-athletes (i.e., to balance health and performance).3,4 In the interest of the health and welfare of collegiate student-athletes, a student-athlete’s health care providers must have clear authority for studentathlete care. The foundational approach for independent medical care is to assume an “athlete-centered care” approach, which is similar to the more general “patient-centered care,” which refers to the delivery of health care services that are focused only on the individual patient’s needs and concerns.5 The following 10 guiding principles, listed in the Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges,5 are paraphrased below to provide an example of policies that can be adopted that help to assure independent, objective medical care for college student-athletes: 1. The physical and psychosocial welfare of the individual student-athlete should always be the highest priority of the athletic trainer and the team physician. 2. Any program that delivers athletic training services to student-athletes should always have a designated medical director. 3. Sports medicine physicians and athletic trainers should always practice in a manner that integrates the best current research evidence within the preferences and values of each student-athlete. 4. The clinical responsibilities of an athletic trainer should always be performed in a manner that is consistent with the written or verbal instructions of a physician or standing orders and clinical management protocols that have been approved by a program’s designated medical director. 5. Decisions that affect the current or future health status of a student-athlete who has an injury or illness should only be made by a properly credentialed health professional (e.g., a physician or an athletic trainer who has a physician’s authorization to make the decision). 6. In every case that a physician has granted an athletic trainer the discretion to make decisions relating to an individual student-athlete’s injury management or sports participation status, all aspects of the care process and changes in the student-athlete’s disposition should be thoroughly documented. 7. Coaches must not be allowed to impose demands that are inconsistent with guidelines and recommendations established by sports medicine and athletic training professional organizations. 8. An athletic trainer’s role delineation and employment status should be determined through a formal administrative role for a physician who provides medical direction. 9. An athletic trainer’s professional qualifications and performance evaluations must not be primarily judged by administrative personnel who lack health care expertise, particularly in the context of hiring, promotion, and termination decisions. 10. Member institutions should adopt an administrative structure for delivery of integrated sports medicine and athletic training services to minimize the potential for any conflicts of interest that could adversely affect the health and well-being of student-athletes. Team physician authority becomes the linchpin for independent medical care of student-athletes. Six preeminent sports physicians associations agree with respect to “… athletic trainers and other members of the athletic care network report to the team physician on medical issues.”6 Consensus aside, a medical-legal authority is a matter of law in 48 states that require athletic trainers to report to a physician in their medical practice. The NCAA Sports Medicine Handbook’s Guideline 1B opens with a charge to athletics and institutional leadership to “create an administrative system where athletics health care professionals – Appendixes team physicians and athletic trainers – are able to make medical decisions with only the best interests of student-athletes at the forefront.”7 Multiple models exist for collegiate sports medicine. Athletic health care professionals commonly work for the athletics department, student health services, private medical practice, or a combination thereof. Irrespective of model, the answer for the college student-athlete is established independence for appointed athletics health care providers.8 GUIDELINES Institutional medical line of authority should be established independently of a coach, and in the sole interest of student-athlete health and welfare. Medical line of authority should be transparent and evident in athletics departments, and organizational structure should establish collaborative interactions with the medical director and primary athletics health care providers (defined as all institutional team physicians and athletic trainers) so that the safety, excellence and wellness of student-athletes are evident in all aspects of athletics and are student-athlete centered. Institutions should, at a minimum, designate a licensed physician (M.D. or D.O.) to serve as medical director, and that medical director should oversee the medical tasks of all primary athletics health care providers. Institutions should consider a board certified physician, if available. The medical director may also serve as team physician. All athletic trainers should be directed and supervised for medical tasks by a team physician and/or the medical director. The medical director and primary athletics health care providers should be empowered with unchallengeable autonomous authority to determine medical management and return-to-play decisions of student-athletes. REFERENCES 1. Matheson GO. Maintaining professionalism in the athletic environment. Phys Sportsmed. 2001 Feb;29(2) 2. Wolverton B. (2013, September 2) Coach makes the call. The Chronicle of Higher Education. [Available online] http://chronicle.com/ article/Trainers-Butt-Heads-With/141333/ 3. NCAA Bylaw 3.2.4.17 (Div. I and Div. II; 3.2.4.16 (Div. III). 4. National Collegiate Athletic Association. (2013). 2013-14 NCAA Division I Manual. Indianapolis, IN: NCAA. 5. Courson R et al. Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges. J Athletic Training 2014; 49:128-137. 6. Herring SA, Kibler WB, Putukian M. Team Physician Consensus ENDORSEMENTS This Consensus Best Practice, Independent Medical Care for College Student-Athletes, has been endorsed by: • American Academy of Neurology • American College of Sports Medicine • American Association of Neurological Surgeons • American Medical Society for Sports Medicine • American Osteopathic Academy for Sports Medicine • College Athletic Trainers’ Society • Congress of Neurological Surgeons • National Athletic Trainers’ Association • NCAA Concussion Task Force • Sports Neuropsychological Society Statement: 2013 update. Med Sci Sports Exerc. 2013 Aug;45(8):1618-22. 7. National Collegiate Athletic Association. (2013). 2013-14 NCAA Sports Medicine Handbook. Indianapolis, IN: NCAA. 8. Delany J, Goodson P, Makeoff R, Perko A, Rawlings H [Chair]. Rawlings panel on intercollegiate athletics at the University of North Carolina at Chapel Hill. Aug 29, 2013. [Available online] http:// rawlingspanel.web.unc.edu/files/2013/09/Rawlings-Panel_ Intercollegiate-Athletics-at-UNC-Chapel-Hill.pdf (em med] Mm @gm? mt Plan Cmamd: Spring 2016 Purpose: In accordance to the standards of the National Collegiate Athletic Association (NCAA) and the University of Missouri Department of Intercollegiate Athletics, the Mizzou Sports Medicine team has set forth the following guidelines and protocols in an effort to prevent, educate, identify, evaluate, and manage traumatic brain injuries and concussions. These guidelines are set with the accordance and commitment to providing the highest level of health care for the student athlete, keeping their safety and well-being at the forefront of their experience at the University of Missouri. Definition of Concussion: In athletics, the most common form of traumatic brain injury (TBI) is a concussion. These injuries can be further explained as a complex pathophysiological process affecting the brain, induced by traumatic biochemical forces. Characteristics of a concussion can include: Caused by a direct blow to the head or other body structures that results in a massive force transmitted to the head. Results in a rapid onset of neurological impairments that are often shorttermed and resolves within a quick manner of time. Acute symptoms largely reflect functional disturbances rather than structural brain injuries. A result in a graded set of clinical symptoms that may or may not involve loss of consciousness Clinical and cognitive symptoms and functions resolve following a sequential progression, keeping in mind, that post-concussive symptoms may be prolonged. No evidence of abnormality is present on a standard neuroimaging studies. [2] Observable Potential Signs of Concussion: The following list are symptoms or indications that a Student-Athlete has suffered a concussion. If any of these characteristics are noted, please make an Athletic Trainer or Team Physician aware of the situation. Any loss of consciousness Balance and motor coordination deficiencies Examples: Stumbles, trips/falls, slow/labored movement Disorientation; blank/vacant stare Slurred/incoherent speech Delayed verbal/motor responses Athlete Reported Potential Signs of Concussion: The following list are “typical” symptoms related to a concussive injury. The StudentAthlete may describe one or more of the following: Headache, Dizziness, Balance and coordination struggles, Nausea, Retrograde/Anterograde Amnesia, Cognitive sluggishness, Light/Sound Sensitivities, Disorientation/confusion, Visual disturbance, Tinnitus (ringing in the ears), Inability to focus, Irritability, Emotional distress, Fatigue/Excessive drowsiness, Sleep disturbances [3] Mizzou Concussion Safety Protocol Pre-Season Education Annually provide NCAA concussion fact sheets (provided by the NCAA) to the following entities:  Student-Athletes  Coaches  Team physicians  Athletic Trainers  Directors of Athletics Each party provides signed acknowledgment of having read and understand the concussion fact sheet. Pre-Participation Assessment Every University of Missouri Student-Athlete will receive a baseline concussion assessment as part of their yearly physical examination, using the Sport Concussion Assessment Tool – Third Edition (SCAT-3). This will be documented and placed in each Student-Athlete’s medical file. Further, Football Student-Athlete scores kept on Microsoft Surface tablet and will be at all competitions. The SCAT-3 baseline exam will cover:  Brain injury and concussion history  Symptom evaluation  Cognitive assessment  Balance evaluation SCAT-3  Standardized tool for evaluation of injured athletes for concussion  Can be administered by ATC or Team Physician  Quick and effective  Can be used on the sidelines, locker room, and the athletic training room Team Physician will provide clearance or determine the need for additional consultation or testing. [4] Mental Health/Learning Disordered Athlete During initial assessment, if a Student-Athlete is found to have prior mental health and/or learning disabilities listed on the yearly medical appraisal forms, that individual will be referred to Dr. Tom Martin Dr. Tom Martin  Director of Adult Neuropsychology at the University of Missouri  Board Certifications:  Am. Bd. of Professional Psy/Neuropsychology  American Bd. of Professional Psy/Rehabilitation PS ImPact Testing Protocol  Dr. Martin will administer the test; encompassing:  Fifteen minute interview.  Identify mental health and learning disability related issues, these can affect the speed of processing;  Ultimately skewing the results of baseline testing.  ImPact test then conducted.  Results will be kept in Dr. Martin’s files and be confidential.  ATC access when needed through a release form  After each evaluation, Dr. Martin will provide evaluation form to the ATC/Team Physician for Return to Play (RTP.) This meets current Standard of Care techniques and removes liability. Return to Play  Will follow the standard RTP protocol listed.  Examination with Dr. Martin; including an ImPact test administered until previous baseline standards are met Return to Learn  Will follow the standard RTL protocol listed.  Dr. Martin to be a member of the Post-Concussion RTL Team for any individual that had been a previous patient. [5] Recognition and Diagnosis of Concussion Any Student-Athlete believed to have behaviors/symptoms/signs congruent with a concussion: 1. Removed immediately from practice/competition 2. Evaluation completed by ATC or Team Physician  Symptom Evaluation  Physical Evaluation  Neurological Evaluation  Cognitive Evaluation  Balance Evaluation Referral to Emergency Action Plan (EAP) 1. Follow the University of Missouri Department of Athletics EAP 2. Correct and appropriate evaluation for injuries, such as:  Cervical Spine Trauma;  Skull Fracture;  Intracranial bleeding 3. Signs and Symptoms present to warrant EAP response:  Glasgow Coma Scale <13.  See Appendix  Prolonged loss of consciousness.  Focal Neurological deficit  problem with nerve, spinal cord, or brain function  loss of normal bodily functions  Repetitive emesis (vomiting.)  Diminished/worsening mental function or other neurological signs and symptoms  Spine Injury [6] Confirmation of Concussion Removal from practice/competition that calendar day During ALL competitions, the Student-Athlete will be moved to the locker room or Athletic Training Room 1. SCAT-3 Assessment given at this time 2. Eliminates distractive forces related to the field of competition 3. Football: SCAT-3 baseline and subsequent test scores saved into Microsoft Surface files Evaluation by team physician Student-athlete provided a Post-Concussive Care Document. 1. Provided in Appendix 2. Discussion with Student-Athlete and a responsible adult, parent/roommate/significant-other, who will accompany the concussed athlete for the evening and morning Admission into Post-Concussion Return to Play and Return to Learn Notification of the following individuals: 1. Head Coach/Position Coach 2. Academic Advisors 3. Director of Sports Medicine 4. Athletic Performance [7] Return to Play and Learn Activities Return to Play (RTP) Team Physician has FINAL ASSESSMENT and determination for RTP Each Student-Athlete suffering a concussion will undergo:  Supervised stepwise progression by the Athletic Trainer  Student-Athlete will have limited physical and cognitive activity until baseline standards have been met. At this point, the Student-Athlete can begin the RTP Progression PROGRESSION MANAGEMENT PLAN FOR RETURN TO PLAY This RTP is designed to progress as symptoms present themselves. The StudentAthlete must be symptom free for a minimum of 24 hours to progress to the next level. At any point, if any concussive symptom presents itself, the Student-Athlete will return to the prior level and remain there until the concussive symptoms are no longer present. Further, the Student-Athlete will undergo continued post-concussion SCAT-3 testing. 1. Light aerobic exercise with resistance training: Example.: Bike/Cardio 2. Sport-specific exercise and activity without head impact Example: Drill work, fundamental skill practice 3. Non-contact practice/progressive resistance training Example: Practice situations where no contact is possible Return to weight room activities 4. Unrestricted training Example: Complete return to practice 5. Return to competition pending Team Physician approval [8] Return to Learn Management Team The designated sport Athletic Trainer will coordinate and navigate the RTL In complex situations with a perceived prolonged RTL, a multidisciplinary team will be in place to assist the Student-Athlete’s reappearance in the traditional learning/classroom setting. The Post-Concussion RTL Team will consist of the following:  Athletic Trainer  Team Physician  Dr. Deborah Wright, Counseling Psychologist  Dr. Tom Martin, Neuropsychologist  Academic Counselor  Athletic Department Administrator Additional entities that could join RTL Team:  Office of Disability Services  Integrated Treatment Team  Dr. Aaron Gray, Team Physician  Dr. Deborah Wright, Clinical Psychologist  Rex L. Sharp, Sr. Associate Director; Sports Medicine  Dr. Lori Franz, Faculty Athletic Representative  University Administrators  College Directors. Ex.: Education, Business, CAFNR  Course instructors  Coaches/Support Staff  University of Missouri Health Center Specialists Any action taken must remain in compliance with the Americans with Disabilities Act Amendments Act (ADAAA). [9] Return to Learn Protocols RTL should be managed much like the RTP progression Fits the individual and their concussive symptoms Quality RTL is based on cognitive rest immediately following a concussion  Avoidance of potential cognitive stressors  Examples include: School work; video games; reading; texting Return to Cognitive Activity After concussion is diagnosed, the Student-Athlete must avoid the classroom, tutoring, mentoring for at least one day. Levels of RTL is based solely on the return of concussion symptoms PROGRESSION MANAGEMENT PLAN FOR RETURN TO LEARN 1. If the Student-Athlete cannot tolerate 30 minutes of light cognitive activity, that person should contact the ATC and return home. 2. When Student-Athlete is able to reach 45 minutes of cognitive activity without a return of symptoms, they should return to a modified classroom schedule in a step-wise manner. a. Return of cognitive activity will be no longer than 45 minutes b. Followed by a minimum of 15 minutes of rest 3. Levels of adjustment should be decided by the Management Team 4. Amount of involvement will be made on a case-by-case basis [10] Return to Learn: Academic Terminology Majority of RTL cases do NOT need a detailed RTL Plan  Full recovery occurs within two weeks  Cognitive functions quickly return Complex RTL management  Great involvement from the RTL Management Team  General understanding of concepts BEFORE injury occurs Academic Adjustment:  Academic schedule requires some modifications the first 2 weeks following a concussive episode.  Full recovery is anticipated  No meaningful curriculum or testing alterations  Instructor awareness of the situation Academic Accommodation:  For the athlete that has on-going signs and symptoms for more than 2 weeks post-concussion.  Alterations may be needed in class schedules and special arrangements may be needed for tests, projects, and assignments.  Diagnosis of concussion vs. Post-Concussion Syndrome  Post-Concussion Syndrome  Neuro-psychiatric best managed by a multi-disciplinary manner with active interventions.  Prolonged cognitive/physical rest is actually counterproductive in a post-concussive syndrome Student-Athlete Academic Modification:  For a Student-Athlete who is suffering from prolonged difficulties, requiring an Individualized Education Plan (IEP).  IEP: A prescriptive, formal education for that individual, protected by the Individuals with Disabilities Education Act. Team Physician will reevaluate if Concussion Symptoms reappear or worsen during the RTL process. [11] Reducing Exposure to Head Trauma Reducing head trauma exposures will be difficult to acknowledge and quantify. Critical to educate both athletes and coaches regarding the importance of minimizing head trauma exposures. Examples to minimize head trauma injuries:  Adherence to the NCAA consensus for Year-Round Football Practice Guidelines.  Adherence to NCAA consensus for Independent Medical Care Guidelines.  Reducing unneeded contact during practice.  Take a “safety-first” thought and approach to the sport.  Education and direction of taking the head out of the point of impact and contact.  Education of athletes and coaches regarding safe play and the use of proper technique. Consistent and on-going evaluation of practice procedures and protocols [12] APPENDIX A. B. C. D. E. F. G. H. NCAA Concussion Fact Sheet Concussion Acknowledgement Form SCAT-3 Testing Form Dr. Martin Release of Information Sheet Glasgow Coma Scale Post-Concussive Care Document Concussion Flow Sheet Campus Resources [13] Appendix A: NCAA CONCUSSION HANDOUT and CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A CWCUSSION7 Acutudolhnhuh "hi-r7 (Lu: .Pn-uu ?(Mfrs-chukka. HON CAN I PREVENT A lack Iup- you a. uth Wynn-clinch comics 0 ?moaning! swam-ion ifyoum rem-w. dhnn. WNW M?dnohbadlumromm. $090". 0 Mn dlu?mn. WHAT ARE THE OF A Youcu?l noncth Cantu-comm w: oCoo?-ioa ?nd-rho. 0 Lo- choc-(ulna, him robin? Mann .Dou?t otfuqvia'nn. .Semmiymwnu not; 0 Nu. (Runyo- nigh ?4-0 M055. .Cootcna?notnemory in; mutant). ego-admth Emmet-rm MW nlotolcoaam? lulu. to we. at WHATOHOIIDI I Hmwm?cud?cudmm-?h-m mumumumbhapmudumw? WWII-b-MMI-hsuh?uw meImL?Hnm?d-nuch?hu-Ubh "Hidwy?ndu?bh?oq?whm ?ma-chm? BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. lot now who? all um van ad um"- I ?d unanli?mcmafm anal-mum [14] Appendix B: Concussion Acknowledgment Form 1 University of il-iisso nri Sports Medieine Dr. Glenn L. lvlcElrov Sports Medicine Senter HATS Columbia, MEI 55211 Phone SEE-2315 Fair-{ETSjr Edi-3592 Acknowledgement form for having read and understand the NCAA Concussion Fact Sheet I acknowledge that have received, reviewed, and understand the none Concussion Fact Sheet. ills such, I have the direct responsibilityr of reporting anv concussion for mvself or of am; ether MjggouStudent?Athletes to the Mann Sports Medicine Staff. Furthermore, I understand that there is a possibilitv that participation in mg sport may result in a head injurv andlor concussion. Bv signing below, I acknowledge that the Universitv of Missouri has provided me with specific educational materials on what a concussion is and given me an opportunity:r to ask questions and areas and issues that are not clearto me regarding concussions. Signature Printed Name Sport Date [15] Appendix C: SCAT ?3 MIZZOU SPORTS MEDICINE SCATBASSESSMENT Evaluator. Diagnosed with headaches o: magma-T Name: Date. Dominate Hand. Promote. Comussmu: Hospitalized or medical ionizing for apremioua head iupm"? Age. Most Rec-2m and Rama-1.1152: If so: ad whore? Time and Date ofInm? Do you have a learning (Dylan's, ADD: Promote. history' of depiezsioo o: dim:me Ale you on any medications? Please list: Immadia'.e been. magunsad with 'heae conditions? In?lh?lh?lh?l??lhg 5mm 5 mm ochlruss im Drien?ion (1 saint fa:- Lara-:1 111' 1-: EG- . TESS VISION ISSUES SENSIT ?Elf i. wire roiqr.? ?Elf i: rhe- a'qr qf'rke eei.? ?Erie's! i: ?Furrime i: .. Orign?ion Sure: 1J3: film?. Appl'e Caper foiz?e Bl; Mie- Imuliau to?l Commatlm: Dr'ng Each. 32' Lot That 1 Augustin-n. Digit L'st 2-9-3 0 1 5-2-9 3?3-14? 1 1 1 01-1-1: Connematim: MomABEJTY 4- SADNESS I -1- DIR. 1 I 1- Tomi org-worm Warinm possible 33'me more: Waxinmmpos?ie of?i?} 3-2-5 3 I 3-312?3-3' 3-3-3?2-7 YES 33'me geruurre with new nah-fry YES ND ND Ova-11E xvi-Lg: If?frou how he milieu weii piano is 1-1;ij how 11mm?: the [11:35:92 acting compared on their usual WIDE-TRENT mu: Mid. SCCRE wrath ho hr pope." monkey pen'u' .: To." peat-?e Mamie! :Jvu'hf?: :u?er Eamon 11 qgon ?nger from! z?I?j 1?941; Has?Ls rarer-x order (I pr being orrec .5. b?Jar. Nook Examin Minn: nuL'. Fang: 3:;er I'Luw Hrs." :dn: uni-r: 3.: Ewing: Numbtr of ofll Balance Examioalion: Sum.- of 13-2 Susi: ninjas; and ?rm: . mecdial: Manor- of 15 mwmwa Modi?ed BESS test: 'td Recall OFF Tim-quTH Lc-? a: 3:31;: Tandc-m Gait Strondsi 1 Condition: Double Leg 5mm ERRORS Snagle Leg [non amaze] ERRORS Tamde Stanrc {non-dormant: at bait) ERRORS NOTES: T: ode Gait: Tn'? =1 SECONDS SECUNDS SECONDS SECONDS Tm] 1r: Trial 2.1 Triz1 Coordinatioo Examioalion: I'nlrs'r?imo :oora?nrm'rsr: ?shed Lr?! SAC Delay ed Recall: :c or; [16] Appendix C: SCAT-3 INSTRUCTIONS Weir-:13 mix-11.165 311! the instructions tube given tn the athlete for E?l'J'l aettie-u. BEL-11.1 To he completed byte athlete. I11 situalzime Film the scale hemg :nmpleted it should hedeme at least n11.1111tea poet-mm Imetlille Memory. Trill: I 5.3 Complete Leger-115:. 1111111111161: 2. Read'ltuen?otds at a rate ufnteper second SCURE 1 for eath currectreapnnae Tetal stare-equals 5'1111 all 3 trials. Dc NDTin?emtlsa?tMeiunDEL-HID RECALL hunted! Digi? Eithurd: gn 1:111extal1'ltg length. read 111al 1. Due 1u1ni 1l 1msil11e for math sn'iaglength Step aftetincetrect The digite abnulel he the rate efene pat 33101111 Months in Ee'terae Order: w, SCHEE IPDINT 1fet111e aequenze Li tune-:t The delayed recall should he pufntmed aftetcumpletienufthe Balance and 01011111131011 Exam SCORE for each curtectreapnnee BALANCE leatilg: The balance taming 1e haeedenamudl?erl 11:11:11 efthe BEE-5. A Etc-tum Li reqLuIed forth;- 11211111; {:11 Dmblehg?unte: Silgle Leg Since: :15} Tudem Stem-E Balance testing?(mes 1mm n?'?iar: 2. twining En. 4-. ?lling?: Mm .5. lt?ang?te?ntkd 3111 Imelda. Each-cite teamed hf: wm?ngh :a'ocrgec'dm?iadam emu: :mlj.? :lzat The mimn?l begin :cunlzing :a'm a?utl'a trimmed 111:: page! start Fenian. I'll-e landi?etl BEES i3. ?Icahn-d by?ding nu Wit-ranch m1 during LhaJ Ill-semi The mull?n?harel? arm-1': [11: 1.11:: High (undidnnie [female mt: :irahunmulg'. idly-1m miitmded hunt-I and. mile-11]de 311:?: mhjezi: n1. Edge-1:15? acct-Id: lithium-tare 5:551th 5:115. mince. Tudem Gait: CDDEDINATIDN 1111111151101: Upper limb :u-nrtlimliul: Finger-lemon ml: Scermg: 3 tone: aecenele =1 '?'u'nta fer tenets: Alhle?tea fail the rear. If1l1e5'de11ettewi1heir nose. anemithei: ?hnw :11 :le-mtper?zaar. ire repentinne. F?llre sin:qu he scored a: a ll. [17] Appendix D: Dr. Thomas Martin Release of Information UHll-?Er?f?" of Missouri Spoofs Medicine Dr. Glen L. Sports Medicine ICenter 'c-o MATE Columbia. MD 6521' Phone-15.33.1531 -233'5 Fax 334-0592 AUTHORIETIDN FOR THE USE DR DISCLOSURE OF PROTECTED HEALTH INFORMATION As set forth :in our Policies and Procedures manual- sue are by latl.r to obtain your authorinanon for any use or disclosure oF you: health Lnt'ornaation for puiposes other than treatment. payment- or health care operations. In our Policies and Procedures are proudetl you information about Minaou AtlL'etics-Sports Medicine can use or disclose infolnaation. You have a right to tesie?a.? our Policies and Procedures before this authorLaation. Athlete Name: DOB: Address City: State. Eip Fhone Number hereby authorize to release heme of Athlete my me di cal records from the years Heme oi Person and Entity- Fteceis'ing F'hone hi r'1l:er Address of Person and Entit:.r Fteceis'ing Information Fat Hurr her to]! records ot-erE? pages should be mail-sol: Relea se ofthis information is being made For the Following purpose: Signatureol Athlete Date By signing this. fem: you have released all nieclic al informanon pertaining to inju1y or illness in speci?ed dates to the Unit'etstt'y oF Mtssouri Sports blediane Department. [18] Appendix E: Glasgow Coma Scale BEST EYE RESPONSE E BEST VERBAL RESPONSE V BEST MOTOR RESPONSE M Spontaneous---open with blinking at baseline Opens to verbal command or speech Opens to pain, not applied to face None Oriented Confused conversation, able to answer questions Inappropriate responses, words understandable Unable to undersatnd speech None Obeys direction for movement Intentional movement to painful stimulus Withdraws from pain Abnormal (spastic) flexion, decorticate posture Extensor (rigid) response, decerebrate posture None **Medical emergency if an individual grades out with less than 13 points. [19] 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 Appendix F: Post-Concussive Care Document POST-CONCUSSION INFORMATION SHEET Definition: A concussion is a form of traumatic brain injury, generally caused by a force to the head or body that causes your brain to move quickly within the skull. Generally, most people receover quickly from a concussive injury. It is important during this time to allow your brain to recover. SYMPTOMS TO BE AWARE OF: Please contact your athletic trainer if you have any of the following: 1. Repeated vomiting 2. Headache intensifies 3. Increased confusion, agitation 4. Difficulty with balance 5. Weakness/numbness 6. Vision difficulties THINGS YOU CAN DO TO FEEL BETTER: ATHLETIC TRAINER Get plenty of rest and sleep. NAME: __________________ Drink plenty of fluids Eat normally STAY away from computers, phones, video games, movies, and TV PHONE: _________________ ADDITIONAL INSTRUCTIONS: ___________________________________________________ ___________________________________________________ ___________________________________________________ [20] Appendix G: CONCUSSION FLOW SHEET PRE-SEASON CONCUSSION EDUCATION/ASSESSMENT NCAA Fact Sheet (signed and kept in file) SCAT-3 Baseline during yearly physical. Team Physician clears for play or refer to further testing Mental Health/Learning Disabled Athletes Appointment with Dr. Tom Martin Symptoms of Concussion Concussive Force/Hit No symptoms of concussion **Recheck in ~15 minutes EMERGENCY ACTION PROTOCOL CALL 911 REMOVAL by ATC/Team Physician During competition, Athlete moved to Locker Room/Athletic Training Room for evaluation No sign of Concussion No further care needed Examination SCAT-3 Testingcompare to previous testing Notification of Coaches/Academic Advisors, Athletic Performance, Director of Sports Medicine Discussion with Athlete and Responsible Adult  Given Concussion Care Document Return to Play: 5 step protocol. Must complete all steps with no symptoms of concussion. 1. Light Cardio 2. Fundamental/Skills during practice 3. Non-Contact Practice/Progression into Weight Room Activities 4. Unrestricted Training 5. Team Physician gives final clearance for full participation Return to Learn: RTL through Cognitive step-wise protocol Athletic Department Management Team NO CLASSWORK for 24 hours post-injury Less than 2 week injury: Work with academics staff to make slight modifications More than 2 week return: Campus/Athletics Management Team; Campus Disabilities [21] Appendix H: CAMPUS RESOURCES University of Missouri: Campus Disability Center: disabilitycenter.missouri.edu Address: S5 Memorial Union, Columbia, MO 65211 Voice: 573-882-4696 VP: 573-234-6662 Fax: 573-884-5002 E-mail: disabilitycenter@missouri.edu Office Hours: Monday-Friday, 8:00 a.m.–5:00 p.m. Director: Barbara Hammer, M.Ed. University of Missouri Health Care Dr. Tom Martin, Neuropsychologist Carmen Abbott, Physical Therapist Specializing in Vestibular Rehabilitation Lisa Smith, Occupational Therapist at the Neurology Clinic Specializing in cognitive deficits and neurological vision Justin Midyett, Physical Therapist at the Neurology Clinic Specialist in Traumatic Brain Injuries [22] 2015-16 University of Nebraska Athletic Medicine Head Injury Management Protocol The University of Nebraska-Lincoln (UNL) Department of Athletics takes the health and well-being of our student-athletes very seriously. In developing the following Head Injury Management Protocol, the institution reviewed the requirements of NCAA Bylaws 3.2.4.17 and 3.2.4.17.1 and the Concussion Safety Protocol Checklist distributed by the NCAA. The resulting protocol helps protect student-athlete health and well-being and provides the Athletics Department’s medical providers with the authority and professional discretion to act in the best interests of the student-athlete. Head injuries, like concussions, are inherently unpredictable and can occur despite safeguards and best practices employed by those responsible for coaching and providing medical care to student-athletes. When head injuries occur, the Head Injury Management Protocol will provide a plan that helps protect the student-athlete and provides unquestioned authority to the medical providers to diagnose and treat the student-athlete. The Head Injury Management Protocol also recognizes the important role academic services plays in supporting the student-athlete’s academic responsibilities and follows campus protocols regarding how students with cognitive disabilities are treated. Education All student-athletes receive a copy of the “NCAA Concussion Fact Sheet for Student-Athletes” (also available on the NCAA.org website). Student-athletes are provided an opportunity to ask questions and seek clarification from Athletic Medicine staff regarding the fact sheet. Student-athletes receive and are asked to sign a Shared Responsibility for Sports Safety Form which acknowledges the expectations, risk, and that this information was discussed. Athletic Medicine staff, which include Athletics Trainers Certified (hereinafter “ATC”) and the Associate Athletics Director for Athletic Medicine/Head Team Physician (hereinafter “Head Team Physician”), receive and review copies of the “NCAA Concussion Fact Sheet for Student-Athletes” and the “NCAA Concussion Fact Sheet for Coaches.” ATCs provide the “NCAA Concussion Fact Sheet for Coaches” to all coaches. ATCs and coaches sign an acknowledgement form documenting the date the concussion information was reviewed by the ATCs and coaches. The Director of Athletics receives the “Concussion Fact Sheet for Student-Athletes” and the “Concussion Fact Sheet for Coaches” prior to certifying the institution’s Head Injury Management Protocol. The Director of Athletics’ written certification of the protocol serves as acknowledgement of receipt of the Concussion Fact Sheets. 1 Student-Athlete Medical History & Physicals All student-athletes are asked to provide their personal history of head injury and concussions, at the time of pre-participation physicals. Details of previous head injury and/or concussions are reviewed with the student-athlete. All student-athletes receive a one-time baseline evaluation. Evaluations include brain injury and concussion history, symptom evaluation, cognitive assessment, and balance evaluation. The symptom evaluation consists of twenty-two questions included in the ImPact neurocognitive test that student-athletes complete. The cognitive assessment occurs as part of the ImPact test. The balance evaluation consists of the BESS and additional testing by the institution’s Dizziness and Balance Disorder Lab. The Head Team Physician may have student-athletes undergo additional testing or meet with a neurologist depending on the student-athlete’s baseline assessment. Response to Injury & Initial Assessment Immediately upon suspicion or indication that a student-athlete has sustained a head injury the student-athlete is removed from the contest or practice session. An ATC (or physician) in attendance conducts a symptom review and tests memory and balance, as appropriate, based on the student-athlete’s symptoms. If the student-athlete’s response to this initial assessment reveals symptoms or cognitive features consistent with a concussion the student-athlete is referred to a physician. A student-athlete diagnosed with a concussion is precluded from returning to athletics activity (e.g., competition, practice, and conditioning sessions) for at least the remainder of the calendar day. Student-athletes with worsening mental status or other neurological symptoms (such as Glasgow Coma Scale < 13, spine injury, prolonged loss of consciousness, focal neurological deficit suggesting intracranial trauma, repetitive emesis, and persistently diminished/worsening mental status or other neurological signs/symptoms) are referred for immediate follow-up medical care. Physician Assessment and Care Plan Following Initial Assessment After the initial assessment, the physician to which the student-athlete has been referred, obtains a neurologically oriented history and physical exam and records the findings in the student-athlete’s medical record. If the student-athlete's condition is considered stable a responsible individual (generally a roommate or relative of the student-athlete) is asked to remain in the student-athlete's presence for a determined time (usually 12-24 hours), and to agree to report any observed confusion, increasing headache, excessive drowsiness, or any other symptoms of concern to the Head Team Physician. A copy of the head injury form is provided to the student-athlete which includes the contact numbers (cell and home) for the Head Team Physician. A parent (or parents) will be notified of the injury and asked if the parent is comfortable with the 2 care plan. A student-athlete with a prolonged recovery is evaluated by a physician so that additional diagnoses and best management options are considered. Possible additional diagnoses include, but are not limited to: post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression, and ocular or vestibular dysfunction. Furthermore, student-athletes with severe head injuries, recurrent concussions, or post-concussive symptoms lasting more than a few days are referred to a neurologic specialist with experience in managing sports related concussions. Student-athletes are informed that omega-3 supplements may be of benefit in supporting cellular recovery post-concussion and are encouraged to consider omega-3 supplementation. Follow-up and Release for Return to Play Following the care plan, the student-athlete’s symptoms and cognitive function continue to be monitored and assessed. If no photophobia, phonophobia, dizziness, nausea, or severe headache is reported, follow-up assessments may include a neurocognitive test. However, a neurocognitive test is not used if the student-athlete has symptoms which would potentially be aggravated by, or interfere with, performing the concentration and reaction time tests which are integral to the neurocognitive test. If the student-athlete has significant symptoms, rest is advised. The student-athlete's condition is followed on a daily basis. Prior to a release to return to play the student-athlete must complete a computerized neurocognitive test administered and evaluated by the consulting neuropsychologist and attain scores at or above the baseline test. The Head Team Physician checks for any neurologic dysfunction and repeats a balance test. Upon satisfying the Head Team Physician that the student-athlete’s neurologic state has returned to normal, the student-athlete is released to a graduated return to activity that is supervised by a health care provider with experience working with student-athletes with head injuries and concussions. The stepwise progression after the student-athlete returns to physical and cognitive baselines includes: (1) light aerobic exercise without resistance training; (2) sport-specific exercise and activity without head impact; (3) non-contact practice with progressive resistance training; (4) then unrestricted sport activity training. Progression from one step to the next is allowed if the student-athlete does not have worsening or new symptoms. If the unrestricted sport activity training is tolerated without worsening or new symptoms, the student-athlete is allowed to return to full sport participation and competition. The final return-to-play decision is made by the Head Team Physician. Academic Considerations: Return-to-Learn 3 When a student-athlete is diagnosed with a concussion, a return-to-learn management plan will be created, and the student-athlete may require academic modifications. The Head Team Physician will contact the Associate Director for Academic Programs. The Head Team Physician and Associate Director for Academic Programs will coordinate the return-to-learn management plan. They will solicit input, as needed, from the consulting neurologist, sports psychologist/sports psychiatrist, Senior Associate Athletics Director for Academic Services, Academic Counselor for the appropriate sport, and staff from the Office of Services for Students with Disabilities. This multi-disciplinary team will especially be engaged in those more complex cases of prolonged return-to-learn. If a student-athlete experiences post-concussive symptoms that are expected to be very brief, the Associate Director for Academic Programs will contact the student-athlete's course instructors informing them of the student-athlete’s condition, class absences, and possible academic modifications that are warranted. The student-athlete will be withheld from classroom activity on the same day a concussion is diagnosed. If a student-athlete experiences post-concussive symptoms lasting more than a few days, the Associate Director for Academic Programs will contact the Director of Services for Students with Disabilities (or designee) regarding the student-athlete’s condition. The Director of Services for Students with Disabilities (or designee) will work with the student-athlete to determine if academic accommodations through Disability Services are warranted. Accommodations approved by the Office of Services for Students with Disabilities will be implemented, in accordance with the Americans with Disabilities Act as amended (ADAAA). The student-athlete’s individualized initial return to learn plan states that the student-athlete should remain at the student-athlete’s home/dorm if the student-athlete cannot tolerate light cognitive activity. Once the student-athlete can tolerate 30-45 minutes of cognitive activity without return of symptoms, the student-athlete will gradually return to classroom activity, initially attending classes so that there is less than 60 minutes of classroom activity followed by rest of 15 minutes or more. For classes that are longer than 60 minutes, the Associate Director for Academic Programs will communicate with the student-athlete’s course instructor so that appropriate classroom breaks are implemented to account for the student-athlete’s condition and cognitive tolerance levels at that time. The student-athlete will work with the Head Team Physician and the Associate Director for Academic Programs during the stepwise return to class process. The Associate Director for Academic Programs will continue to communicate with the student-athlete and course instructors throughout this process so that appropriate class modifications are implemented. The student-athlete will be reevaluated by the Head Team Physician if the student-athlete’s concussion symptoms worsen with academic challenges. The student-athlete will be also re-evaluated by the Head Team Physician and the multidisciplinary team, as appropriate, when symptoms last longer than two weeks. Reducing Exposure to Head Injuries 4 The Athletics Department takes steps to help reduce student-athletes’ potential exposure to head injuries. For example, practice activities are conducted consistent with NCAA rules and compliance with these rules is monitored by the Athletics Department’s Compliance Office. Coaches shall teach proper practice techniques aimed at reducing exposure to head injuries. Using the Catapult GPS program, practices in football and women’s soccer are monitored for duration and student-athlete load (a measure of the student-athlete’s physical exertion). As a result, practices may be shortened to reduce physical wear on student-athletes. Athletics Department equipment staff members monitor the condition of football helmets, sending identified helmets to the manufacturer for refurbishment and purchasing some new helmets each academic year. The equipment staff also works with each student-athlete to make sure the student-athlete’s helmet fits properly. The Athletics Department collaborates with the UNL’s Center for Brain, Biology, and Behavior on research and testing that seek to reduce the exposure to head injuries by student-athletes and the general public. Effective with the 2015 football season, the Big Ten Conference will station an independent ATC in the video replay booth to monitor the game activity and have the ability to communicate directly with officials on the field. Review of Head Injury Management Protocol The Athletics Department will review its Head Injury Management Protocol annually and will meet at least once per year to discuss head injury cases that occurred during the academic year. This annual review will include review of the protocol for the identification, removal from game or practice, and assessment of student-athletes for possible concussions. Existing and revised Head Injury Management Protocol will be take into consideration best known practices and Inter-Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines. Certification of Compliance The Director of Athletics will annually certify written compliance with the Head Injury Management Protocol. Effective Date of Head Injury Management Protocol: May 1, 2015 5 Northwestern University Intercollegiate Sports Medicine Concussion Management Protocol It is well recognized that the management of mild traumatic brain injury (MTBI) is a field in evolution. The most common type of MTBI seen within athletics is a concussion. In order to provide our student-athletes with a consistent message in addition to exemplary care, it is necessary to follow a standard protocol in the management of a concussion. There are more than forty consensus-based definitions of concussion. A published evidence-based definition of concussion is a change in brain function following a force to the head or body which may be accompanied by temporary loss of consciousness, but is identified in most individuals with measures of neurologic and cognitive dysfunction. The ultimate return to play decision is based on the Head Team Physician’s, or designee’s assessment of the student athlete, using multiple means of evaluation. Each concussion is unique thus is managed as such. SPORT-RELATED CONCUSSION PREVENTION 1. Primary prevention of some injuries may be possible by delivering safetyfirst an n u a l education, coaching proper technique and enforcing the rules of play in all sports. 2. Biomechanical studies have shown a reduction in impact forces to the brain with the use of helmets, but these findings have not been translated to show a reduction in concussion incidence. Helmets are best suited to prevent injuries such as fractures, bleeding and lacerations. Helmets have not been shown to reduce the incidence and severity of concussions. As such, coaches are encouraged by the administration and medical staff to reduce gratuitous contact during practice. This is accomplished by limiting the number and repetitions of contact drills to those deemed necessary. 3. Athletes are coached to take their head out of contact through the execution of specific drills designed to repeat appropriate technique and head out of contact behaviors. 4. There is no current evidence that mouth guards can reduce the severity of, or prevent sport-related concussions. 5. Secondary prevention may be possible through accurate head injury history, accurate symptom reporting and appropriate return to play management. 6. NU will monitor and adhere to all inter-association consensus statements regarding head trauma, which include following specific practice contact guidelines and limitations. 7. NU will educate coaches and administrative staff continually through the Northwestern University Presidential Directive which states that medical staff (e.g. team physicians and athletic trainers) will have the unchallengeable authority to make medical decisions including but not limited to removal from and return to play. ANNUAL EDUCATION The NU Intercollegiate Sports Medicine team expects the student athlete to be active participants in their own healthcare. As such, the student athlete has the direct responsibility for reporting all injuries. Annually, each student athlete, coach, sport administrator (including the Director of Athletics), staff athletic trainer (AT) and team physician will be provided with education on head injuries and the importance of immediately reporting symptoms of a head injury/concussion to the sports medicine staff (pre-season team meeting as well as Appendix A). Additionally, each student athlete, coach, sport administrator, staff athletic trainer and team physician will acknowledge that NU has provided educational materials on concussion (Appendix B) and will be given an opportunity to ask questions about areas and issues that are not clear. BASELINE TESTING 1. Neurocognitive testing including symptom evaluation, brain injury history, concussion injury history and cognitive assessment will be administered to all student athletes in conjunction with their pre-participation physical (Appendix C). a. Student-athletes should be baseline tested upon entrance to Northwestern University and again in their 3rd year of athletic participation. b. Testing should occur in a quiet, controlled setting where interruptions/distractions can be minimized. c. It is recommended that five or fewer student-athletes participate in baseline testing concurrently in the same facility. d. It is recommended that baseline testing occur in the morning hours or the afternoon hours based on the typical in-season practice time for the student-athlete. 2. The Balance Error Scoring System (BESS) (Appendix C) will assess Balance and motor control systems. The AT will conduct the BESS test for each student athlete using consistent methods. 3. A Team Physician and a qualified neuropsychologist will review all baseline test results to verify that an accurate, normalized baseline result exists. If a test abnormality is discovered, time for follow-up testing and evaluation should be allotted. A Team Physician will determine pre-participation clearance based off of the pre-participation assessment information described above. CONCUSSION EVALUATION Upon sustaining a head injury, or if a head injury is suspected, the Team Physician/Athletic Trainer will administer a standardized concussion evaluation to the student-athlete provided other serious injuries do not take precedence over the head injury. In the initial management, the Team Physician/Athletic Trainer will refer for immediate transport for emergency medical evaluation with evidence of a spine injury, prolonged loss of consciousness, evidence of intracranial trauma, evidence of Glasgow Coma Scale < 13, repetitive emesis and/or consistently diminished mental status/neurological signs and symptoms (Appendix D). Team Physician will make final decision on disposition status. The standardized concussion evaluation includes, but is not limited to: symptom assessment, physical and neurological exam, cognitive assessment, balance exam, and clinical exam for cervical spine trauma, skull fracture, and an intracranial bleed (Appendix D). a. If diagnosed with a concussion, the student athlete must be removed from that practice/contest immediately, and for the remainder of that day. Close monitoring through serial exams should occur. b. Prior to leaving the Team Physician or AT for the day, education should be provided to both the student-athlete and a roommate/ teammate/ parent, including a signed acknowledgement (Appendix E). c. If the Team Physician, or his/her designee, does not classify the head injury as a concussion, return-to-play will be at the discretion of the AT or Team Physician. 2. Post-concussion evaluation by a Team Physician should be done as soon as possible and preferably within 24 hours of the concussive event. POST-CONCUSSIVE CARE Initial Management 1. Student-athletes who sustain a concussion will maximize rest from cognitive and physical exertion as well as excessive stimulation until their symptoms are clear for 24 hours 2. In conjunction with the Team Physician, the AT will document communication of all applicable recommendations, restrictions, limitations and necessary adaptations to the student-athlete and another responsible adult (Appendix E). 3. The Team Physician and/or AT will document communication of all applicable recommendations, restrictions, limitations and necessary adaptations to the appropriate athletic department support staff (eg. Coaches, Sport Performance Coaches, Academic Support Staff, and Equipment Staff) (Appendix F). 4. Symptom checklists and serial evaluation (Appendix G) should be completed daily to assess the student-athlete. Results will be given to the team physician for review. Return to Play Progression The return to play progression is based in part on accurate symptom reporting. A Team Physician/AT will make the determination of ‘asymptomatic’. Asymptomatic can be challenging to define. The representative symptoms of sport-related concussion are decidedly nonspecific, not necessarily related to brain injury, and are common in people with a variety of other medical condition. 1. Once asymptomatic for 24 hours, and a normal exam is established by the team physician, the student-athlete will be exertion challenged to assess for return of symptoms (non-impact cardio 50% - 70% aged-predicted maximal heart rate for 20-25 minutes.) 2. If asymptomatic during and for a minimum of 3 hours following the exertion test, the student athlete should complete post-concussive neurocognitive testing and motor control test. Both the Team Physician and neuropsychologist will review results of neurocognitive testing. 3. If repeat neurocognitive and/or motor control testing is abnormal, despite clearance of symptoms and normal exertion testing, further evaluation by the Team Physician will occur. The Team Physician may determine that evaluation by the neuropsychologist is warranted. The neuropsychologist may require additional neurocognitive testing. 4. Important components of management after the initial period of physical and cognitive rest may include associated therapies such as cognitive, vestibular, physical, and psychological therapy, and consideration of assessment of other causes of prolonged symptoms. 5. If the student-athlete remains asymptomatic with an exertional challenge and the post-injury neurocognitive and motor control testing is determined normal by the Team Physician and neuropsychologist, the student-athlete, under supervision of an AT, will progress through a graded exercise program. a. Example protocol is as follows:  Stage 1: Non-impact cardio without resistance <70% agepredicted maximal heart rate for 20-25 minutes  Stage 2: Sport-specific activities with increased intensity without the threat of contact from others  Stage 3: Non-contact training involving others, progressive resistance training  Stage 4: Unrestricted training, including contact/collision, but not participation in a competition  Stage 5: Return to full participation, including competition b. A typical timeframe between stages consists of 24 hours. However, if activity at any stage results in a return of symptoms, or new symptoms, then the activity should be immediately halted and restarted the next day if asymptomatic. In cases of recurrent symptoms, the treating Team Physician should be notified and will determine whether re-evaluation is warranted. c. Some student athletes may have minimal concussive symptomology with minimal symptom duration and no modifiers (conditions that may prolong recovery such as prior concussion, migraine, ADHD, ocular motor/vestibular disturbance, sleep dysfunction, depression/anxiety). In scenarios of this nature, at the direction of the Team Physician, the return to play progression may be modified to determine the best management options. 6. If the student-athlete experiences prolonged symptoms or if severity of symptoms increases, the Team Physician will consider additional evaluation and consultations. Low-level exercise for those who are slow to recover may be of benefit as determined by the Team Physician or sub-specialist. 7. Prior to final clearance the student athlete will have a routine return to play evaluation by an independent neurological consultant. 8. Final clearance is based on the student-athlete being symptom-free at rest and with progressive activity, normalized neurocognitive testing, normalized motor control testing, and a physical examination. 9. The final return to play decision is made by an NU Team Physician or designee in consultation with a neuropsychologist, independent neurological consultant, and other specialist as appropriate. 10. Special academic accommodations should be considered for the concussed student-athlete as described below. Return to Learn Following concussion, there is presumed to be a brain energy crisis. The brain energy crisis is a common explanation for many concussion symptoms, including delayed reaction time, poor working memory, dizziness, imbalance and a number of other cognitive, emotional and physical symptoms. Although a concussion can have obvious direct effects on learning, there is also increasing evidence that cognitive activity with a concussed brain may worsen concussion symptoms and prolong recovery. Increasing cognitive activities are hypothesized to add additional stress to an energy-deprived brain, which may worsen symptoms. The goal during concussion recovery is to avoid overexerting the brain to the level of worsening symptoms. Determining the appropriate balance between how much cognitive exertion and rest is needed is the hallmark of the management plan during cognitive recovery. Experts agree that return-to-activity should be accomplished in a step-wise manner, beginning with physical rest. Return-to-learn (RTL) is a parallel concept following concussion. Cognitive rest is at the centerpiece of the RTL plan. Cognitive rest means avoiding potential cognitive stressors such as academic work, reading, texting, video games, and viewing television. Like return-to-activity, it is not always easy to provide prescriptive recommendations for RTL because the student athlete may appear physically normal but is unable to perform at her/his expected baseline, due to concussive symptoms. RTL recommendations should be made within the context of a multi-disciplinary team that includes, but is not limited to physicians, athletic trainers, academic advising staff, coaches, administrators, professors and teammates. The challenge of the multidisciplinary team is to balance the need for the student to be active academically with the appropriate adjustments for the cognitive demands that have the potential of increasing symptoms. RTL multidisciplinary team members should be well versed in their roles and responsibilities and keep communication open among all parties regarding decisions to progress, regress, or maintain status quo during the RTL process. Multidisciplinary Teams may include: Medical Team Role- evaluate the concussion, assess for more serious injury, prescribe physical and cognitive rest as appropriate until symptom-free, manage rehabilitation and act as the primary communication line to coaches. Team members include, but are not limited to Team Physician, Staff Athletic Trainer (AT), Neurological Sub-specialist, Psychologist, and Psychiatrist. The AT will serve as the point person to navigate the RTL process. Academic Team Role- to coordinate the return to cognitive exertion and help to facilitate the appropriate level of academic adjustments and learning aids necessary to reduce or eliminate symptoms. Team members include, but are not limited to Athletic Academic Advisor, Campus Academic Advisor, Faculty Athletic Representative, Assistant Dean of Students, Office of Services with Students with Disabilities (AccessibleNU), Sport Administrator, Academic Dean, Professors and teaching assistants. Family Team Role- to enforce rest and reduce cognitive stimulation to the student during the recovery process. Team members include, but are not limited to roommates, teammates, parents, coaches, and close friends. When prescribed, cognitive rest following concussion means avoiding academic-related activity for at least one day. This includes no classroom work on the same day as concussion diagnosis. The gradual return to cognitive activity is based on the return of concussion symptoms following cognitive exposure. An individualized plan will be developed that will consider the following: 1. If the student cannot tolerate 30 minutes of light cognitive activity, s/he should remain at their residence or recover according to medical team recommendations. 2. Once the student can tolerate 30-45 minutes of cognitive activity without return of symptoms, s/he should return to the classroom in a step-wise manner. Such return should include no more than 30-45 minutes of cognitive activity at one time followed by at least 15 minutes of rest. 3. The Medical Team and the Academic Team, on a case-by-case basis, should decide the levels of adjustment required. 4. If concussion symptoms worsen with academic challenges, the student will be re-evaluated by the Team Physician. The majority of students who are concussed do not need a detailed RTL program because full recovery occurs within 7-10 days. RTL management becomes more challenging when the student has ongoing symptoms for greater than 7-10 days. In those cases, the Multidisciplinary Team will re-evaluate the student and may need to enact academic adjustment, accommodation, or modification. Academic Adjustment- the student’s academic schedule requires some modification in the first week or two following concussion. In this case, full recovery is anticipated, and the student will not require any meaningful curriculum or testing alterations. The Medical Team will communicate missed class excuses with the Academic Team. Academic Accommodation- the student has persistent symptoms and may require change in the class schedule as well as special arrangements for exams, projects and papers. There is no timeline for academic accommodation. The Medical Team will communicate ongoing symptoms with the athletic department members of the Academic Team. The athletic department Academic Team members will work closely with the full Academic Team, including all campus resources, to enact necessary adjustments in the school setting in compliance with the American Disabilities Act Amendments Act (ADAAA). These may include: Symptom Headaches Dizziness Visual Symptoms Noise Sensitivity Difficulty Concentrating Sleep Disturbances Accommodation Frequent breaks Identifying aggravators and reducing exposure to them Rest in quiet areas Referral to Medical Team Avoid the initiating stimuli Reduce exposure to computers, tablets, smart boards Reduce brightness on screens Use of hat or sunglasses indoors Turn off fluorescent lights as needed (in dorm) Seat closer to center of classroom (for blurry vision) Consider use of earplugs Early dismissal to avoid crowded hallways Avoid (delay) testing or completion of major projects Provide extra time to complete non-standardized tests Consider the use of pre-printed notes, note takers, Smart Pen, or reader for oral test taking Allow for prolonged rest breaks Academic Modification- a more challenging scenario in which the student suffers with prolonged cognitive difficulties, which may require a more specialized educational plan, usually within the construct of an Individualized Education Plan (IEP) and in compliance with ADAAA. The Academic Team, in concert with on-campus resources like AccessibleNU and Learning Specialists will coordinate the IEP. Additionally, prolonged symptoms that remove a student from the classroom for an extended period may require a Medical Leave for the remainder of the academic quarter. This intervention will require detailed coordination between the student and the Academic Team, in consultation with the Medical Team. Comorbid conditions such as mental health issues (i.e. depression), ADHD, learning disabilities, and sleep disorders have been reported as a consequence of sport-related concussion. Although mental health issues may be multifactorial in nature, the treating physician will consider these issues in the treatment recommendations and communicate with multidisciplinary team. Although healing may be prolonged with some concussions, the expectation is still for a full recovery that no longer would require academic adjustments, accommodations, or modifications. Staff and Faculty Education Plan: Given the large number of concussions occurring each year, education of all individuals involved is paramount to helping students who may need assistance. Education will be available annually to the academic community regarding concussion, symptoms, the role of cognitive and physical rest, and RTL strategies. Specifically, it is essential for the individuals directly involved in the management of a concussed student to receive ongoing, tailored education as needed. Return to Learn Resources: Center for Disease Control and Prevention: Heads Up for Schools www.cdc.gov/concussion/HeadsUp/schools.html Center for Disease Control and Prevention: Fact Sheet for School Professionals on Returning to School after a Concussion www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf Brain 101: Concussion Handbook: http://brain101.orcasinc.com/1000 References: Broglio SP et al: National Athletic Trainers’ Association Position Statement: Management of Sport Concussion. Journal of Ath Train. 2014; 49(2) 245-265. Hainline B: Concussion: Return-to-Learning Guidelines, December 2013. National Collegiate Athletic Association News. Halstead ME et al: Returning to Learning Following a Concussion, October 2013. Pediatrics. 2013; 132; 948. Howell D et al: Effects of Concussion on Attention and Excessive Function in Adolescents. Med Sci Sports Exerc. 2013;45(6): 1030-1037. Inter-Associations Consensus: Diagnosis and Management of Sport-related Concussion Guidelines. NCAA Sport Science Institute. 2014 McCrory P et al. Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sports held in Zurich, November 2012. Br J Sports Med. 2013; 47:250-258. Sady MD et al: School and the Concussed Youth: Recommendations for Concussion Education and Management. Phys Med Rehabil Clin N Am. 2011; 22(24):701-719, ix. West AD and Marion DW: Current Recommendations for the Diagnosis and Treatment of Concussion in Sport: A Comparison of Three New Guidelines. Journal of Neurotrauma. 2014; 31: 159-168. Appendix A Northwestern University Intercollegiate Sports Medicine CONCUSSION EDUCATION What is a concussion? A concussion is an injury to the brain caused by a direct or indirect blow to the head. It results in your brain not working as it should. The concussion may or may not cause you to black out or pass out. It can happen from a fall, a hit to head, or a hit to the body that causes your head and your brain to move quickly back and forth. The concussion can present itself differently for each athlete and can occur during practice or competition in any sport. How do I know if I have a concussion? There are many signs and symptoms, ranging from mild to severe, that you may have after a concussion. A concussion can affect your thinking, the way your body feels, your mood, or your sleep. Signs and symptoms may not happen right away. Here is what to look for in the following symptoms: Thinking      Difficulty remembering Slowed reaction time Taking longer to figure things out Difficulty concentrating Difficulty thinking clearly Physical        Feeling sick to your stomach/queasy Headache Fuzzy or blurry vision Dizziness Vomiting/throwing up Balance problems Sensitivity to noise or light Emotional/Mood      Irritability-things bother you more easily Sadness Crying more Being more moody Sleep     Sleeping more than usual Feeling tired Sleeping less than usual Trouble falling asleep Feeling nervous or worried Table is adapted from the Centers for Disease Control and Prevention (http://www.cdc.gov/concusion/). What should I do if I think I have a concussion? If you are having any of the signs or symptoms listed above, you should tell your athletic trainer, team physician, coach, teammate, or parents so you can get the help you need. If a parent notices these symptoms, he or she should inform the athletic trainer. When should I be particularly concerned? If you have a headache that gets worse over time, you are unable to control your body, you throw up repeatedly or feel more and more sick to your stomach, or your words are coming out funny or slurred, let your athletic trainer, coach, team physician, parent know right away, so you can get the help you need before things get any worse. What are some of the problems that may affect me after a concussion? You may have trouble in some of your classes at school or even with activities at home. Avoid prolonged studying, computer work, and video games. If you continue to play or return to play too early after a concussion, you may have long term trouble remembering things or paying attention, headaches may last a long time, or personality changes can occur. Once you have a concussion, you are more likely to have another concussion. How do I know when it’s OK to return to physical activity and my sport after a concussion? After telling your athletic trainer, team physician, coach, parent, or any available medical staff that you think you have a concussion, you will be seen by a physician training in helping people with concussions. Your school has a policy in place on how to treat concussions. You should not return to play or practice on the same day as your suspected concussion occurred. You should not begin the return-to-play progression until all symptoms are gone, both at rest and during the after activity. Symptoms indicate that your brain has not yet recovered from the concussion and needs more rest. Severe brain injuries can change your whole life. Revised April 2015 Appendix B Northwestern University Intercollegiate Sports Medicine CONCUSSION EDUCATION ACKNOWLEDGEMENT FORM The NU Intercollegiate Sports Medicine team expects the student-athlete to be an active participant in their own healthcare. As such, the student-athlete has the responsibility for reporting all of his/her injuries and illnesses to the sports medicine staff of Northwestern (e.g., team physician, athletic trainer), including head injury and concussion. The student-athlete recognizes that his/her condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. Annually, each student-athlete will be provided with education on head injuries and the importance of immediately reporting symptoms of a head injury/concussion to the sports medicine staff. Additionally, each student-athlete will acknowledge that Northwestern has provided educational materials on what a concussion is and given student-athletes an opportunity to ask questions about issues that are not clear. By signing below I, are accurate. Signature of student-athlete _, have read the above and agree that the statements Date Michael Milligan MD Head Team Physician Signature of Head Team Physician Revised April 2015 Appendix C Utilized and Administered by: Northwestern University Intercollegiate Sports Medicine ImPACT's Test is computerized and takes about 25 minutes to complete. ImPACT recommends that it be administered by an ImPACT trained athletic trainer, school nurse, athletic director, team doctor or psychologist. Baseline tests are suggested every two years. If a concussion is suspected, the baseline report will serve as a comparison to a repeat ImPACT test, which professionals can use to assess potential changes or damage caused by a concussion. IMPACT Features  Measures player symptoms  Measures verbal and visual memory, processing speed, and reaction time  Reaction time measured to a 1/100th of second  Provides reliable baseline test information  Produces a comprehensive report of test results  Automatically stores data from repeat testing The test modules consist of a near infinite number of alternate forms by randomly varying the stimulus array for each administration. This feature was built in to the ImPACT Test to minimize the "practice effects" that have limited the usefulness of more traditional neurocognitive tests. The program measures multiple aspects of cognitive functioning in athletes, including:  Attention span  Working memory  Sustained and selective attention time  Response variability  Non-verbal problem solving  Reaction time Revised April 2015 Section 1: Demographic Profile and Health History Questionnaire  Section 1 of the ImPACT Test requires the test-taker to input basic demographic information and descriptive information through a series of easy-to-follow instructional screens. The test-taker inputs this information via a keyboard and must utilize an external mouse to navigate/select responses on the screen.  Many of the questions can be answered using "pull down" menus in the window. This section asks the test-taker to answer questions regarding height, weight, sport, position, concussion history, history of learning disabilities and other important descriptive information. Section 2: Current Concussion Symptoms and Conditions  This section of the ImPACT Test asks questions about the test-taker’s most recent concussion date, hours slept last night, and current medications. The test-taker is then to rate the current severity of 22 concussion symptoms via a 7-point Likert scale.  This Likert scale is currently utilized by the NFL and NHL and has been endorsed by the Vienna Concussion in Sports (CIS) group.  The concussion symptom scores are displayed in the ImPACT test report along with the symptom total score. Revised April 2015 Section 3: Baseline and Post-Injury Neurocognitive Tests  After completing the Demographic and Current Symptoms, the test-taker will begin the neurocognitive test section, which is comprised of six modules.  Module 1: Word Discrimination  Evaluates attentional processes and verbal recognition memory utilizing a word discrimination paradigm.  Module 2: Design Memory  Evaluates attentional processes and visual recognition memory using a design discrimination paradigm.  Module 3: X's and O's  Measures visual working memory as well as visual processing speed and consists of a visual memory paradigm with a distractor task that measures response speed  Module 4: Symbol Matching  Evaluates visual processing speed, learning and memory.  Module 5: Color Match  Represents a choice reaction time task and also measures impulse control and response inhibition.  Module 6: Three Letter Memory  Measures working memory and visual-motor response speed. Section 4: Graphic Display of ImPACT Test Scores There are five ImPACT Test scores calculated from the neuropsychological tests administered, and each is displayed graphically: Composite 1: Verbal Memory Composite This score is comprised of the average of the following scores:  Total memory percent correct  Symbol match (total correct hidden symbols)  Three letters (total percent of total letters correct) A higher score indicates better performance on the Verbal Memory Composite. Composite 2: Visual Memory Composite This score is comprised of the average of the following scores:  Design memory (total percent correct score) Revised April 2015  X's and O's (total correct memory score) A higher score indicates better performance on the Visual Memory Composite. Composite 3: Processing Speed Composite This score is comprised of the average of the following scores:  X's and O's (total correct (interference))  Three-letters (average counted correctly) A higher score indicates better performance on the Processing Speed Composite. Composite 4: Reaction Time Composite This score is comprised of the average of the following scores:  X's and O's (average correct RT (interference))  Symbol match (average correct RT/3)  Color match (average correct RT) A lower score indicates better performance on the Reaction Time Composite. Composite 5: Impulse Control Composite This score is comprised of the average of the following scores:  X's and O's (total incorrect (interference))  Color match (total commissions) A lower score indicates better performance on the Impulse Control composite. Total Symptom Composite This score represents the total for all 22 symptom descriptors. A lower score indicates fewer endorsed symptoms by the test-taker. This series of graphs allows direct comparison of test performance in these core areas across multiple testing sessions. The composite scores were constructed to provide summary information regarding different broad cognitive domains. Thus far, ImPACT's studies have indicated the verbal memory, visual memory, processing speed, reaction time and symptom scores assist in making a determination between concussed and non-injured individuals. Revised April 2015 B.E.S.S. Test Report Monday, March 02, 2015 Client: Test Patient Test Date: 3/2/2015 Over the past several years, there has been an increased focus on better understanding and assessing concussions in sports. The BESS test (or modified BESS test) is a balance assessment protocol that was developed specifically for assessing sports concussions. It is part of the SCAT3™ Sport Concussion Assessment Tool. Although the BESS test is generally accepted by the clinical research community, some concerns have been raised about inter- and intra-rater reliability of the manual scoring. MobileMat BESS addresses these concerns by automating the process and virtually eliminating the opportunity for human error. This is a new software that would walk testers through the BESS protocol and provide a reliable score. In order to ensure the product scored the BESS test accurately, Tekscan sent it for validation testing with researchers at the University of Delaware. The researchers there, led by Dr. Thomas Kaminski, tested the scoring of the MobileMat BESS system against their usual testing protocol. After testing nearly 100 athletes at their facility, they found that the MobileMat BESS scored balance errors just as well as their three trained testers. MobileMat BESS ensures scores for their athletes will always be determined in the same way, regardless of the training and experience levels of the tester. This system gives them the peace of mind and confidence that they can meaningfully compare and trend their athletes’ BESS scores relative to their baseline, even over multiple seasons. MobileMat BESS will be administered by a NU Healthcare Provider for both baseline assessments, as well as, any and all post-head injury assessments, reviewed for comparison and used in the determination of return to play for the student-athlete. Revised April 2015 Appendix D Northwestern University Intercollegiate Sports Medicine HEAD-INJURY INITIAL EVALUATION TOOL Athlete Sport Date Completed Time Completed Injury Date Injury during: PRACTICE / GAME / Other Injury Time Other Circumstances Exam Location Opponent A. Symptom Checklist - Athlete should score themselves on the following symptoms, as applicable, based on how they feel at the time checklist is completed. (i.e. 0 = none/non present, 1 = mild, 3 = moderate, 6 = severe) Headache "Pressure in head" Neck pain Nausea or vomiting Dizziness Blurred vision Balance problems Sensitivity to light Sensitivity to noise Feeling slowed down Feeling like "in a fog" "Don't feel right" 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 Difficulty Concentrating Difficulty Remembering Fatigue or low energy Confusion Drowsiness More Emotional Irritability Sadness Nervous or Anxious Trouble Falling Asleep 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 B. Word Recall 5 Words read to athlete Immediate Recall Yes No Indicate to athlete that delayed recall will be tested in greater than 5 minutes C. Orientation - Did they provide correct answers What month is it? What is the day of the week? What year is it? What time is it right now? (within an hour) Where are we? What drill/quarter/half is it right now? What is the score? Who is winning? (If applicable) Who did we play last game? Did we win the game? Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No D. Concentration - Months in Reverse Order (Did they provide a correct sequence) Dec - Nov - Oct - Sept - Aug - Jul - Jun - May - Apr - Mar - Feb - Jan Yes No Revised April 2015 E. Physical & Neurological Exam - Examination of Cervical Spine, Skull, Facial Bones and Assessment of Cranial Nerves, Oculovestibular Exam, Reflexes, Myotomes & Dermatomes and Manual Muscle Tests (any signs of..) Skull - Appearance/palpation of point of impact Yes No Facial Bones - Battle's Sign / Racoon Eyes / Jaw deformity Yes No Cervical Spine - FROM / Paravertebral muscle spasm / Torticolis / Tenderness Yes No Eyes - PERRLA / Anisocoria / Nystagmus / Hyphema Yes No Ears - Hemotympanum / Discharge or drainage Yes No Nose - Deformity / Epistaxis Yes No Oropharynx - Intraoral lacerations / Missing or loose teeth Yes No Cranial Nerves - All 12 intact Oculovestibular Exam - Convergence / REM & stationary head / Rapid head rotation & fixed gaze / Ambulation w/ alternating head rotation Reflexes - Biceps (C5-6) / Brachioradialis (C6) / Triceps (C7) / Patella (L2-L4) / Achilles (S1) Sensory / Motor Exam Manual Muscle Tests - Upper and lower quadrant screen Any signs of Intracranial Bleeding WNL Abnormal WNL WNL WNL WNL Yes Abnormal Abnormal Abnormal Abnormal No If applicable - BESS or MobileMat F. Modified BESS - This is calculated by adding 1 error point for each error during the three 20-sec tests. The maximum total # of errors for any single condition is 10. The higher the score, the worse the player's balance. Balance testing - examples of errors Reminders1. Hands lifted off illiac crest Hands on iliac crests 2. Opening eyes Eyes closed 3. Step, stumble, or fall Maintain position for 20 sec 4. Moving hip into > 30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of test position > 5 sec Non-dominant foot tested Left Right Double leg stance (feet together) Single leg stance (non dominant foot) Tandem stance (non dominant foot at back) Firm Foam # errors # errors # errors G. Delayed Word Recall - Complete 5 minutes after Section B Words recalled H. Obvious Signs of Disqualification (i. e. "No Go") LOC or unresponsiveness? (for any period of time) If so, how long? Confusion? (any disorientation or inability to respond appropraitely to questions) Amnesia (retograde / anterograde)? New and/or persistent symptoms: see checklist? (e.g. headache, nausea, dizziness) Abnormal neurological finding? (any motor, sensory, cranial nerve, balance issues, seizures) Progressive, persistent, or worsening symptoms? Completed by: Physician Present: YES Yes Yes Yes Yes Yes Yes No No No No No No NO Physician Reviewed: Revised April 2015 Appendix E Northwestern University Intercollegiate Sports Medicine POST-INJURY EDUCATION About Your Diagnosis A concussion is an injury to the brain caused by a blow to the head, neck or body, or by striking the head with another object. It may, or may not, result in loss of consciousness or confusion. It may cause Amnesia or loss of memory about the events related to the concussion as well as a variable amount of time before or after. Many individuals with a concussion may also be dizzy, have a decrease in muscle coordination or have a decrease in their ability to concentrate. The effects of a concussion usually resolve completely within a few hours or days. What can you do to speed recovery? If any of the symptoms below develop before the follow up appointment with either your athletic trainer or team physician, please call your athletic trainer or sports medicine staff immediately.       Decreasing level of consciousness Increasing confusion Increasing irritability Loss of or fluctuating level of consciousness Numbness in the arms or legs Pupils becoming unequal in size      Repeated vomiting Seizures Slurred speech or inability to speak Inability to recognize people or places Worsening headaches Otherwise, you can follow the instructions outlined below. It is OK to  Use acetaminophen (Tylenol) for headaches  Use ice pack on head and neck as needed for comfort  Go to sleep and get plenty of rest  Keep meals light, but carbohydrate-rich, and stick to clear fluids  Discuss current medications with physician to see if you should stop taking them while recovering Do NOT  Drink alcohol  Do not use aspirin or ibuprofen type medications  Drive a car or operate machinery  Engage in physical activity (eg, exercise, weight lifting, sport participation)  Engage in mental activity (eg, classwork, homework, job, TV, computer games, cell phone use, email) that makes symptoms worse or until your physician has laid out your recovery plan  Lie about your symptoms being better as it will put you at more risk I, _, acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting to the sports medicine staff of my institution. I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms and complaints. I hereby affirm that I will also disclose any future symptoms and complaints related to my concussion. I have been provided with education on post-concussion care and understand the importance of immediately reporting symptoms of a head injury/concussion to my sports medicine staff member(s). By signing below, I acknowledge that my institution has provided me with specific educational materials on postconcussion care and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. Signature of Student Athlete Signature of Healthcare Provider Date Date Signature of Responsible Adult Date Revised April 2015 Appendix F Northwestern University Intercollegiate Sports Medicine Post-Head Injury Care Recommendations for Support Staff Student Athlete M F Examination Date Injury Date Sport Physician Primary Concussion Mechanism Sport Performance Recommendations/Limitations Name: Academic Services Recommendations/Limitations Name: Equipment Staff Recommendations/Limitations Name: Other Support Staff Recommendations/Limitations Athletic Trainer Date Team Physician Date Revised July 2014 Appendix G Northwestern University Intercollegiate Sports Medicine POST-HEAD INJURY SYMPTOM CHECKLIST Student Athlete: Date of Injury: Sport: Date and Time Checklist Completed: Headache 0 1 2 3 4 5 6 “Pressure in head” 0 1 2 3 4 5 6 Neck pain 0 1 2 3 4 5 6 Nausea or vomiting 0 1 2 3 4 5 6 Dizziness 0 1 2 3 4 5 6 Blurred vision 0 1 2 3 4 5 6 Balance problems 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 Feeling slowed down 0 1 2 3 4 5 6 Feeling like “in a fog” 0 1 2 3 4 5 6 “Don’t feel right” 0 1 2 3 4 5 6 Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6 Fatigue or low energy 0 1 2 3 4 5 6 Confusion 0 1 2 3 4 5 6 Drowsiness 0 1 2 3 4 5 6 Trouble falling asleep 0 1 2 3 4 5 6 More emotional 0 1 2 3 4 5 6 Irritability 0 1 2 3 4 5 6 Sadness 0 1 2 3 4 5 6 Nervous or Anxious 0 1 2 3 4 5 6 Do the symptoms get worse with physical activity? Yes No N/A Do the symptoms get worse with mental activity? Yes No N/A Total number of symptoms (max possible 22) Symptom severity score (max possible 132) Signature of Administer Printed Name of Administer Revised June 2015 The University of North Carolina at Chapel Hill Sport Concussion Policy Developed by the Matthew A. Gfeller Sport-­­Related Traumatic Brain Injury Research Center and Campus Health Services Division of Sports Medicine The University of North Carolina at Chapel Hill has been recognized as a leading institution for the evaluation and treatment of sport-related concussions. This is due in part to the long-standing collaborations between UNC Campus Health Services’ team physicians and certified athletic trainers, and clinical researchers at the Matthew A. Gfeller Sport-Related Traumatic Brain Injury Research Center (hereinafter referred to as “Gfeller Center”). Our concussion policy and concussion management protocol have been developed over the past several years, and are derived from the most recent literature on sport-­­related concussion. Our clinical research conducted at UNC­Chapel Hill’s Gfeller Center, and corroborated by others, has shown that an athlete's balance and/or cognitive functioning are often depressed following a concussion – even in the absence of self­reported symptoms. It has been demonstrated that it typically takes anywhere from 3 to 10 days for an athlete to return to their normal state following a concussion. However, in some cases athletes can experience post­concussion syndrome in which the symptoms last beyond 3 weeks. The UNC Sports Medicine staff utilizes a three-fold approach when determining an athlete’s readiness to return to play following a concussion. In the event of a suspected concussion, the concussion management protocol requires the evaluation of the athlete's symptoms, neurocognitive function, and balance, which provide the sports medicine staff with the objective information necessary to return the athlete to play safely. The findings of these post­injury assessments are then compared to pre­season baseline assessments, conducted on all studentathletes participating in UNC varsity sports during their first year. Any athlete sustaining a concussion during a season is also re-baseline tested prior to the start of the following season. All athletes on all UNC varsity teams are preseason baseline tested. The following concussion policy and concussion management protocol have been adopted by UNC Sports Medicine and are to be followed by all teams for managing athletes suspected of sustaining a concussion. The clinical research team in the Matthew Gfeller Center will evaluate only athletes under the direct medical care of UNC team physicians. Updated July 15, 2015 1 UNC Concussion Policy 1) All UNC student-athletes must read the NCAA Concussion Fact Sheet and sign the attached student athlete statement acknowledging that: a. They have read and understand the NCAA Concussion Fact Sheet b. They accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. 2) All UNC coaches (head coaches and assistant coaches) must read and sign the attached coaches statement acknowledging that they: a. Have read and understand the NCAA Concussion Fact Sheet b. Will encourage their athletes to report any suspected injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions; and that they accept the responsibility for referring any athlete to the medical staff suspected of sustaining a concussion. c. Have read and understand the UNC Concussion Management Protocol 3) All primary and secondary administrators must read and sign the attached administrator statement acknowledging that they: a. Have read and understand the NCAA Concussion Fact Sheet b. Will encourage their coaches and athletes to report any suspected injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions; and that they accept the responsibility for referring any athlete to the medical staff suspected of sustaining a concussion c. Have read and understand the UNC Concussion management Protocol 4) All UNC team physicians (primary care), athletic trainers, graduate assistant athletic trainers, and undergraduate athletic training students, must read and sign the attached medical provider statement acknowledging that they: a. Will provide athletes with the NCAA Concussion Fact Sheet and encourage their athletes to report any suspected injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. b. Have read, understand, and will follow the UNC Concussion Management Protocol 5) The head athletic trainer for each team will coordinate the distribution, educational session, signing, and collection of the necessary documents. The head athletic trainer will turn the signed documents into Campus Health Services Sports Medicine where they will be kept in the student-athlete’s medical file. This session may be done in conjunction with the team’s annual compliance meetings. 6) The Athletic Director or his designee and the Director of Sports Medicine will coordinate the signing of the aforementioned documents on an annual basis for the medical personnel, coaches, and administrators. The Department of Athletics and Division of Sports Medicine at Campus Health Services will keep the signed documents, along with the established UNC Concussion Policy, on file. A copy of the UNC Concussion Policy will also be distributed through Updated July 15, 2015 2 the Policies and Procedures manuals for each of the athletic training facilities and the Athletic Department staff manual. 7) The Director of Sports Medicine will coordinate an annual meeting each May to review and update the Concussion Policy with the medical staff as well as the Athletic Director or his designee. Any changes to the policy will be effective immediately, and posted to the UNC Campus Health Services network (“J”) drive. 8) While exposure to head trauma is inherent with many sports, the UNC-Chapel Hill Department of Athletics and its coaches are committed to reducing unnecessary exposure to head trauma. Coaches will conform to current best practices and recommendations for their sport in regards to reducing exposures to head trauma. a. This may include, but not be limited to: 1. Adherence to the Inter-Association Consensus: Year-­­Round Football Practice Contact Guidelines 2. Adherence to Inter-Association Consensus: Independent Medical Care Guidelines 3. Always taking a “safety first” approach to the sport 4. Taking the head out of contact 5. Utilizing proper coaching techniques and student-athlete education regarding safe play. 6. Tracking of injury data in regards to injury rates in different activities and equipment types with recommendations for change annually to reduce injury risk as indicated. b. This is reinforced with coaches and athletes through the following actions: 1. Coaching and student-athlete education regarding safe play and proper technique 2. Beginning of the season education sessions 3. Reminders at coaches meetings 4. Poster and video reminders 5. Coaching improved and appropriate technique 6. Review of film 7. Reducing practice and gratuitous contact sessions Updated July 15, 2015 3 UNC Concussion Management Protocol Concussions and other brain injuries can be serious and potentially life threatening injuries in sports. Research indicates that these injuries can also have serious consequences later in life if not managed properly. In an effort to combat this injury the following concussion management protocol will be used for UNC student­athletes suspected of sustaining a concussion. A concussion occurs when there is a direct or indirect insult to the brain. As a result, transient impairment of mental functions such as memory, balance/equilibrium, and vision may occur. It i s important to recognize that many sport­related concussions do not result in loss of consciousness and, therefore, all suspected head injuries should be taken seriously. Coaches and fellow teammates can be helpful in identifying those who may potentially have a concussion, because a concussed athlete may not be aware of their condition or potentially be trying to hide the injury to stay in the game or practice. 1) Concussion management begins with pre-season baseline testing. Every new (first-year or transfer) varsity student-athlete will undergo a preparticipation examination by the team physician including a brain injury and concussion history. All UNC varsity athletes must receive a pre­season baseline assessment for concussion. This may include a graded symptom checklist (GSC), Standard Assessment of Concussion (SAC), Balance Error Scoring System (BESS), computerized neuropsychological test (CNS Vital Signs) and computerized posturography/balance test (NeuroCom SOT). These data will be kept on file at the Gfeller SportRelated TBI Research Center (located in the Stallings-Evans Sports Medicine Center), unless otherwise specified below. a. The respective team’s athletic trainers will conduct the GSC, SAC, and BESS assessments for all new athletes. b. The Gfeller Center staff will conduct an additional Graded Symptom Checklist, CNS Vital Signs (neurocognitive testing), and NeuroCom SOT (balance). In the event of a suspected concussion, the student-athlete will be re-assessed and compared to pre­ season baseline measures according to the outlined protocol below. c. The respective team’s athletic trainers will keep a copy of baseline GSC, SAC, and BESS scores on file so they can have easy access for away contests and tournaments. The Gfeller center staff will retain all GSC, CNS Vital Signs, and NeuroCom SOT data within their facility. Clearance for the athlete to participate in sport is determined by the team physician. 2) An athlete suspected of having a concussion will be evaluated by the team physician and/or athletic trainer on site and more serious injuries such as cervical spine injury, skull fracture and/or intracranial bleed will be ruled out. The initial evaluation will include a symptom assessment and physical exam with an emphasis on neurological exam. During the initial on­field assessment, the presence of any of the following, alone or in combination, requires the initiation of the spine injury management protocol: unconsciousness or altered level of consciousness, bilateral neurologic findings or complaints, significant midline spine pain with or without palpation, and obvious spinal column deformity. Updated July 15, 2015 4 The proper preparedness for on-field/sideline medical management of a serious head injury or cervical spine injury is paramount when dealing with a quickly deteriorating condition. In cases where the athlete presents with a Glasgow Coma Score less than 13, prolonged unconsciousness, focal neurologic deficit, repetitive emesis, persistent worsening/diminishing mental status, spine injury or other indications of more involved brain or brain stem impairment are developing (e.g. posturing, altered breathing patterns, etc.), the athletic trainer and/or physician will immediately activate the emergency action plan for transport to the emergency department, while monitoring and preparing to perform manual ventilations through bag-valve­mouth resuscitation as needed. These procedures will be initiated if the athlete is not oxygenating well (becoming dusky or blue; ventilations are not full and slower than normal 12-15/minute), as per the NATA’s Position Statement: Preventing Sudden Death in Sport and Physical Activity. Activation of Emergency Action plans will follow the Emergency Action Plans for each individual sport and/or facility on file with the procedures and policies of UNC Sports Medicine. The team physician or team’s athletic trainer will evaluate cognition and balance using the Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and Graded Symptom Checklist (GSC). Should the team physician not be present, the athletic trainer will notify the team physician as soon as possible to develop an evaluation and treatment plan. Ideally, an assessment of symptoms will be performed at the time of the injury and then serially thereafter (i.e. 2-3 hours post-injury, 24 hours, 48 hours, etc). The presence or absence of symptoms will dictate the inclusion of additional neurocognitive and balance testing. The evaluation, plan and discussion of the plan with the athlete and another adult who will be with the athlete should be well documented in the medical record. A concussion instruction form will be given to the athlete and a responsible adult who will have direct contact with the athlete for the initial 24 hours following the injury. This form will help them know what signs and symptoms to watch for, as well as to provide useful recommendations on follow up care. When at all possible, these instructions are given to the athlete as well as those who will be with them or nearby, i.e., roommates, teammates, coaches, or parents, depending on the situation. The home care instruction form abstracted from the NATA’s Position Statement: Proper Management of Concussion in Sport is used for UNC athletes with a suspected concussion. 3) Any student-athlete with a suspected concussion or diagnosed concussion shall not return to activity for the remainder of that day. The team physician, or combination of team physician and athletic trainers, involved with the athlete’s concussion management will determine medical clearance. 4) The team athletic trainer will notify the Gfeller Center of any concussion sustained within 24 hours of the injury. The athletic trainer, following consultation with the team physician, will contact the Gfeller Center (concussion@listserv.unc.edu) to schedule an appointment after the athlete is symptom free, as determined by the GSC. Call the primary contacts first, followed by secondary contacts. Testing usually takes about an hour to complete, and athletes should expect to be there the entire time. Updated July 15, 2015 5 5) If requested by the team physician or athletic trainer (typically for the purpose of evaluating whether an athlete should return to class, reschedule exams, etc), testing may be conducted while the athlete is still symptomatic. Performing this testing while the athlete is symptomatic may worsen and protract the athlete’s symptoms. 6) If the athlete has not returned to normal functioning compared to baseline scores upon laboratory testing, another appointment will be scheduled at a time deemed appropriate by the team physician, athletic trainer, and Gfeller Center staff. In the rare event that an athlete does not have baseline scores, age­ and sport­matched normative percentile scores will be used for comparison to post­injury scores. 7) If the student–athlete is not recovering the team physician will evaluate further and manage the following potential conditions (but not limited to): ocular dysfunction, vestibular dysfunction, depression, anxiety, and/or sleep dysfunction 8) The management of all concussions will include a plan to return to classroom activities as well as a return to sport activities. a. Once a student­athlete is diagnosed with a concussion, the physician or ATC will notify the Academic counselor responsible for that student-athlete and their sport c. If merited, the physician will also contact the Dean of Students office providing them information that the student should be excused from academic activities until symptoms have improved and re­evaluated by a physician. d. Return to learn will be initiated with cognitive rest. This will include avoiding stressors such as going to class, reading, studying, looking at a computer, playing video games, and texting. e. The student should then begin an individualized return to academic activities based on symptoms. Their return should include: 1. 2. 3. 4. Compliance with ADAAA. No classroom activity on same day as concussion. Individualized initial plan that includes: Remaining at home/dorm if student-athlete cannot tolerate light cognitive activity. 5. Gradual return to classroom/studying as tolerated. f. Re-evaluation by team physician will occur if concussion symptoms worsen with academic challenges 1. If the student remains symptomatic, a multi-disciplinary team will meet and assess conditions requiring more prolonged care. This team may include but not be limited to: Team physician Athletic trainer Psychologist/counselor Neuropsychologist Faculty athletics representative Updated July 15, 2015 6 Academic counselor Course instructor(s) College administrators Office of Accessibility Resources and Service representatives Coaches g. The return to learn process may require specific adjustments to be made within the student’s academic schedule. h. If symptoms are prolonged and last over two weeks, academic modifications may be initiated to accommodate a student’s testing schedule, written compositions or papers, class projects, and/or presentations. i. In certain situations when symptoms are prolonged, it may be necessary to contact one of several campus resources available for students requiring more specialized services. Such campus resources must be consistent with ADAAA, and include at least one of the following: 1. Learning specialists. 2. Office of Accessibility Resources and Service. 9) The team physician and/or team certified athletic trainer will be notified as soon as possible of the test results. The Gfeller Center staff will verbally communicate all results to the team physician and certified athletic trainer within a reasonable time frame, and aim to submit a written report of our evaluation within 24-­­48 hours for patient files. 10) The following assessment and return to play plan will be used for all concussions: Concussion Assessment: NO ATHLETE SUSPECTED OF HAVING A CONCUSSION IS PERMITTED TO RETURN TO PLAY THE SAME DAY, AND NO ATHLETE IS PERMITTED TO RETURN TO PLAY WHILE SYMPTOMATIC FOLLOWING A CONCUSSION. -­­ Baseline testing: conducted on each athlete upon entering as a first-year student, transfer, or for those athletes sustaining a concussion the previous season (re-baseline); --­ Time of Injury: clinical evaluation & symptom checklist; --­ 1-3 hrs. post-injury: symptom checklist; referral if necessary; -­­ Next Day: follow-up clinical evaluation & symptom checklist; -­­ Follow-up evaluations daily to track symptom recovery; --­ Once athlete becomes asymptomatic for 24 hours: 1. Determine where athlete is relative to baseline on the following measures which may include: a. Symptom Assessment (Graded Symptom Checklist) b. Mental Status Assessment (Standardized Assessment of Concussion) c. Neuropsychological Assessment (CNS Vital Signs) d. Balance Assessment (Balance Error Scoring System & NeuroCom SOT) Updated July 15, 2015 7 2. If the measures (a-­­d) listed above are at least 95% of baseline scores and the athlete remains asymptomatic for 1 additional day following these tests, the physician can instruct the athletic trainer to begin a 5-step graduated exertional return to play (RTP) protocol (see below) with the athlete and to assess for increasing signs and symptoms. Symptoms will be reassessed immediately following all exertional activities. Note: We recognize there are situations where altering this timeline may be warranted. For instance, if an athlete has already been asymptomatic for 24 hours and remains asymptomatic during this period even after a full return to classroom activities, the team physician may begin the graduated exertional return to play on the same day the athlete achieves 95% of their baseline scores. 3. If the athlete remains asymptomatic on the day following the first step(s) of the graduated exertional RTP protocol, the athlete will be reassessed using the measures above (#1), and continue with the next step(s) on the graduated exertional RTP protocol. 4. All scores on the aforementioned assessments or exertional activities below will be recorded in the athlete’s medical record by the team’s athletic trainer. IF AT ANY POINT DURING THIS PROCESS THE ATHLETE BECOMES SYMPTOMATIC, THE ATHLETE WILL BE RE-ASSESSED DAILY UNTIL ASYMPTOMATIC. ONCE ASYMPTOMATIC, THE ATHLETE WILL THEN FOLLOW STEPS 1-4 ABOVE. 5‐Step Graduated Exertional Return to Play Protocol This exertional protocol allows a gradual increase in volume and intensity during the return to play process. The athlete is monitored for any concussion­like signs/symptoms during and after each exertional activity. The following steps are not ALL to be performed on the same day. In some cases, steps 1, 2, or 3 (or even 4) may be completed on the same day, but typically will occur over multiple days. Steps 4 and 5 will each be performed on separate and subsequent days: Exertion Step 1: 20 minute stationary bike ride (10-14 MPH) Exertion Step 2: Interval bike ride: 30 sec sprint (18-20 MPH/10-14 MPH)/30 sec recovery x 10; and bodyweight circuit: Squats/Push Ups/Sit-ups x 20 sec x 3 Exertion Step 3: 60 yard shuttle run x 10 (40 sec rest); and plyometric workout: 10 yard bounding/10 medicine ball throws/10 vertical jumps x 3; and non­contact, sports­specific drills for approximately 15 minutes Exertion Step 4: Limited, controlled return to non­contact practice and monitoring for symptoms Exertion Step 5: Full sport participation in a practice No athlete can return to full activity or competitions until they are asymptomatic in limited, controlled, and full-contact activities, and cleared by the team physician. Updated July 15, 2015 8 CO N C U SSIO N A fAct sheet for student-Athletes What is a concussion? A concussion is a brain injury that: • Is caused by a blow to the head or body. – From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. • Can change the way your brain normally works. • Can range from mild to severe. • Presents itself differently for each athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness. hoW can i prevent a concussion? Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport. What are the symptoms of a concussion? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. it’s better to miss one game than the Whole season. When in doubt, get checked out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. University of North Carolina at Chapel Hill Administrator C o n c u s s i o n Statement □ I have read and understand the UNC Concussion Management Protocol. □ I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion fact sheet and reviewing the UNC Concussion Management Protocol, I am aware of the following information: A concussion is a brain injury, which athletes should report to the medical staff. Initial Initial A concussion can affect an athlete’s ability to perform everyday activities, reaction time, balance, sleep, and classroom performance. You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. I will enforce with the coaching staff to not knowingly allow an athlete to return to play in a game Initial Initial or practice if they have received a blow to the head or body that results in concussion related symptoms. Players shall not return to play in a game or practice on the same day that they are suspected of having a concussion. I will enforce with coaches that if they suspect one of their athletes has a concussion, it is their Initial Initial Initial responsibility to have that athlete see the medical staff. I understand that although certified helmets meeting a standard for helping to prevent catastrophic injuries may be used in my sport, they do not prevent cerebral concussions. Players should wear helmets at all times during participation. I will encourage coaches to have their athletes to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussions. Initial Following concussion the brain needs time to heal. Concussed athletes are much more likely to have a repeat concussion, if they return to play before their symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage and even death. Initial I am aware that every first---year student---athlete participating on specified UNC teams must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition, and balance if the athlete were to become injured. Initial I am aware that athletes diagnosed with a concussion will be assessed at the Matthew Gfeller Center once symptoms have resolved. Athletes will begin a graduated return to play following full recovery of neurocognition and balance. Signature of Administrator Printed name of Administrator Date University of North Carolina at Chapel Hill Coaches Concussion Statement □ I have read and understand the UNC Concussion Management Protocol. □ I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion fact sheet and reviewing the UNC Concussion Management Protocol, I am aware of the following information: Initial Initial Initial Initial Initial Initial Initial Initial Initial A concussion is a brain injury which athletes should report to the medical staff. A concussion can affect the athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. I will not knowingly allow the athlete to return to play in a game or practice if he/she has received a blow to the head or body that results in concussionrelated symptoms. Athletes shall not return to play in a game or practice on the same day that they are suspected of having a concussion. If I suspect one of my athletes has a concussion, it is my responsibility to have that athlete see the medical staff. I will encourage my athletes to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussions. Following concussion the brain needs time to heal. Concussed athletes are much more likely to have a repeat concussion if they return to play before their symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. I am aware that every first-year student-athlete participating on specified UNC teams must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition, and balance if the athlete were to become injured. I am aware that athletes diagnosed with a concussion will be assessed at the Gfeller Center once symptoms have resolved. Athletes will begin a graduated return to play protocol following full recovery of neurocognition and balance. Signature of Coach Printed name of Coach Date University of North Carolina at Chapel Hill Student-Athlete Concussion Statement □ I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. □ I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion fact sheet, I am aware of the following information: Initial Initial A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer. A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. Initial You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Initial If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer. Initial Initial Initial I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms. Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. Signature of Student-Athlete Printed name of Student-Athlete Date University of North Carolina at Chapel Hill Medical Provider Concussion Statement □ I have read and understand the UNC Concussion Management Protocol. □ I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet and reviewing the UNC Concussion Management Protocol, I am aware of the following information: Initial A concussion is a brain injury which athletes should report to the medical staff. Initial A concussion can affect the athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. Initial You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Initial I will not knowingly allow the athlete to return to play in a game or practice if he/she has received a blow to the head or body that results in concussionrelated symptoms. Initial If I suspect the athlete has a concussion, it is my responsibility to to refer that athlete to the appropriate medical staff. Initial I will encourage the athlete to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussions. Initial Initial Initial Following concussion the brain needs time to heal. Concussed athletes are much more likely to have a repeat concussion if they return to play before their symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. I am aware that every first-year student-athlete participating on specified UNC teams must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition, and balance if the athlete were to become injured. I am aware that athletes diagnosed with a concussion will be assessed at the Gfeller Center once symptoms have resolved. Athletes will begin a graduated return to play protocol following full recovery of neurocognition and balance. Signature of Medical Provider Printed name of Medical Provider Date NC State University Sports Medicine Concussion Policy Table of Contents 1. 2. 3. 4. 5. 6. 7. 8. NC State University Concussion Management Policies and Procedures Concussion Management Procedural Outline Concussion Management Flow-Chart Physician Referral Checklist Post-Concussion Take Home Instructions NC State University’s Compliance with NCAA Recommended Best Practices NC State University’s “Concussion Awareness Release” Temporary Classroom Accommodations with Academic Support and Disability Services 2 14 17 20 21 22 24 25 References 1. 2. 3. 4. 5. Behind the Blue Disk “NCAA Approach to Concussions 1/18/2010” Concussion Fact-Sheet for Student-Athletes Concussion Fact Sheet for Coaches ImPACT Information Guide Modified Sport Concussion Assessment Tool 3 (SCAT3) 26 27 28 30 31 Supplemental Policies 1. 2. 3. 4. 5. 6. 7. 8. NC State University Sports Medicine Emergency Action Plans Coaches Acknowledgement Checklist for Emergency Management Positive Sickle Cell Notification to Coaches Scope of Practice Sports Medicine Sport Assignments Medical History Pre-Participation Physical Exam Assumption of Risk 33 43 51 55 57 58 65 66 NC STATE UNIVERSITY SPORTS MEDICINE Concussion Management Policy & Procedures  In an effort to provide quality standards of care for our student-athletes, NC State University’s Sports Medicine Department has established the following policy and procedural instructions for the management of concussions. The statements made in this policy are taken from the “Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008” and the “National Athletic Trainers’ Association Position Statement: Management of the Sport-Related Concussion, September 2004”. Statements have been modified from the original versions of these documents to provide a clear decision between options provided within the original documents or to better explain the adaptation of policy as it pertains specifically to NC State University. Some statements have also been omitted which do not pertain to NC State University. Other statements have been added which directly pertain to NC State University’s policy. 1. CONCUSSION 1.1 Definition of Concussion Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged. 5. No abnormality on standard structural neuro-imaging studies is seen in concussion. 2. CONCUSSION EVALUATION 2.1 CONCUSSION ASSESSMENT TOOLS Sports medicine clinicians are increasingly using standardized methods to obtain a more objective measurement of post-concussion signs and symptom (SCAT2/3), cognitive dysfunction (SCAT2/3, ImPACT), and postural instability (SCAT2/3, BESS). These methods allow the clinician to quantify the severity of injury and measure the player’s progress over the course of post-injury recovery. An emerging model of sport concussion assessment involves the use of brief screening tools to evaluate postconcussion signs and symptoms, cognitive functioning, and postural stability on the sideline immediately after a concussion and neuropsychological testing to track recovery further out from the time of injury. Ultimately, these tests, when interpreted with the physical examination and other aspects of the injury evaluation, assist the ATC and other sports medicine professionals in the return to play decision-making process. 2.2 Symptoms and Signs of Acute Concussion The diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, behavior, balance, sleep and cognition. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination. The detailed clinical assessment of concussion is outlined in the SCAT2/3 form. The suspected diagnosis of concussion can include one or more of the following clinical domains: (a) Symptoms: somatic (e.g., headache), cognitive (e.g., feeling like in a fog) and/or emotional symptoms (b) Physical signs (e.g., loss of consciousness, amnesia) (c) Behavioral changes (e.g., irritability) (d) Cognitive impairment (e.g., slowed reaction times) (e) Sleep disturbance (e.g., drowsiness) If any one or more of these components is present, a concussion should be suspected and the appropriate management strategy instituted. 2.3 On-field or Sideline Evaluation of Acute Concussion When a player shows ANY features of a concussion: (a) The player should be medically evaluated onsite using standard emergency management principles, and particular attention should be given to excluding a cervical spine injury. (b) The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged. (c) Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT2/3 or other similar tool. (d) The player should not be left alone following the injury, and serial monitoring for deterioration is essential over the initial few hours following injury. (e) A player with diagnosed concussion should not be allowed to return to play on the day of injury. Sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the Maddocks questions and the Standardized Assessment of Concussion (SAC). Both of these tests are included within the SCAT2/3. It is worth noting that standard orientation questions (e.g., time, place) have been shown to be unreliable in the sporting situation when compared with memory assessment. It is recognized, however, that abbreviated testing paradigms are designed for rapid concussion screening on the sidelines and are not meant to replace comprehensive neuropsychological testing which is sensitive to detect subtle deficits that may exist beyond the acute episode nor should they be used as a stand-alone tool for the ongoing management of sports concussions. It should also be recognized that the appearance of symptoms might be delayed several hours following a concussive episode. Focal or posttraumatic intracranial mass lesions include subdural hematomas, epidural hematomas, cerebral contusions, and intracerebral hemorrhages and hematomas. These are considered uncommon in sport but are serious injuries; the ATC must be able to detect signs of clinical deterioration or worsening symptoms during serial assessments. Signs and symptoms of these focal vascular emergencies can include LOC, cranial nerve deficits, mental status deterioration, and worsening symptoms. Concern for a significant focal injury should also be raised if these signs or symptoms occur after an initial lucid period in which the athlete seemed normal. Not every sport-related concussion warrants immediate physician referral, but ATCs must be able to recognize those injuries that require further attention and provide an appropriate referral for advanced care, which may include neuro-imaging. Serial assessments and physician follow-up are important parts of the evaluation of the athlete with a concussion. Referrals should be made to medical personnel with experience managing sport-related concussion. The ATC should monitor vital signs and level of consciousness periodically after a concussion until the athlete’s condition stabilizes and improves. The athlete should also be monitored over the next few hours and days after the injury for delayed signs and symptoms and to assess recovery. The “Physician Referral Checklist” is an outline of scenarios that warrant physician referral or, in many cases, transport to the nearest hospital emergency department. The ATC-physician team must also consider referral options to specialists such as neurologists, neurosurgeons, neuropsychologists, and neuro-otologists, depending on the injury severity and situation. Referrals for imaging tests such as CT, MRI, or electronystagmography are also options that sometimes can aid in the diagnosis and/or management of sport-related concussion but are typically used only in cases involving LOC, severe amnesia, abnormal physical or neurologic findings, or increasing or intensified symptoms. 2.4 Evaluation in the Athletic Training Room or Emergency Room by Medical Personnel An athlete with concussion may be evaluated in the emergency room or doctor’s office as a point of first contact following injury or may have been referred from another care provider. In addition to the points outlined above, the key features of this exam should encompass: (a) A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance. (b) A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury. (c) A determination of the need for emergent neuro-imaging in order to exclude a more severe brain injury involving a structural abnormality. In large part, these points above are included in the SCAT2/3 assessment, which forms part of the Zurich consensus statement. 3. CONCUSSION INVESTIGATIONS 3.1 Neuro-imaging Brain CT (or, where available, MR brain scan) contributes little to concussion evaluation but should be employed whenever suspicion of an intra-cerebral structural lesion exists. Examples of such situations may include prolonged disturbance of conscious state, focal neurological deficit or worsening symptoms. Newer structural MRI modalities including gradient echo, perfusion and diffusion imaging have greater sensitivity for structural abnormalities. However, the lack of published studies, as well as absent preinjury neuro-imaging data, limits the usefulness of this approach in clinical management at the present time. In addition, the predictive value of various MR abnormalities that may be incidentally discovered is not established at the present time. Other imaging modalities such as fMRI demonstrate activation patterns that correlate with symptom severity and recovery in concussion. While not part of routine assessment at the present time, they nevertheless provide additional insight to pathophysiological mechanisms. Alternative imaging technologies (e.g., positron emission tomography, diffusion tensor imaging, magnetic resonance spectroscopy, functional connectivity), while demonstrating some compelling findings, are still at early stages of development and cannot be recommended other than in a research setting. A physician’s prescription is required to perform any of the above imaging studies. 3.2 Objective Balance Assessment Published studies using both sophisticated force plate technology, as well as those using less sophisticated clinical balance tests (e.g., Balance Error Scoring System (BESS)), have identified postural stability deficits lasting approximately 72 hours following sport-related concussion. It appears that postural stability testing provides a useful tool for objectively assessing the motor domain of neurologic functioning and should be considered a reliable and valid addition to the assessment of athletes suffering from concussion, particularly where symptoms or signs indicate a balance component. A modified version of the BESS is included in the SCAT2/3. 3.3 Neuropsychological Assessment (ImPACT) The application of neuropsychological (NP) testing such as ImPACT in concussion has been shown to be of clinical value and continues to contribute significant information in concussion evaluation. Although in most case cognitive recovery largely overlaps with the time course of symptom recovery, it has been demonstrated that cognitive recovery may occasionally precede or more commonly follow clinical symptom resolution suggesting that the assessment of cognitive function should be an important component in any return to play protocol. It must be emphasized, however, that NP assessment should not be the sole basis of management decisions; rather, it should be seen as an aid to the clinical decision making process in conjunction with a range of clinical domains and investigational results. Neuropsychologists are in the best position to interpret NP tests by virtue of their background and training. However, there may be situations where neuropsychologists are not available and other medical professionals may perform or interpret NP screening tests. The ultimate return to play decision should remain a medical one in which a multidisciplinary approach, when possible, has been taken. In the absence of NP and other (e.g., formal balance assessment) testing, a more conservative return to play approach may be appropriate. In the majority of cases, NP testing will be used to assist return to play decisions and will not be done until the patient is symptom free. There may be situations (e.g., child and adolescent athletes) where testing may be performed early whilst the patient is still symptomatic to assist in determining management. This will normally be best determined in consultation with a trained neuropsychologist. Baseline neuropsychological testing is recommended, when possible, to establish a normative level of neurocognitive functioning for individual athletes. Baseline neuropsychological testing typically takes 20 to 30 minutes per athlete. Sport concussion batteries should include measures of cognitive abilities most susceptible to change after concussion, including attention and concentration, cognitive processing (speed and efficiency), learning and memory, working memory, executive functioning, and verbal fluency. Tests of attention and concentration and memory functioning have been reported as the most sensitive to the acute effects of concussion. The athlete’s age, sex, primary language, and level of education should be considered when selecting a test battery. Neuropsychological testing following a concussion will only be performed after the injured player reports that his or her symptoms are completely gone. This approach is based on the conceptual foundation that an athlete should not participate while symptomatic, regardless of neuropsychological test performance. Unnecessary serial neuropsychological testing, in addition to being burdensome and costly to the athlete and medical staff, also introduces practice effects that may confound the interpretation of performance in subsequent post injury testing sessions. Measuring ‘‘recovery’’ on neuropsychological tests and other clinical instruments is often a complex statistical matter, further complicated by practice effects and other psychometric dynamics affected by serial testing, even when pre-injury baseline data are available for individual athletes. The use of statistical models that empirically identify meaningful change while controlling for practice effects on serial testing may provide the clinician with the most precise benchmark in determining post injury recovery, above and beyond the simple conclusion that the player is ‘‘back to baseline.’’ Further research is required to clarify the guidelines for determining and tracking recovery on specific measures after concussion. The clinician should also be aware that any concussion assessment tool, either brief screening instruments or more extensive neuropsychological testing, comes with some degree of risk for false negatives (e.g., a player performs within what would be considered the normal range on the measure before actually reaching a complete clinical recovery after concussion). Therefore, test results should always be interpreted in the context of all clinical information, including the player’s medical history. Also, caution should be exercised in neuropsychological test interpretation when pre-injury baseline data do not exist. Numerous factors apart from the direct effects of concussion can influence test performance (Table 1). Table 1. Factors Influencing Neuropsychological Test Performance Previous concussions Medications, alcohol, or drugs Educational background Psychiatric disorders Learning disability Pre-injury level of cognitive functioning Attention deficit/hyperactivity Cultural background Certain medical conditions Age Primary language other than English Test anxiety Previous neuropsychological testing Distractions Sleep deprivation 4. CONCUSSION MANAGEMENT The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play. The recovery and outcome of this injury may be modified by a number of factors that may require more sophisticated management strategies. These are outlined in the section on modifiers below. The majority of concussions will recover spontaneously over several days. In these situations, it is expected that an athlete will proceed progressively through a stepwise return to play strategy. During this period of recovery, while symptomatically following an injury, it is important to emphasize to the athlete that physical AND cognitive rest is required. Activities that require concentration and attention (e.g., scholastic work, videogames, text messaging, etc.) may exacerbate symptoms and possibly delay recovery. In such cases, apart from limiting relevant physical and cognitive activities (and other risktaking opportunities for re-injury), while symptomatic, no further intervention is required during the period of recovery, and the athlete typically resumes sport without further problem. The ATC must recognize that no 2 concussions are identical and that the resulting symptoms can be very different, depending on the force of the blow to the head, the degree of metabolic dysfunction, the tissue damage and duration of time needed to recover, the number of previous concussions, and the time between injuries. All these factors must be considered when managing an athlete suffering from cerebral concussion. The two most recognizable signs of a concussion are LOC and amnesia; yet, as previously mentioned, neither is required for an injury to be classified as a concussion. A 2000 study of 1003 concussions sustained by high school and collegiate football players revealed that LOC and amnesia presented infrequently, 9% and 27% of all cases, respectively, whereas other signs and symptoms, such as headache, dizziness, confusion, disorientation, and blurred vision, were much more common. It has been suggested that LOC and amnesia, especially when prolonged, should not be ignored, but evidence for their usefulness in establishing return to play guidelines is scarce. Loss of consciousness, whether it occurs immediately or after an initially lucid interval, is important in that it may signify a more serious vascular brain injury. 4.1 Grading Scales Although it is common practice to use a grading scale on a wide variety of injuries, it is purely speculative to grade a concussion based on the initial assessment. In many cases, signs and symptoms may linger for a much longer time than might be expected based on their severity during initial evaluation. Grading is likely to be more important for treating subsequent injuries rather than for the progression of the current injury. Determining/grading the severity of the concussion should be avoided until the symptoms have resolved and return to play has been authorized. 4.2 Home Care Once it has been determined that a concussion has been sustained, a decision must be made as to whether the athlete can return home or should be considered for overnight observation or admission to the hospital. If the athlete is allowed to return home or to the dormitory room, the ATC should counsel a responsible friend, teammate, or parent to closely monitor the athlete. The teammate, parent, or friend must understand that the athlete should not be left alone. A concussion instruction form (Post-Concussion Take Home Instructions) should be given to the athlete and a responsible adult who will have direct contact with the athlete for the initial 24 hours after the injury. This form outlines signs and symptoms to watch for and provides useful recommendations on follow-up care. It should also suggest avoiding activities that may increase symptoms (e.g., staying up late studying and physical education class) and should denote resuming normal activities of daily living, such as attending class and driving, once symptoms begin to resolve or decrease in severity. Traditionally, part of these instructions included a recommendation to wake up the athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma. This recommendation has raised some debate about unnecessary wake-ups that disrupt the athlete’s sleep pattern and may increase symptoms the next day because of the combined effects of the injury and sleep deprivation. Serial monitoring during sleep is best performed in a hospital setting. If signs of deterioration are present or suspected, the athlete should be referred to the emergency room for observation. 4.3 Diet Evidence is limited to support the best type of diet for aiding in the recovery process after a concussion. A cascade of neurochemical, ionic, and metabolic changes occur after brain injury. Furthermore, some areas of the brain demonstrate glycolytic increases and go into a state of metabolic depression as a result of decreases in both glucose and oxidative metabolism with a reduction in cerebral blood flow. Some studies have suggested that severely brain-injured subjects unknowingly ate larger meals and increased their daily caloric intake when compared with controls. This may suggest the brain increases caloric intake to assist recovery. Although limited information is available regarding the recommended diet for the management of concussion, it is well accepted that athletes should be instructed to avoid alcohol, illicit drugs, and central nervous system medications that may interfere with cognitive function. A normal, well-balanced diet should be maintained to provide the needed nutrients to aid in the recovery process from the injury. 4.4 Graduated Return to Play Protocol Return to play protocol following a concussion follows a stepwise process as outlined in Table 2. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. A rest period of 16-24 hours should be given between stages to achieve a goal of 8 hours of sleep/recovery. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the beginning of the Graduated Return to Play Protocol and try to progress again after a further 16-24-hour asymptomatic period of rest has passed. This progression may be altered/prolonged for athletes who are withheld for several weeks compared with those athletes withheld for just a few days. It is highly recommended that this progression be followed when any of the modifying factors listed in section 5 of this document are conditional to the individual. Any changes to this progression must be approved by the team physician. TABLE 2. Graduated Return to Play Protocol Rehabilitation Stage 1. No Activity 2. Light aerobic exercise 3. Sport-specific exercise 4. Non-contact training drills 5. Full contact practice 6. Return to play Functional Exercise Complete physical and cognitive rest Walking, swimming or stationary cycling keeping intensity <70% MPHR; no resistance training Skating drills, running drills, no head impact activities Progression to more complex training drills, e.g.. Passing drills; may start progressive resistance training Following medical clearance, participate in normal training activities Normal game play Objective of Each Stage Recovery Increased HR Add movement Exercise, coordination, and cognitive load Restore confidence and assess functional skills by coaching staff 4.5 Individualized Assessment and Return to Play With adult athletes, in some settings, where there are team physicians experienced in concussion management and sufficient resources (e.g., access to neurosurgeons, consultants, neuro-imaging, etc.), as well as access to immediate (ie, sideline) neuro-cognitive assessment, return to play management may be more rapid. The return to play strategy must still follow the same basic management principles, namely, full clinical and cognitive recovery before consideration of return to play. This approach is supported by published guidelines, such as the American Academy of Neurology, US Team Physician Consensus Statement, and US National Athletic Trainers’ Association Position Statement. There is data, however, demonstrating that, at the collegiate and high school level, athletes allowed to return to play on the same day may demonstrate NP deficits post-injury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms. It should be emphasized, however, that the young (<18) elite athlete should be treated more conservatively even though the resources may be the same as an older professional athlete. (See section 6.1.) A team physician will have sole authority to utilize a more rapid return to play guideline. Many return to play guidelines call for the athlete to be symptom free for at least 7 days before returning to participation after a grade 1 or 2 concussion. Although many clinicians deviate from these recommendations and are more liberal in making return to play decisions, recent studies by Guskiewicz and McCrea et al suggest that perhaps the 7-day waiting period can minimize the risk of recurrent injury. On average, athletes required 7 days to fully recover after concussion. Same-season repeat injuries typically take place within a short window of time, 7 to 10 days after the first concussion, supporting the concept that there may be increased neuronal vulnerability or blood-flow changes during that time, similar to those reported by Giza, Hovda, et al in animal models. Returning an athlete to participation should follow a progression that begins once the athlete is completely symptom free. All signs and symptoms should be evaluated using a graded symptom scale or checklist (described in ‘‘Concussion Assessment Tools’’) when performing follow-up assessments and should be evaluated both at rest and after exertional maneuvers such as biking, jogging, sit-ups, and pushups. Baseline measurements of neuropsychological and postural stability are strongly recommended for comparing with post-injury measurements. If these exertional tests do not produce symptoms, either acutely or in delayed fashion, the athlete can then participate in sport-specific skills that allow return to practice but should remain out of any activities that put him or her at risk for recurrent head injury. For the basketball player, this may include shooting baskets or participating in a walk-thru, and for the soccer player, this may include dribbling or shooting drills or other sport-specific activities. These restricted and monitored activities should be continued for the first few days after becoming symptom free. The athlete should be monitored periodically throughout and after these sessions to determine if any symptoms develop or increase in intensity. Before returning to full contact participation, the athlete should be reassessed using neuropsychological and postural-stability tests if available. If all scores have returned to baseline or better, return to full participation can be considered after further clinical evaluation. It is strongly recommended that after recurrent injury, especially within-season repeat injuries, the athlete be withheld for an extended period of time (approximately 7 days) after symptoms have resolved. 4.6 Psychological Management and Mental Health Issues In addition, psychological approaches may have potential application in this injury, particularly with the modifiers listed below. Care givers are also encouraged to evaluate the concussed athlete for affective symptoms such as depression, as these symptoms may be common in concussed athletes. 4.7 The Role of Pharmacological Therapy Pharmacological therapy in sports concussion may be applied in two distinct situations. The first of these situations is the management of specific prolonged symptoms (e.g., sleep disturbance, anxiety, etc.). The second situation is where drug therapy is used to modify the underlying pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms. In broad terms, this approach to management should be only considered by clinicians experienced in concussion management. It has been suggested that concussed athletes avoid medications containing aspirin or non-steroidal antiinflammatories. These medications decrease platelet function and potentially increase intracranial bleeding, mask the severity and duration of symptoms, and possibly lead to a more severe injury. It is also recommended that acetaminophen (Tylenol, McNeil Consumer & Specialty Pharmaceuticals, Fort Washington, PA) be used sparingly in the treatment of headache-like symptoms in the athlete with a concussion. Other substances to avoid during the acute post-concussion period include those that adversely affect central nervous function, in particular alcohol and narcotics. An important consideration in return to play is that concussed athletes should not only be symptom free but also should not be taking any pharmacological agents/medications (e.g. Tylenol) that may mask or modify the symptoms of concussion. Where antidepressant therapy may be commenced during the management of a concussion, the decision to return to play while still on such medication must be considered carefully by the treating clinician. 4.8 The Role of Pre-participation Concussion Evaluation Recognizing the importance of a concussion history, and appreciating the fact that many athletes will not recognize all the concussions they may have suffered in the past, a detailed concussion history is of value. Such a history may pre-identify athletes that fit into a high risk category and provides an opportunity for the healthcare provider to educate the athlete in regard to the significance of concussive injury. A structured concussion history should include specific questions as to previous symptoms of a concussion, not just the perceived number of past concussions. It is also worth noting that dependence upon the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable. The clinical history should also include information about all previous head, face or cervical spine injuries, as these may also have clinical relevance. It is worth emphasizing that, in the setting of maxillofacial and cervical spine injuries, coexistent concussive injuries may be missed unless specifically assessed. Questions pertaining to disproportionate impact versus symptom severity matching may alert the clinician to a progressively increasing vulnerability to injury. As part of the clinical history it is advised that details regarding protective equipment employed at time of injury be sought, both for recent and remote injuries. The benefit a comprehensive pre-participation concussion evaluation allows for modification and optimization of protective behavior and is an opportunity for education. Data from objective measures of cognitive functioning, postural stability, and post-concussion signs and symptoms are most helpful in making a determination about severity of injury and post-injury recovery when pre-injury baseline data for an individual athlete are available. Baseline testing provides an indicator of what is ‘‘normal’’ for that particular athlete while also establishing the most accurate and reliable benchmark against which post-injury results can be compared. It is important to obtain a baseline symptom assessment in addition to baseline cognitive and other ability testing. Without baseline measures, the athlete’s post-injury performance on neuropsychological testing and other concussion assessment measures must be interpreted by comparison with available population normative values, which ideally are based on a large sample of the representative population. Normative data for competitive athletes on computerized neuropsychological tests and other concussion assessment measures are now more readily available from large-scale research studies, but baseline data on an individual athlete still provide the greatest clinical accuracy in interpreting post-injury test results. When performing baseline testing, a suitable testing environment eliminates all distractions that could alter the baseline performance and enhances the likelihood that all athletes are providing maximal effort. Most important, all evaluators should be aware of a test’s user requirements and be appropriately trained in the standardized instructions for test administration and scoring before embarking on baseline testing or adopting a concussion testing paradigm for clinical use. Several models exist for implementing baseline testing. Ideally, preseason baseline testing is conducted before athletes are exposed to the risk of concussion during sport participation. Some programs choose to conduct baseline testing as part of the pre-participation physical examination process. In this model, stations are established for various testing methods (e.g., history collection, symptom assessment, neuropsychological testing, and balance testing), and athletes complete the evaluation sequence after being seen by the attending physician or ATC. This approach has the advantage of testing large groups of athletes in 1 session, while they are already in the mindset of undergoing a preseason physical examination. Collecting histories on individual athletes is also a vital part of baseline testing, especially in establishing whether the athlete has any history of concussion, neurologic disorder, or other remarkable medical conditions. Specifically with respect to concussion, it is important to establish (1) whether the player has any history of concussions and, if so, how many and (2) injury characteristics of previous concussions (e.g., LOC, amnesia, symptoms, recovery time, time lost from participation, and medical treatment). For athletes with a history of multiple concussions, it is also important to clarify any apparent pattern of (1) concussions occurring as a result of lighter impacts, (2) concussions occurring closer together in time, (3) a lengthier recovery time with successive concussions, and (4) a less complete recovery with each injury. Documenting a history of attentional disorders, learning disability, or other cognitive development disorders is also critical, especially in interpreting an individual player’s baseline and post-injury performance on neuropsychological testing. If resources do not allow for preseason examinations in all athletes, at least a concerted effort to evaluate those athletes with a previous history of concussion should be made because of the awareness of increased risk for subsequent concussions in this group. 5. MODIFYING FACTORS IN CONCUSSION MANAGEMENT The consensus panel agreed that a range of “modifying” factors may influence the investigation and management of concussion and in some cases may predict the potential for prolonged or persistent symptoms. These modifiers would also be important to consider in a detailed concussion history and are outlined in Table 3. Table 3: Concussion Modifiers Factors Modifier Symptoms Number Duration (>10) Severity Signs Prolonged LOC (>1min), amnesia Sequelae Concussive convulsions Temporal Frequency – repeated concussions over time Timing – injuries close together in time Recent history – recent concussion or TBI Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Age Child and adolescent (<18 years old) Co-and Pre-morbidities Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Medication Psychoactive drugs, anticoagulants Behavior Dangerous style of play Sport High-risk activity, contact and collision sport, high sporting level In this setting, there may be additional management considerations beyond simple return to play advice. There may be a more important role for additional investigations including formal NP testing, balance assessment, and neuro-imaging. It is envisioned that athletes with such modifying features would be managed in a multidisciplinary manner coordinated by a physician with specific expertise in the management of concussive injury. The role of female gender as a possible modifier in the management of concussion was discussed at length by the panel. There was not unanimous agreement that the current published research evidence is conclusive that this should be included as a modifying factor, although it was accepted that gender may be a risk factor for injury and/or influence injury severity. 5.1 The Significance of Loss of Consciousness (LOC) In the overall management of moderate to severe traumatic brain injury, duration of LOC is an acknowledged predictor of outcome. While published findings in concussion describe LOC associated with specific early cognitive deficits, it has not been noted as a measure of injury severity. Consensus discussion determined that prolonged (<1 minute duration) LOC would be considered as a factor that may modify management. 5.2 The Significance of Amnesia and Other Symptoms There is renewed interest in the role of post-traumatic amnesia and its role as a surrogate measure of injury severity. Published evidence suggests that the nature, burden and duration of the clinical postconcussive symptoms may be more important than the presence or duration of amnesia alone. Further, it must be noted that retrograde amnesia varies with the time of measurement post-injury and hence is poorly reflective of injury severity. 5.3 Motor and Convulsive Phenomena A variety of immediate motor phenomena (e.g., tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury. 5.4 Depression Mental health issues (such as depression) have been reported as a long-term consequence of traumatic brain injury including sports related concussion. Neuro-imaging studies using fMRI suggest that a depressed mood following concussion may reflect an underlying pathophysiological abnormality consistent with a limbic-frontal model of depression. 6. SPECIAL POPULATIONS 6.1 Elite vs. Non-Elite Athletes The panel unanimously agreed that all athletes, regardless of level of participation, should be managed using the same treatment and return to play paradigm. A more useful construct was agreed whereby the available resources and expertise in concussion evaluation were of more importance in determining management than a separation between elite and non-elite athlete management. Although formal baseline NP screening may be beyond the resources of many sports or individuals, it is recommended that in all organized high-risk sports consideration be given to having this cognitive evaluation regardless of the age or level of performance. 6.2 Chronic Traumatic Brain Injury Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case reports have noted anecdotal cases where neuropathological evidence of chronic traumatic encephalopathy was observed in retired football players. Panel discussion was held, and no consensus was reached on the significance of such observations at this stage. Clinicians need to be mindful of the potential for long-term problems in the management of all athletes. 7. DISQUALIFYING THE STUDENT-ATHLETE 7.1 Disqualifying for the Season Guidelines from Cantu and the American Academy of Neurology both recommend termination of the season after the third concussion within the same season. The decision is more difficult if one of the injuries was more severe or was a severe injury resulting from a minimal blow, suggesting that the athlete’s brain may be at particular risk for recurrent injury. In addition, because many athletes participate in year-round activities, once they are disqualified for the ‘‘season,’’ it may be difficult to determine at what point they can resume contact play. Other issues without clear-cut answers in the literature are when to disqualify an athlete who has not been rendered unconscious and whose symptoms cleared rapidly or one who suffered multiple mild to moderate concussions throughout the career and whether youth athletes should be treated differently for initial and recurrent concussive injuries. In any case, the inability to resolve symptoms or the return of symptoms will preclude any return to play decisions. Additionally, persistent symptoms may provoke a consideration into acquiring a medical hardship or permanent disqualification. To qualify for a medical hardship, certain parameters must be met. An accurate description of these parameters can be found within the NCAA Division I Bylaw 14.2.4. As of 2010, both of the following criteria must be met: 1) The student-athlete must not have competed in more than 30% of the team’s scheduled contests, and 2) The student-athlete must not have competed in an event during the second half of the team’s championship segment. 7.2 Disqualifying for the Career When to disqualify an athlete for a career is a more difficult question to answer. The duration of symptoms may be a better criterion as to when to disqualify an athlete for the season or longer. Merril Hoge, Eric Lindros, Chris Miller, Al Toon, and Steve Young provide highly publicized cases of athletes sustaining multiple concussions with recurrent or post-concussion signs and symptoms that lasted for lengthy periods of time. Once an athlete has suffered a concussion, he or she is at increased risk for subsequent head injuries. Guskiewicz et al found that collegiate athletes had a 3-fold greater risk of suffering a concussion if they had sustained 3 or more previous concussions in a 7-year period and that players with 2 or more previous concussions required a longer time for total symptom resolution after subsequent injuries. Players also had a 3-fold greater risk for subsequent concussions in the same season, whereas recurrent, in-season injuries occurred within 10 days of the initial injury 92% of the time. In a similar study of high school athletes, Collins et al found that athletes with 3 or more prior concussions were at an increased risk of experiencing LOC (8-fold greater risk), anterograde amnesia (5.5-fold greater risk), and confusion (5.1fold greater risk) after subsequent concussion. Despite the increasing body of literature on this topic, debate still surrounds the question of how many concussions are enough to recommend ending the player’s career. Some research suggests that the magic number may be 3 concussions in a career. Although these findings are important, they should be carefully interpreted because concussions present in varying degrees of severity, and all athletes do not respond in the same way to concussive insults. Most important is that these data provide evidence for exercising caution when managing younger athletes with concussion and athletes with a history of previous concussions. Disqualification is often an emotional and traumatic event in the life of a student-athlete. The decision will be made by the team physicians in consultation with the Director of Sports Medicine when it is determined that the student-athlete is at an unacceptable level of risk for permanent consequences as a result of participation or exertion. Once a decision is made to disqualify the student-athlete, a formal meeting should take place to discuss and explain the rationale for disqualification. 8. INJURY PREVENTION 8.1 Protective Equipment – Helmets and Headgear Biomechanical studies have shown a reduction in impact forces to the brain with the use of head gear and helmets, but these findings have not been translated to show a reduction in concussion incidence. Although wearing a helmet will not prevent all head injuries, a properly fitted helmet for certain sports reduces the risk of such injuries. A poorly fitted helmet is limited in the amount of protection it can provide, and the ATC must play a role in enforcing the proper fitting and use of the helmet. Protective sport helmets are designed primarily to prevent catastrophic injuries (ie, skull fractures and intracranial hematomas) and are not designed to prevent concussions. A helmet that protects the head from a skull fracture does not adequately prevent the rotational and shearing forces that lead to many concussions. The National Collegiate Athletic Association requires helmets be worn for the following sports: baseball, field hockey (goalkeepers only), football, ice hockey, women’s lacrosse (goalkeepers only), men’s lacrosse, and skiing. Helmets are also recommended for recreational sports such as bicycling, skiing, mountain biking, roller and inline skating, and speed skating. Headgear standards are established and tested by the National Operating Committee on Standards for Athletic Equipment and the American Society for Testing and Materials. More recently, the issue of headgear for soccer players has received much attention. Although several soccer organizations and governing bodies have approved the use of protective headbands in soccer, no published, peer-reviewed studies support their use. Recommendations supporting the use and performance of headgear for soccer are limited by a critical gap in biomechanical information about head impacts in the sport of soccer. Without data linking the severity and type of impacts and the clinical sequelae of single and repeated impacts, specifications for soccer headgear cannot be established scientifically. These types of headgear may reduce the ‘‘sting’’ of a head impact, yet they likely do not meet other sports headgear performance standards. This type of headgear may actually increase the incidence of injury. Players wearing headgear may have the false impression that the headgear will protect them during more aggressive play and thereby subject themselves to even more severe impacts that may not be attenuated by the headgear. 8.2 Protective Equipment – Mouth Guards The wearing of a mouth guard is thought by some to provide additional protection for the athlete against concussion by either reducing the risk of injury or reducing the severity of the injury itself. Mouth guards aid in the separation between the head of the condyle of the mandible and the base of the skull. It is thought that wearing an improperly fitted mouth guard or none at all increases this contact point. This theory, which is based on Newtonian laws of physics, suggests that the increased separation between 2 adjacent structures increases the time to contact, thus decreasing the amount of contact and decreasing the trauma done to the brain. However, no biomechanical studies support the theory that the increased separation results in less force being delivered to the brain. High school football and National Collegiate Athletic Association football rules mandate the wearing of a mouth guard, but the National Football League rulebook does not require players to wear a mouth guard. The National Collegiate Athletic Association requires mouth guards to be worn by all athletes in football, field hockey, ice hockey, and lacrosse. Researchers have found no advantage in wearing a custom-made mouth guard over a boil-and-bite mouth guard to reduce the rise of cerebral concussion in athletes. 8.3 Risk Compensation An important consideration in the use of protective equipment is the concept of risk compensation. This is where the use of protective equipment results in behavioral change such as the adoption of more dangerous playing techniques, which can result in a paradoxical increase in injury rates from a false sense of security. 8.4 Aggression vs. Violence in Sport The competitive/aggressive nature of sport which makes it fun to play and watch should not be discouraged. However, sporting organizations should be encouraged to address violence that may increase concussion risk. Fair play and respect should be supported as key elements of sport. 9. KNOWLEDGE TRANSFER As the ability to treat or reduce the effects of concussive injury after the event is minimal, education of athletes, colleagues and the general public is a mainstay of progress in this field. Athletes, referees, administrators, parents, coaches and health care providers must be educated regarding the detection of concussion, its clinical features, assessment techniques and principles of safe return to play. Methods to improve education including web-based resources, educational videos and international outreach programs are important in delivering the message. In addition, concussion working groups, plus the support and endorsement of enlightened sport groups such as Fe´de´ration Internationale de Football Association (FIFA), International Olympic Commission (IOC), International Rugby Board (IRB) and International Ice Hockey Federation (IIHF) who initiated this endeavor, have enormous value and must be pursued vigorously. Fair play and respect for opponents are ethical values that should be encouraged in all sports and sporting associations. Similarly, coaches, parents and managers play an important part in ensuring these values are implemented on the field of play. 10. MEDICAL LEGAL CONSIDERATIONS This consensus document reflects the current state of knowledge and will need to be modified according to the development of new knowledge. It provides an overview of issues that may be of importance to healthcare providers involved in the management of sports related concussion. It is not intended as a standard of care and should not be interpreted as such. This document is only a guide and is of a general nature consistent with the reasonable practice of a healthcare professional. Individual treatment will depend on the facts and circumstances specific to each individual case. Concussion Management Procedural Outline I. Staff Role Delineation A. Team Physicians 1. General oversight and approval 2. Review of Medical History and Predisposition 3. Clinical evaluation 4. Changes to standard care 5. Interpretation of ImPACT 6. Authorization of progression 7. Release to the Care of the ATC for Return to Play B. Various Specialists 1. Neurosurgeons 2. Neurologists C. ATC 1. Implementation of the Concussion Management Policies and Procedures 2. Education of Athletes, Coaches, and Staff 3. Review of Medical History and Predisposition 4. Conduct Baseline Testing 5. Initial Assessment 6. Immediate Plan 7. Subsequent Evaluations and Monitoring 8. Referral Decisions 9. Follow-up Serial Evaluations 10. Communication with coaches and physicians 11. Initiation of Exertional Testing 12. Return to Play following Physician Release 13. Subsequent Injuries D. Coaches 1. Acknowledgment of the Concussion Management Plan 2. Encourage Safe Play 3. Refer to the Sports Medicine Team for updates regarding an athlete’s progression 4. Follow the recommendations of the Sports Medicine Team E. Student Athletes 1. Provide an accurate medical history to the Sports Medicine Team 2. Participate within the rules of the game without malicious intent 3. Report all injuries and illnesses immediately 4. Assist teammates by reporting injuries when a teammate are in need 5. Follow the recommendations of the Sports Medicine Team F. Academic Advisor 1. Acknowledgment of the Concussion Management Plan 2. Refer to the Sports Medicine Team for updates regarding an athlete’s progression 3. Follow the recommendations of the Sports Medicine Team 4. Assist in Coordination of DSO 5. Develop Individual Return To Learn Plans II. Assessment Tools A. Symptom Based Testing a. Modified SCAT3 b. SCAT2, c. SCAT3 d. Symptom Evaluation & BESS e. Componets of C3Logix B. Neuropsychological Assessment a. ImPACT b. C3Logix III. Education (Written, Online, & Verbal) A. Initial Team Meeting B. ATC In-Services and Orientation C. Coaches Meeting D. Sport Supervisors Meeting E. NCAA Materials F. Time of Injury IV. Baseline Testing/Pre-Participation Testing A. Performed during the initial physical process for all incoming student-athletes B. Conducted prior to the first potential head injury training session C. Re-Assess Baseline Testing for student-athletes with a concussive episode in the previous 12 months D. Assessment Tools (Minimum of 1 Symptom Based Test and 1 Neuropsychological Assessment) V. Injury Assessment: Recognition and Diagnosis A. Symptom Assessment (included in Modified SCAT3) B. Physical and neurological assessment (included in Modified SCAT3) C. Cognitive assessment (included in Modified SCAT3) D. Balance Exam (included in Modified SCAT3) E. Clinical Assessment of C-Spine/Head Neck Trauma (included in Modified SCAT3) VI. Immediate Plan A. Remove student-athlete from practice or competition 1. Serial Assessments 2. Observation B. Referral if needed C. Release to a Responsible Adult with Home Care Instructions VII. Follow-up Plan A. Subsequent Evaluations and Monitoring (Symptom Based Testing) B. Notify Academic Advisor C. Refer to Physician for Evaluation D. Resolution of Symptoms E. Subsequent Evaluation of Neuropsychological Testing F. Refer to Physician for Progression (may be after initiating exertional testing) G. Exertional Testing H. Return to Play VIII. Exertional Testing A. Progression to Sport Specific and full return a. No Activity i. Complete physical and cognitive rest ii. Resolution of Symptoms iii. Neuropsychological Testing approximates with baseline iv. Progress to light aerobic exercise following 16-24 hrs rest while asymptomatic b. Light Aerobic Exercise i. Preform Symptom Evaluation ii. Walking, swimming, or stationary cycling keeping intensity iii. Below 70% of max heart rate; no resistance training iv. 10-15 mins in duration v. Perform Symptom Based Testing vi. Return to No-Activity if student-athlete experiences a recurrence of symptoms vii. Progress to sport specific exercise in an appropriate timeframe c. Sport Specific Exercise i. Preform Symptom Evaluation ii. Jogging, Shooting drills; Movement with no contact activities iii. 10-30 mins in duration iv. Perform Symptom Based Testing v. Return to No-Activity if student-athlete experiences a recurrence of symptoms vi. Progress to non-contact drills in an appropriate timeframe d. Non-Contact Training Drills i. Perform Symptom Evaluation ii. Complex training drills; running routes/plays emphasis on coordination and cognitive load iii. May implement progressive resistance exercise iv. 20-60 mins in duration v. Perform Symptom Based Testing vi. Return to No-Activity if student-athlete experiences a recurrence of symptoms vii. Progress to full contact practice in an appropriate timeframe e. Full contact Practice i. Perform Symptom Evaluation ii. Participate in normal training activities iii. 20-120 mins in duration iv. Perform Symptom Based Testing v. Return to No-Activity if student-athlete experiences a recurrence of symptoms vi. Release to return to play in an appropriate timeframe f. Return To Play i. Perform Symptom Evaluation ii. Return to No-Activity if student-athlete experiences a recurrence of symptoms iii. Normal participation and/or game play B. Physician Changes a. May advance the progress b. Evaluation for recurrence of symptoms or second insult c. Consideration given to modifiers IX. Return to Play A. Determined by Physician B. Monitoring C. Re-Assessment if needed X. Return to Learn A. Implementation of the Return to Learn Management Plan B. Home and classroom modification via DSO and Academic Support C. Monitor for worsening symptoms D. Release to full cognitive load Concussion Management Sideline Evaluation Suspected Head Injury Immediate Referral Required? YES Immediate Referral Activate EMS 911 Educate Athlete/Coaches/Roommates/Parents NO YES Symptoms Changing to Critical? Sideline Concussion Evaluation SCAT2/3 NO Continue Serial Evaluations Follow Take-Home Instructions Ensure Monitoring at Home Set Appointment for Follow-Up Concussed Concussion Symptoms? YES Remove Athlete From Participation Educate Athlete/Coaches/Roommates Perform Serial Follow-up Evaluations Set up Physician Evaluation NO Physically Exert (40 yd sprints & push-ups) Re-Evaluate SCAT 2/3 YES Concussion Symptoms? NO Return to Play Monitor Athlete Closely Re-Evaluate Post-Game Concussion Management Follow-Up Assessment Protocol Perform Clinical Evaluation & SCAT2/3 8-48 Hours Post Concussion Symptoms Changing to Critical? Immediate Referral YES Transport to Emergency Facility or Activate EMS 911 Educate Athlete/Coaches/Roommates/Parents NO YES NO Compare Baseline SCAT to Follow-Up Scores Return to Baseline ? NO Symptoms Changing to Critical? REST - NO ACTIVITY Schedule Follow-Up Routinely Frequent Evaluations Initially Progress to Every 2-3 Days Perform Clinical Evaluation & SCAT YES Perform ImPACT Neuro-Psychological Testing Compare Baseline ImPACT to Follow-Up Scores Return to Baseline ? YES Rest 16-24 Hours Then Proceed with Exertional Testing Protocol NO YES Symptoms Return at Any Point? NO Return to Play Monitor Athlete Closely Re-Evaluate As Needed Concussion Management Exertional Testing Protocol Post-Concussion Testing SCAT2/3 & ImPACT Returned to Baseline Rest 16-24 Hours Then Proceed with Exertional Testing Protocol Return to Baseline ? Perform Aerobic Activity Bike 10 mins <70 Max HR REST - NO ACTIVITY Symptoms Return? YES NO Remove From Activity Until Symptoms Resolve If Symptoms Persist Consider Extended Rest Between Exertional Testing Perform Clinical Evaluation SCAT2/3 & ImPACT Rest 16-24 Hours Perform Sport Specific Drills Light Jog, Shooting No Head Contact Symptoms Return? YES NO Rest 16-24 Hours Perform Non-Contact Drills Increase Cognitive Load Begin Progressive Resistance Symptoms Return? YES NO Rest 16-24 Hours Perform Full-Contact Drills Resume Normal Activities YES Symptoms Return? Return to Play NO Monitor Athlete Closely Re-Evaluate As Needed Concussion Management Physician Referral Checklist Immediate Referral 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Glasgow Coma Scale <13 Prolonged loss of consciousness Deterioration of neurologic function Focal neurological deficit suggesting intracranial trauma Persistently diminished/worsening mental status or other neurological signs/symptoms Decrease or irregularity in respirations Decrease or irregularity in pulse Repetitive vomiting Unequal, dilated, or un-reactive pupils Cranial nerve deficits Any signs or symptoms of associated injuries, spine or skull fracture, or bleeding Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation Seizure activity/posturing Sub-Acute Referral 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Loss of consciousness on the field Amnesia lasting longer than 15 min Increase in blood pressure Vomiting Motor deficits subsequent to initial on-field assessment Sensory deficits subsequent to initial on-field assessment Balance deficits subsequent to initial on-field assessment Cranial nerve deficits subsequent to initial on-field assessment Post-concussion symptoms that worsen Additional post-concussion symptoms as compared with those on the field Post-concussion symptoms worsen or do not improve over time Post-concussion symptoms begin to interfere with the athlete’s daily activities (ie, sleep disturbances) Post-Concussion Take Home Instructions I believe that__________________________________ sustained a concussion or direct contact to the head on________________. This is a potentially dangerous or even life threatening situation To make sure he/she recovers, please follow the following important recommendations: 1. Please remind him/her to report to the athletic training room tomorrow at______________ for a follow-up evaluation. 2. Please review the items outlined on the enclosed Symptom Checklist. If any of these problems develop prior to his/her visit, please call ___________________________ at ______________________ or contact the local emergency medical system at 911 if you feel that it is an emergency. Otherwise, please follow the instructions outlined below. It is OK to: Use acetaminophen (Tylenol) for headaches Use ice pack on head and neck as needed for comfort Eat a normal diet Return to school – report any increase in symptoms Go to sleep There is NO need to: Check eyes with flashlight Wake up every hour Stay in bed Avoid strenuous mental tasks Avoid text messaging and video games Do NOT use Advil, Ibuprofen, Aleve, or aspirin Do NOT drink alcohol Do NOT take pain killers or tranquilizers Do NOT eat spicy foods Do NOT drive until symptoms resolve Do NOT exercise or perform exertional activity Specific recommendations: _______________________________________________________________________ Recommendations provided to: _________________________________Signature: __________________________ Recommendations provided by: _________________________________ Date: ______________ Time: _________ Please feel free to contact me if you have any questions. I can be reached at: ________________________________ Signature: _______________________________ Date: ___________________ Symptom Checklist 1. Loss of consciousness – passed out 2. Excessive drowsiness 3. Increase in the severity of headache 4. Dizziness 5. Lack of coordination - unsteadiness 6. Change in speech pattern -slurring 7. Inability to concentrate 8. Blurred or double vision 9. Unequal pupil size 10. A stiff neck or pain around the neck or head 11. Any area of numbness, tingling, or weakness develops 12. Seizure activity or convulsions 13. Vomiting 14. Amnesia – has no memory or can’t remember 15. Change in behavior or emotional instability 16. Agitation or becomes easily aggravated 17. Loss of bowel or bladder function – inability to control going to the bathroom NC State University’s Compliance with NCAA Recommended Best Practices for a Concussion Management Plan for all NCAA Institutions 1. Institutions shall require student-athletes to sign a statement in which student-athletes accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. During the review and signing process student-athletes should be presented with educational material on concussions. (Concussion Fact-Sheet for Student-Athletes and NC State University’s “Concussion Awareness Release”) 2. Institutions should have on file and annually update an emergency action plan for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses. All athletics healthcare providers and coaches should review and practice the plan at least annually. (NC State University Sports Medicine Emergency Action Plans, Coaches Acknowledgement Form for Emergency Management Positive Sickle Cell Notification to Coaches) 3. Institutions should have on file an appropriate healthcare plan that includes equitable access to athletics healthcare providers for each NCAA sport. (NCAA Sports Medicine Handbook and Sports Medicine Sport Assignments) 4. Athletics healthcare providers should be empowered to have the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. For example, a countable coach should not serve as the primary supervisor for an athletics healthcare provider nor should they have sole hiring or firing authority over that provider. (Coaches Acknowledgement Form for Emergency Management) 5. Institutions shall have on file a written team physician–directed concussion management plan that specifically outlines the roles of athletics healthcare staff (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neuropsychologist). (NC State University Concussion Management Policies and Procedures and Concussion Management Procedural Outline) In addition, the following components have been specifically identified for the collegiate environment: a. Institutions should ensure coaches have acknowledged they understand the concussion management plan, their role within the plan and that they received education about concussions. (Concussion Fact Sheet for Coaches and Coaches Acknowledgement Form for Emergency Management) b. Athletics healthcare providers should practice within the standards as established for their professional practice (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neurologist, neuropsychologist). (Scope of Practice and Concussion Management Procedural Outline) c. Institutions should record a baseline assessment for each student-athlete prior to the first practice in the sports of baseball, basketball, diving, equestrian, field hockey, football, gymnastics, ice hockey, lacrosse, pole vaulting, rugby, soccer, softball, water polo, and wrestling, at a minimum. The same baseline assessment tools should be used post-injury at appropriate time intervals. The baseline assessment should consider one or more of the following areas of assessment. (Concussion Management Procedural Outline, Sport Concussion Assessment Tool 3 (SCAT3), and ImPACT Information Guide) 1) At a minimum, the baseline assessment should consist of the use of a symptoms checklist and standardized cognitive and balance assessments (e.g., SAC; SCAT3; Balance Error Scoring System (BESS, Neurocom). (Concussion Management Procedural Outline, Sport Concussion Assessment Tool 3 (SCAT3), and ImPACT Information Guide) 2) Additionally, neuropsychological testing (e.g., computerized, standard paper and pencil) has been shown to be effective in the evaluation and management of concussion. The development and implementation of a neuropsychological testing program should be performed in consultation with a neuropsychologist. Ideally, post injury neuropsychological test data should be interpreted by a neuropsychologist. (Concussion Management Procedural Outline and ImPACT Information Guide) d. When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, the athlete shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. (Concussion Management Procedural Outline) e. A student-athlete diagnosed with a concussion shall be withheld from the competition or practice and not return to activity for the remainder of that day. (Concussion Management Procedural Outline and Concussion Management Flow-Chart) f. The student-athlete should receive serial monitoring for deterioration. Athletes should be provided with written instructions upon discharge; preferably with a roommate, guardian, or someone that can follow the instructions. (Concussion Management Procedural Outline and Post-Concussion Take Home Instructions) g. The student-athlete should be evaluated by a team physician as outlined within the concussion management plan. Once asymptomatic and post-exertion assessments are within normal baseline limits, return to play should follow a medically supervised stepwise process. (Concussion Management Procedural Outline, Concussion Management Flow-Chart, and NC State University Concussion Management Policies and Procedures Table 2) h. Final authority for Return-to-Play shall reside with the team physician or the physician’s designee. (Concussion Management Procedural Outline) 6. Institutions should document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion. (Concussion Management Procedural Outline) 7. Although sports currently have rules in place; athletics staff, student-athletes and officials should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced. (Concussion Fact-Sheet for StudentAthletes, Concussion Fact Sheet for Coaches, Coaches Acknowledgement Form for Emergency Management, and Concussion Management Procedural Outline) NC State University Sports Medicine Concussion Awareness What is a concussion? A concussion is a brain injury that:  Is caused by a blow to the head or body. (From contact with another player, hitting a hard surface such as the ground or floor, or being hit by a piece of equipment such as a bat or a ball.)  Can change the way your brain normally works.  Presents itself differently for each athlete.  Can occur during practice or competition in ANY sport.  Can happen even if you do not lose consciousness. How can I prevent a concussion? Basic steps you can take to protect yourself from concussion:  Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet.  Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head may all cause concussions.  Follow the Athletics Department’s rules for safety and the rules of the sport.  Practice good sportsmanship at all times. What are the symptoms of a concussion? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include:  Feeling sluggish, foggy or groggy.  Balance problems or dizziness.  Amnesia.  Feeling unusually irritable.  Double or fuzzy vision.  Confusion.  Slowed reaction time.  Sensitivity to light or noise.  Headache.  Nausea (feeling that you might vomit).  Concentration or memory problems  Loss of consciousness. Although most athletes that experience a concussion recover within 7-10 days, some concussion may take much longer to resolve. There is evidence to suggest that sustaining a concussion or even multiple sub-concussive brain injuries may lead to long term consequences such as prolonged symptoms, psychological distress, depression, and/or Chronic Traumatic Encephalopathy (CTE). CTE is a progressive brain disease believed to be caused by repetitive trauma to the brain, including concussions or sub-concussive blows. CTE is characterized by symptoms such as memory impairment, emotional instability, erratic behavior, depression, and problems with impulse control. The disease may ultimately progress to full-blown dementia. Ultimately, sustaining a concussion could lead to death. What should I do if I think I have a concussion? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not continue to participate in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as a headache or tiredness) to reappear or get worse. Get help by talking to your athletic trainer. IT’S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. By signing below, I acknowledge that I understand that there are certain risks involved in participating in athletics at NC State University, including those risks associated with head injuries and concussions. I agree to report all signs and symptoms of my injuries to the Sports Medicine Staff immediately. Additionally, I will help protect my teammates by reporting their signs and symptoms to the Sports Medicine Staff. I understand that each head injury is different and the each injury will be treated individually, with each return to play decision performed on an individual basis. By signing this, I agree to follow the direction of treatment and care designated by the NC State Sports Medicine Staff. I understand that I must be cleared by an NC State Sports Medicine physician before returning to play. _______________________________________ Athlete’s Name Printed ___________________________________ Athlete’s Signature _________________ Date _______________________________________ Parent/Legal Guardian’s Printed (if under18) ___________________________________ Parent/Legal Guardian’s Signature _________________ Date Concussion Management Temporary Academic Accommodations There is a growing body of evidence to suggest that complete rest is the most ideal environment when recovering from a concussion. Cognitive function as well as physical activity should be addressed when considering the treatment plan. Any activity which exasperates concussion symptoms should be avoided in order to shorten the recovery process. Temporary academic accommodations may need to be established for a student-athlete who presents symptoms while participating in the academic setting. Setting up temporary academic accommodations should be a cooperative effort between Sports Medicine, Academic Support, and Disability Services. The following guideline should be used when requesting accommodations for student-athletes who have sustained a concussion. 1.) 2.) 3.) 4.) 5.) 6.) 7.) 8.) 9.) A student-athlete is diagnosed with a concussion by a team physician, ER physician or ATC. The ATC contacts Academic Support to initiate the Concussion Protocol for concussed Athletes A request for temporary accommodations must be made with Disability Services. Disability Services and Academic Support will coordinate with the appropriate faculty members to request additional vigilance or temporary leave. Sports Medicine, Disability Services and Academic Support stay in frequent contact (every 3-5 days) regarding the student-athlete’s progression. Serial evaluations are made by Sports Medicine to determine recovery back to baseline levels. Sports Medicine releases the student-athlete to full participation notifying Academic support. Disability Services determines the necessity of continued classroom modifications and maintains communication with the appropriate faculty members. Sports Medicine and Academic Support maintain a high level of vigilance with all previously concussed student-athletes. Behind the Blue Disk NCAA Approach to Concussions What is a concussion? A concussion is a minor traumatic brain injury characterized by a rapid onset of cognitive impairment. Concussions are often difficult to detect since most don’t lead to a loss of consciousness or have other immediately recognizable symptoms. What causes a concussion? Concussions typically occur from blows to the head either from contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. What are the numbers on concussion? The NCAA is constantly seeking to protect the health and safety of its student-athletes. One way it does is by using an injury surveillance program to monitor injury trends. The data from the program show concussions represent 5 to 18 percent of the total reported injuries, depending on the sport. As with many injuries, there is reason to believe these numbers are understated since student-athletes may not necessarily report injuries for fear of losing playing time. Common signs and symptoms of concussions: Loss of consciousness Confusion Amnesia Balance Problems Headache Visual Disturbance “Whenever you play competitive sports, there is the risk of injury. When it comes to concussion, clear return-to-play guidelines, proper coaching techniques, enforcement of existing rules and the use of properly fitted equipment can minimize the risk.” David Klossner, Director of Health and Safety What is the NCAA doing to prevent further concussions? In addition to funding studies, the NCAA informs student-athletes, institutional staff and sport officials on current prevention and return-to-play measures. When appropriate, it recommends changes to Association playing rules to make competitions safer. Does the NCAA require neuropsychological testing? The NCAA Sports Medicine Handbook guidelines recommend a number of evaluation measures for student-athletes who have sustained a concussion, including neuropsychological testing. The NCAA does not require one specific assessment tool. What does the NCAA recommend regarding concussion management? It is essential no student-athlete return to participation in a game, practice or other contest when symptoms persist either at rest or exertion. A student-athlete with any injury that involves unconsciousness, amnesia or persistent confusion should not be allowed to return to play the same day. What role do NCAA rules play in the prevention of concussions? NCAA rules committees oversee the playing rules of each sport and work closely with the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports and other medical experts to make competitions safer. What role does the school play in the prevention and treatment of concussions? Ultimately, it is the school’s responsibility to protect the health of its student-athletes. The NCAA publishes its sports medicine handbook to provide specific guidance on the treatment and prevention of concussions. Please access Behind the Blue Disk via www.ncaa.org for the most up-to-date information. For more information, contact NCAA Public and Media Relations at 317/917-6117. 1/8/2010 CONCUSSION A fact sheet for student-athletes What is a concussion? A concussion is a brain injury that: • Is caused by a blow to the head or body. – From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. • Can change the way your brain normally works. • Can range from mild to severe. • Presents itself differently for each athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness. How can I prevent a concussion? Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport. What are the symptoms of a concussion? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. What should I do if I think I have a concussion? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. It’s better to miss one game than the whole season. When in doubt, get checked out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. CONCUSSION A fact sheet for Coaches The Facts • A concussion is a brain injury. • All concussions are serious. • Concussions can occur without loss of consciousness or other obvious signs. • Concussions can occur from blows to the body as well as to the head. • Concussions can occur in any sport. • Recognition and proper response to concussions when they first occur can help prevent further injury or even death. • Athletes may not report their symptoms for fear of losing playing time. • Athletes can still get a concussion even if they are wearing a helmet. • Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries, depending on the sport. What is a concussion? A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Recognizing a possible concussion To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; -AND2. Any change in the student-athlete’s behavior, thinking or physical functioning (see signs and symptoms). Signs and Symptoms Signs Observed By Coaching Staff • Appears dazed or stunned. • Is confused about assignment or position. • Forgets plays. • Is unsure of game, score or opponent. • Moves clumsily. • Answers questions slowly. • Loses consciousness (even briefly). • Shows behavior or personality changes. • Can’t recall events before hit or fall. • Can’t recall events after hit or fall. Symptoms Reported By Student-Athlete • Headache or “pressure” in head. • Nausea or vomiting. • Balance problems or dizziness. • Double or blurry vision. • Sensitivity to light. • Sensitivity to noise. • Feeling sluggish, hazy, foggy or groggy. • Concentration or memory problems. • Confusion. • Does not “feel right.” PREVENTION AND PREPARATION As a coach, you play a key role in preventing concussions and responding to them properly when they occur. Here are some steps you can take to ensure the best outcome for your student-athletes: • Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to-play. – Review and practice your emergency action plan for your facility. – Know when you will have sideline medical care and when you will not, both at home and away. – Emphasize that protective equipment should fit properly, be well maintained, and be worn consistently and correctly. – Review the Concussion Fact Sheet for Student-Athletes with your team to help them recognize the signs of a concussion. – Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete. • Insist that safety comes first. – Teach student-athletes safe-play techniques and encourage them to follow the rules of play. – Encourage student-athletes to practice good sportsmanship at all times. – Encourage student-athletes to immediately report symptoms of concussion. • Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death. IF YOU THINK YOUR STUDENT-ATHLETE HAS SUSTAINED A CONCUSSION: IF A CONCUSSION IS SUSPECTED: Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion. 1. Remove the student-athlete from play. Look for the signs and symptoms of concussion if your student-athlete has experienced a blow to the head. Do not allow the student-athlete to just “shake it off.” Each individual athlete will respond to concussions differently. An athlete who exhibits signs, symptoms or behaviors consistent with a concussion, either at rest or during exertion, should be removed immediately from practice or competition and should not return to play until cleared by an appropriate health care professional. Sports have injury timeouts and player substitutions so that student-athletes can get checked out. 2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the studentathlete to the appropriate athletics medical staff, such as a certified athletic trainer, team physician or health care professional experienced in concussion evaluation and management. 3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return-to-play progression should occur in an individualized, step-wise fashion with gradual increments in physical exertion and risk of contact. 4. Develop a game plan. Student-athletes should not return to play until all symptoms have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact, as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change. It’s better they miss one game than the whole season. When in doubt, sit them out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. Overview and Features of the ImPACT Test ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the first, most-widely used, and most scientifically validated computerized concussion evaluation system. Developed in the early 1990's by Drs. Mark Lovell and Joseph Maroon, ImPACT is a 20-minute test that has become a standard tool used in comprehensive clinical management of concussions for athletes of all ages. ImPACT Applications, Inc. was co-founded by Mark Lovell, PhD, Joseph Maroon, MD, and Michael (Micky) Collins, PhD. Given the inherent difficulties in concussion management, it is important to manage concussions on an individualized basis and to implement baseline testing and/or post-injury neurocognitive testing. This type of concussion assessment can help to objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion. In fact, neurocognitive testing has recently been called the "cornerstone" of proper concussion management by an international panel of sports medicine experts. ImPACT can be administered by an athletic trainer, school nurse, athletic director, team coach, team doctor, or anyone trained to administer baseline testing. ImPACT is the most widely used computer-based testing program in the world and is implemented effectively across high school, collegiate, and professional levels of sport participation. Test Features           Measures player symptoms Measures verbal and visual memory, processing speed and reaction time Reaction time measured to 1/100th of second Assists clinicians and athletic trainers in making difficult return-to-play decisions Provides reliable baseline test information Produces comprehensive report of test results Results can be e-mailed or faxed for fast consultation by a neuropsychologist Automatically stores data from repeat testing Testing is administered online for individuals or groups Compatible with PC and MAC The test battery consists of a near infinite number of alternate forms by randomly varying the stimulus array for each administration. This feature was built in to the program to minimize the "practice effects" that have limited the usefulness of more traditional neurocognitive tests. ImPACT takes approximately 20 minutes to complete. The program measures multiple aspects of cognitive functioning in athletes, including:  Attention span  Working memory  Sustained and selective attention time  Response variability  Non-verbal problem solving  Reaction time Test Overview      Section 1: Demographic Information & Health History Questionnaire Section 2: Current Symptoms and Conditions Section 3: Neuropsychological Tests (baseline testing and post-injury testing) o Module 1: Word Memory o Module 2: Design Memory o Module 3: X's and O's o Module 4: Symbol Matching o Module 5: Color Match o Module 6: Three Letter Memory Section 4: Injury Description Section 5: ImPACT Test Scores SCAT3 ™ Sport Concussion Assessment Tool – 3rd edition For use by medical professionals only Modified for use within NC State Sports Medicine Name Symptom Evaluation Sport / Team How do you feel? “You should score yourself on the following symptoms, based on how you feel now”. Date / Time of injury none Date / Time of assessment Age Gender M F Examiner Progression Phase Baseline mild moderate severe Headache 0 1 2 3 4 5 6 “pressure in head” 0 1 2 3 4 5 6 neck pain 0 1 2 3 4 5 6 nausea or vomiting 0 1 2 3 4 5 6 Dizziness 0 1 2 3 4 5 6 Blurred vision 0 1 2 3 4 5 6 Balance problems 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 Initial Post Concussion Rest Follow-Up Light Bike <70 max HR Feeling slowed down 0 1 2 3 4 5 6 Light Jogging Feeling like “in a fog“ 0 1 2 3 4 5 6 “Don’t feel right” 0 1 2 3 4 5 6 Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6 Fatigue or low energy 0 1 2 3 4 5 6 Confusion 0 1 2 3 4 5 6 History Drowsiness 0 1 2 3 4 5 6 How many concussions do you think you have had in the past? trouble falling asleep 0 1 2 3 4 5 6 more emotional 0 1 2 3 4 5 6 When was the most recent concussion? irritability 0 1 2 3 4 5 6 How long was your recovery from the most recent concussion? Sadness 0 1 2 3 4 5 6 nervous or Anxious 0 1 2 3 4 5 6 Non-contact Activity Pre-Exercise Post-Exercise Blood Pressure Contact Activity Pulse Have you ever been diagnosed with headaches or migraines? Y n Do you have a learning disability, dyslexia, ADD / ADHD? Y n Have you ever been diagnosed with depression, anxiety Y n Y n or other psychiatric disorder? Has anyone in your family ever been diagnosed with any of these problems? Are you on any medications? if yes, please list: Notes: Y n Total number of symptoms (Maximum possible 22) Symptom severity score (Maximum possible 132) Do the symptoms get worse with physical activity? N/A Y n Do the symptoms get worse with mental activity? N/A Y n self rated self rated and clinician monitored clinician interview self rated with parent input overall rating: if you know the athlete well prior to the injury, how different is the athlete acting compared to his / her usual self?  Please circle one response: no different very different unsure N/A On a scale of 0-100, how normal do you feel? How many hours of sleep did you get last night? Have you eaten today? Y n Are you well hydrated? Y n Athlete Signature SCAT3 Sport ConCuSSion ASSeSment tool 3 PAge 1 Any loss of consciousness? Y n Cognitive assessment Standardized Assessment of Concussion (SAC) 4 “if so, how long?“ Balance or motor incoordination (stumbles, slow / laboured movements, etc.)? Y n Disorientation or confusion (inability to respond appropriately to questions)? Y n loss of memory: Y n “if so, how long?“ “Before or after the injury?" Blank or vacant look: Y n Visible facial injury in combination with any of the above: Y n orientation (1 point for each correct answer) What month is it?  0 1 What is the date today?  0 1 What is the day of the week?  0 1 What year is it?  0 1 What time is it right now? (within 1 hour) 0 1 orientation score Cranial Nerves Special Tests Eye Exam of 5 immediate memory List Trial 1 Trial 2 Trial 3 Alternative word list Smile Big WNL Abnormal Abnormal Facial Sensation WNL Abnormal elbow 0 1 0 1 0 1 candle baby finger WNL Abnormal Hearing WNL Abnormal apple 0 1 0 1 0 1 paper monkey penny Nystagmus WNL Abnormal Swallow WNL Abnormal carpet 0 1 0 1 0 1 sugar perfume blanket Accuity WNL Abnormal Shoulder Shrug WNL Abnormal saddle 0 1 0 1 0 1 sandwich sunset lemon Stick Out Tongue WNL Abnormal bubble 0 1 0 1 0 1 wagon iron insect Equal Pupils WNL Abnormal Reactive Pupils WNL Tracking Total glasgow coma scale (gCS) of 15 immediate memory score total Best eye response (e) no eye opening 1 eye opening in response to pain 2 eye opening to speech 3 eyes opening spontaneously 4 Concentration: digits Backward List Best verbal response (v) Trial 1 Alternative digit list 4-9-3 0 1 6-2-9 5-2-6 4-1-5 3-8-1-4 0 1 3-2-7-9 1-7-9-5 4-9-6-8 6-2-9-7-1 0 1 1-5-2-8-6 3-8-5-2-7 6-1-8-4-3 7-1-8-4-6-2 0 1 5-3-9-1-4-8 8-3-1-9-6-4 7-2-4-8-5-6 no verbal response 1 incomprehensible sounds 2 inappropriate words 3 Concentration: month in reverse order (1 pt. for entire sequence correct) Confused 4 Dec-nov-oct-Sept-Aug-Jul-Jun-may-Apr-mar-Feb-Jan oriented 5 Concentration score Total of 4 0 1 of 5 Best motor response (m) no motor response 1 extension to pain 2 Abnormal fl exion to pain  3 Flexion / Withdrawal to pain  4 localizes to pain 5 obeys commands 6 glasgow Coma score (e + v + m) Neck Examination: Range of motion T pper and lower limb sensation & strength U Findings:  of 15 Balance examination 20-second trials Do one or both of the following tests. 2 maddocks Score3 Footwear (shoes, barefoot, braces, tape, etc.)  “I am going to ask you a few questions, please listen carefully and give your best effort.” Modifi ed Maddocks questions (1 point for each correct answer) What venue are we at today?  0 1 Which half is it now? 0 1 Who scored last in this match? 0 1 What team did you play last week / game? 0 1 Did your team win the last game? 0 1 maddocks score of 5 Scoring Summary: test Domain Score Date: number of Symptoms of 22 Symptom Severity Score of 132 orientation of 5 immediate memory of 15 Concentration of 5 Date: Date: Modified Balance Error Scoring System (BESS) testing5 Which foot was tested (i.e. which is the non-dominant foot) Left  Right Testing surface (hard floor, field, etc.)  Condition Errors Double leg stance: Single leg stance (non-dominant foot): Errors Tandem stance (non-dominant foot at back): Errors types of errors 1. Hands lifted off iliac crest 2. opening eyes 3. Step, stumble, or fall 4. moving hip into > 30 degrees abduction 5. lifting forefoot or heel 6. remaining out of test position > 5 sec Coordination examination Upper limb coordination Which arm was tested: Left  Right Coordination score of 1 Delayed recall of 5 SAC Total BESS (total errors) Tandem Gait (seconds) 8 SAC Delayed Recall4 Delayed recall score of 5 Coordination of 1 SCAT3 Sport Concussion Assesment Tool 3 Page 2 Emergency Action Plan Doak Baseball Stadium A. EMERGENCY PERSONNEL • Emergency Phone Numbers EMS Student Health WB Training Room Josh Geruso Rob Murphy 911 (919) 515-2563 (919) 515-2111 (919) 819-8337 (478) 951-7115 Certified athletic trainers are on site for all official events and practices. B. EMERGENCY NUMBERS • • If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses, call 911. If a non-life-threatening condition occurs call (dial 7 for an outside line)  Weisiger-Brown Athletic Training Room (919) 515-2111  Student Health Services (919) 515-2563  Rex Emergency Room (919) 783-3038 C. ROLES OF FIRST RESPONDER • • Immediate care of injured or ill person Activate Emergency Medical Service (EMS) by calling 911  Give your name  Location/Address (see below)  # calling from  State the emergency  Approx. age of victim  Conscious: Y/N?  Breathing: Y/N?  Pulse: Y/N?  Severe Bleeding: Y/N D. DIRECTIONS TO DOAK BASEBALL STADIUM • 1050 Varsity Dr, Raleigh NC • On the corner of Varsity Dr and Sullivan Dr on the NC State Campus. • Limit scene to first aid providers and remove all bystanders • Have 1 bystander outside to meet EMS E. EMERGENCY EQUIPMENT • Available equipment located in Doak Baseball Athletic Training Room  AED  Splints  Crutches Emergency Action Plan DAIL BASKETBALL CENTER EMERGENCY PERSONNEL • A. EMS Student Health WB Training Room Ryan Holleman, ATC Rob Murphy 911 (919) 515-2563 (919) 515-2111 (919) 816-5395 (478) 951-7115 Certified Staff and graduate athletic trainers are on site for all events and practices. Additional staff may also be found in the basement level athletic training room or (919) 5152111. EMS staff will be on site for all events. EMERGENCY NUMBERS • • B. Emergency Phone Numbers If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses, call 911. If a non-life-threatening condition occurs call o Weisiger-Brown Athletic Training Room (919) 515-2111 o Student Health Services (919) 515-2563 or 5-2563 (campus line) o Rex Emergency Room (919) 783-3038 (dial 7 for an outside line) ROLES OF FIRST RESPONDER • Immediate care of injured or ill person • Activate Emergency Medical Service (EMS) by calling 911 - Give your name - Conscious: Y/N? - Location/Address (see below) - Breathing: Y/N? - # calling from - Pulse: Y/N? - State the emergency - Severe bleeding Y/N? - Approx. age of victim C. DIRECTIONS TO DAIL BASKETBALL CENTER • Right on Warren Carroll Drive and follow the road to the back entrance. Enter through the double doors of the Dail Basketball Center near the trash dumpster. • Limit scene to first aid providers and remove all bystanders • Have 1 bystander outside to meet EMS D. EMERGENCY EQUIPMENT • Available equipment located in Weisiger-Brown Athletic Training Room - AED - Splints - Crutches Emergency Action Plan Dail Soccer Field EMERGENCY PERSONNEL • A. EMS 911 Student Health (919) 515-2563 WB Training Room (919) 515-2111 Rob Murphy(MSOC) (478) 951-7115 Abby Whiteside (WSOC)(937)243-5480 It is recommended that a Certified Athletic Trainer (ATC) be present for all events, practices, camps, etc. In the event that an ATC is not present the person in charge should designate a first responder who will be responsible for activating the emergency action plan. EMERGENCY NUMBERS • • B. Emergency Phone Numbers If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses call 911. If a non-life-threatening condition occurs call o The athlete’s parents, legal guardian, coach, etc. and advise them to seek medical care with a family physician or at the emergency room o Rex Emergency Room (919) 783-3038 (dial 7 for an outside line if using a campus phone) ROLE OF FIRST RESPONDER 1. Immediate care of injured or ill person 2. Activate Emergency Medical Service (EMS) Call 911 - Give your name - Conscious: Y/N? - Location/Address (see below) - Breathing: Y/N? - # calling from - Pulse: Y/N? - State the emergency - Severe bleeding Y/N? - Approx. age of victim C. DIRECTIONS TO DAIL SOCCER FIELD • From Western Blvd turn onto Morrill Dr. • Turn Right onto Cates Ave. • Dail Soccer Field is located on the Right • Go past the Soccer field and take a right down the field’s access road. • Someone will be waiting at the locker room building Reviewed: 12/13/12 Emergency Action Plan Dail Softball Stadium EMERGENCY PERSONNEL Emergency Phone Numbers EMS Student Health Reynolds Training Room Amber Gast Casi Dailey Rob Murphy 911 919-515-2563 919-513-7801 419-722-2402 919-815-0741 478-951-7115 Certified staff and graduate athletic trainers are on site for all events and practices. A. EMERGENCY NUMBERS • • B. If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses call 911. If a non-life-threatening condition occurs call o Reynolds Athletic Training Room 919-513-7801 o Weisiger-Brown Athletic Training Room 919-515-2111 o Student Health Services 919-515-2563 or 5-2563 (campus line) o Rex Emergency Room 919-783-3038 (dial 7 for an outside line) ROLE OF FIRST RESPONDER 1. Immediate care of injured or ill person 2. Activate Emergency Medical Service (EMS) - Call 911 • Give your name • Location/Address (see below) • # calling from • State the emergency • Approx. age of victim • Conscious: Y/N? • Breathing: Y/N? • Pulse: Y/N? • Severe bleeding: Y/N? C. DIRECTIONS TO DAIL SOFTBALL STADIUM • Main Entrance to the stadium is located at the Corner of Morrill and Cates Ave. • Some one will be waiting at the Main Entrance to the stadium. Access field via staircase behind first base dug out. • Limit scene to first aid providers and remove all bystanders. Reviewed: 10/21/13 Emergency Action Plan Wolfpack Training Complex EMERGENCY PERSONNEL Emergency Phone Numbers EMS 911 Student Health (919) 515-2563 WB Training Room (919) 515-2111 Rob Murphy (MSOC) (478) 951-7115 Abby Whiteside(WSOC)(937)-243-5480 Certified Staff and graduate athletic trainers are on site for all events and practices. Additional staff may also be found in the athletic training room or (919) 515-2111. A. EMERGENCY NUMBERS • • B. If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses call 911. If a non-life-threatening condition occurs call o Weisiger-Brown Athletic Training Room (919) 515-2111 o Student Health Services (919) 515-2563 or 5-2563 (campus line) o Rex Emergency Room (919) 783-3038 (dial 7 for an outside line) ROLE OF FIRST RESPONDER 1. Immediate care of injured or ill person 2. Activate Emergency Medical Service (EMS) Call 911 - Give your name - Conscious: Y/N? - Location/Address (see below) - Breathing: Y/N? - # calling from - Pulse: Y/N? - State the emergency - Severe bleeding Y/N? - Approx. age of victim • • • DIRECTIONS TO Wolfpack Training Complex From Western Blvd turn onto Morrill Drive. Training Complex will be on the Left. Reviewed: 12/13/12 Emergency Action Plan CARMICHEAL GYMNASTICS EMERGENCY PERSONNEL • A. Public Safety Student Health WB Training Room Rob Murphy Nicole Neal (919) 515-3333 (919) 515-2563 (919) 515-2111 (478) 951-7115 (919) 819-0092 Certified Staff and graduate athletic trainers are on call in the Weisiger Brown Athletic Training Room or at (919) 515-2111 during all team practices. Certified graduate assistant athletic trainer will be on site for all meets. EMERGENCY NUMBERS • • B. Emergency Phone Numbers If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses, call 911. If a non-life-threatening condition occurs call o Weisiger-Brown Athletic Training Room (919) 515-2111 o Student Health Services (919) 515-2563 or 5-2563 (campus line) o Rex Emergency Room (919) 783-3038 *dial 7 for an outside line ROLES OF FIRST RESPONDER 1. Immediate care of injured or ill person 2. Activate Emergency Medical Service (EMS) a. 911, if on campus (919) 515-3333 - Give your name - Conscious: Y/N? - Location/Address (see below) - Breathing: Y/N? - # calling from - Pulse: Y/N? - State the emergency - Severe bleeding Y/N? - Approx. age of victim C. DIRECTIONS TO CARMICHEAL GYMNASTIC ROOM • Enter campus via Morrill Drive. Take Morrill Drive past the intramural fields on the left and take left on Cates Ave. Enter Carmicheal through the glass doors at top of brick ramp - Some one will be waiting at the glass doors to direct EMS into the Gymnastic Room. - Limit scene to first aid providers and remove all bystanders D. EMERGENCY EQUIPMENT Available equipment (located in Weisiger Brown Athletic Training Room) - AED - Crutches/Splints Emergency Action Plan Reynolds Coliseum A. EMERGENCY PERSONNEL • B. Public Safety Student Health Reynolds Athletic Training Room Rob Murphy Nicole Neal 911 515-2563 513-7790 (478) 951-7115 (919) 819-0092 Certified and graduate athletic trainers are on site for all events and practices. Additional staff may also be found in the basement level athletic training room or (919) 513-7790. EMS staff will be on site or on call for all events. EMERGENCY NUMBERS • • C. Emergency Phone Numbers If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses, call 911. If a non-life-threatening condition occurs call o Reynolds Athletic Training Room (919) 513-7790 o Student Health Services (919) 515-2563 or 5-2563 (campus line) o Rex Emergency Room (919) 783-3038 *dial 7 for an outside line if using a land line phone. ROLES OF FIRST RESPONDER 1. Immediate care of injured or ill person 2. Activate Emergency Medical Service (EMS) 911 - Give your name - Conscious: Y/N? - Location/Address (see below) - Breathing: Y/N? - # calling from - Pulse: Y/N? - State the emergency - Severe bleeding Y/N? - Approx. age of victim D. DIRECTIONS TO REYNOLDS COLISEUM • On the corner of Cates and Morrill Dr. Enter through red doors across from Derr Track OR can enter on the west side parking lot behind Case Dinning Hall -Limit scene to first aid providers and remove all bystander -Have 1 bystander outside to meet EMS E. EMERGENCY EQUIPMENT • Available equipment (located in Reynolds Athletic Training Room) -AED -Crutches/Splints Emergency Action Plan J.W. ISENHOUR TENNIS CENTER Emergency Phone Numbers Public Safety Student Health WB Training Room Rob Murphy Josh Geruso Wes Bell Alyssa Schramm (919) 515-3333 (919) 515-2563 (919) 515-2111 (478) 951-7115 (919) 819-0092 (919) 356-4713 (614) 620-0997 EMERGENCY PERSONNEL • A. EMERGENCY NUMBERS • • B. Certified athletic trainers are on site for all events and practices. Additional staff may also be found next door at the baseball stadium or by calling (919) 515-2111. If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses, call 911. If a non-life-threatening condition occurs call o Weisiger-Brown Athletic Training Room (919) 515-2111 o Student Health Services (919) 515-2563 or 5-2563 (campus line) o Rex Emergency Room (919) 783-3038 *dial 7 for an outside line ROLES OF FIRST RESPONDER 1. Immediate care of injured or ill person 2. Activate Emergency Medical Service (EMS) a. 911, if on campus (919) 515-3333 - Give your name - Conscious: Y/N? - Location/Address (see below) - Breathing: Y/N? - # calling from - Pulse: Y/N? - State the emergency - Severe bleeding Y/N? - Approx. age of victim C. DIRECTIONS TO J.W. ISENHOUR TENNIS CENTER • Take Western Blvd. to Varsity Dr. The tennis center is located on Varsity Dr. across the street from the Doak Baseball Stadium. Enter through the front door and proceed through the lobby. • Limit scene to first aid providers and remove all bystanders • Have 1 bystander outside to meet EMS D. EMERGENCY EQUIPMENT Available equipment (located in Doak Baseball Athletic Training Room across the street) - AED - Crutches/Splints Reviewed and updated 10/07/2013 Emergency Action Plan Weisiger-Brown Wrestling Room EMERGENCY PERSONNEL Emergency Phone Numbers EMS Student Health WB Athletic Training Room Will Conlon Rob Murphy 911 (919) 515-2563 (919) 515-2111 (919) 623-8361 (478) 951-7115 Certified Staff and graduate athletic trainers are on site for all events and practices. Additional staff may also be found in the athletic training room or (919) 515-2111. A. EMERGENCY NUMBERS • • B. If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses, activate the yellow emergency call box. If a non-life-threatening condition occurs call o Weisiger-Brown Athletic Training Room (919) 515-2111 o Student Health Services (919) 515-2563 or 5-2563 (campus line) o Rex Emergency Room (919) 783-3038 (dial 7 for an outside line) ROLE OF FIRST RESPONDER 1. Immediate care of injured or ill person 2. Activate Emergency Medical Service (EMS) Call 911 - Give your name - Conscious: Y/N? - Location/Address (see below) - Breathing: Y/N? - # calling from - Pulse: Y/N? - State the emergency - Severe bleeding Y/N? - Approx. age of victim C. DIRECTIONS TO WB WRESTLING ROOM • Right on Warren Carroll Drive and follow the road to the front entrance. Enter through the double glass doors at the front of the Weisiger Brown Building. • Some one will be waiting at the door to direct EMS. • Limit scene to first aid providers and remove all bystanders Reviewed: 10/14/13 Emergency Action Plan WILLIS CASEY AQUATIC CENTER EMERGENCY PERSONNEL • A. Public Safety Student Health WB Athletic Training Room Casi Dailey Rob Murphy (919) 515-3333 (919) 515-2563 (919) 515-2111 (919) 815-0741 (478) 951-7115 Certified Staff and graduate athletic trainers are on call in the Weisiger Brown Athletic Training Room or at (919) 515-2111 during all team practices. Certified graduate assistant athletic trainer will be on site for all meets. EMERGENCY NUMBERS • • B. Emergency Phone Numbers If a life-threatening condition occurs, including but not limited to concussion, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses, call 911. If a non-life-threatening condition occurs call o Weisiger-Brown Athletic Training Room (919) 515-2111 o Student Health Services (919) 515-2563 or 5-2563 (campus line) o Rex Emergency Room (919) 783-3038 *dial 7 for an outside line ROLES OF FIRST RESPONDER 1. Immediate care of injured or ill person 2. Activate Emergency Medical Service (EMS) a. 911, if on campus (919) 515-3333 - Give your name - Conscious: Y/N? - Location/Address (see below) - Breathing: Y/N? - # calling from - Pulse: Y/N? - State the emergency - Severe bleeding Y/N? - Approx. age of victim C. DIRECTIONS TO WILLIS CASEY AQUATIC CENTER • Enter campus via Morrill Drive. Take Morrill Drive past the intramural fields on the left and enter the next parking lot on the left. Enter through the glass doors facing the parking lot and to the left of the Carmichael Recreation Center. - Some one will be waiting at the glass doors to direct EMS into the Aquatic Center. - Limit scene to first aid providers and remove all bystanders D. EMERGENCY EQUIPMENT Available equipment (located in Weisiger Brown Athletic Training Room) - AED - Crutches/Splints NC State University Sports Medicine Coaches Acknowledgement Checklist o Sickle Cell o Concussion o Heat and Hydration/Acclimatization o Lightning o EAP o Drug Testing o HIPAA o Day-to Day (injury reports who, how, how often) o Team Mtgs needs specific to sports _________________________________________________ Head Coach Signature ______________ Date _________________________________________________ Athletic Trainer Signature ______________ Date NC State University Sports Medicine Strength & Conditioning Coaches Checklist o o o o o o o o o Sickle Cell Concussion Heat and Hydration/Acclimatization Lightning EAP Drug Testing HIPAA Day-to Day (injury reports who, how, how often) Provide list of medical conditions for student-athletes working out with them (concussion history, sickle cell, heat, cardiac, diabetes, asthma, allergies) _________________________________________________ Strength Coach Signature ______________ Date _________________________________________________ Athletic Trainer Signature ______________ Date NC State University Sports Medicine Sickle Cell Trait In general, student-athletes with sickle cell trait should: • • • • • • • • • • • • • Slowly build up their intensity while training. Have their fitness tests scheduled later in the training program. Use a progressive, periodized program and evaluate their performance once they are acclimated to the stress about to be placed upon them. Be allowed to set their own pace while conditioning. Implement a slow and gradual preseason conditioning regimen that prepares them for the rigors of the sport. Be provided adequate rest and recovery between repetitions, especially during “gassers” and intense station or “mat” drills. Be given alternatives for performance testing, rather than serial sprints or timed mile runs, especially if these activities are not specific to the sport. Stop activity immediately upon struggling or experiencing symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness. Stay well hydrated at all times, in hot and humid conditions. Refrain from consuming high caffeine energy drinks and supplements, or other stimulants, as they may contribute to dehydration. Maintain proper asthma management. Refrain from extreme exercise during acute illness, if feeling ill, or while experiencing a fever. Beware when adjusting to a change in altitude, e.g., a rise in altitude of as little as 2,000 feet. Modify training and have supplemental oxygen available. Seek prompt medical care when experiencing unusual physical distress. NC State University Sports Medicine Concussion Management Signs and Symptoms • Appears dazed or stunned. • States he had his “bell rung.” • Complains of a headache • Is confused about assignment or position. • Forgets plays. • Is unsure of game, score or opponent. • Moves clumsily. • Answers questions slowly. • Loses consciousness (even briefly). • Shows behavior or personality changes. • Can’t recall events before or after a hit or fall. IF A CONCUSSION IS SUSPECTED: 1. Remove the student-athlete from play. 2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. 3. Allow the student-athlete to return to play only with permission from our team physicians and athletic trainers. 4. Check with your athletic trainer to better understand the management of your athlete’s health. RETURN TO PLAY Athlete may not return to play on the same day the concussion has been diagnosed. In gerneral, expect the athlete will be removed from participation for a minimum of 4 days. Our team physicians will make the final decision on return to play. NC State University Sports Medicine Heat & Dehydration Weight Monitoring for Hydration During 2-a-day/ 3-a-day sessions athletes must weigh in before and after practice. Losses of 3-5% body weight after practice indicates dehydration. A return weigh-in before the next practice should be within 1-2% of original weight. Athletes with a 2% or greater weight loss between practices will be held out of all activity & report to the athletic trainer for instruction on proper hydration. Athletes also will be required to weigh within 2% of the previous day’s weight prior to beginning activity. The athletic training room will provide weight charts & scales. Athletic trainers and coaches must take responsibility for implementation of appropriate weight monitoring procedure. The sports medicine staff will evaluate the data. The Heat Index is the temperature the body feels when heat and humidity are combined. The chart below shows the Heat Index that corresponds to the actual air temperature and relative humidity. This chart is based upon shady, light wind conditions. Exposure to direct sunlight can increase the Heat Index by up to 15 degrees Fahrenheit. Relative Humidity (%) 40 45 50 55 60 65 70 75 80 85 90 95 100 110 136 - - - - - - - - - - - - 108 130 137 - - - - - - - - - - - 106 124 130 137 - - - - - - - - - - 104 119 124 131 137 - - - - - - - - - 102 114 119 124 130 137 - - - - - - - - 100 109 114 118 124 129 136 - - - - - - - 98 105 109 113 117 123 128 134 - - - - - - 96 101 104 108 112 116 121 126 132 - - - - - 94 97 100 102 106 110 114 119 124 129 135 - - - 92 94 96 99 101 105 108 112 116 121 126 131 - - 90 91 93 95 97 100 103 106 109 113 117 122 127 132 88 88 89 91 93 95 98 100 103 106 110 113 117 121 86 85 87 88 89 91 93 95 97 100 102 105 108 112 84 83 84 85 86 88 89 90 92 94 96 98 100 103 82 81 82 83 84 84 85 86 88 89 90 91 93 95 With Prolonged Exposure to Heat and/or Physical Activity Alert 1: Alert 2: Alert 3: Alert 4: Fatigue possible Sunstroke, muscle cramps, and or heat exhaustion possible sunstroke, muscle cramps, and/or exhaustion likely Heat stroke or sunstroke likely Alert 1: Alert 2: Alert 3: Alert 4: Index<90 Index 90-103 Outdoor Helmeted Normal Practice Index 104-127 Normal practice gear HELMETS ONLY REMOVE HELMETS during breaks REMOVE HELMETS during breaks 5min break every 15-20mins 5min break every 10-15mins Index >127 NO PRACTICE Outdoor Non-Helmeted Alert 1: Alert 2: Alert 3: Alert 4: Index<90 Index 90-103 Index 104-127 Index >127 Normal Practice 5min break every 45-50mins 5min break every 30-35mins NO PRACTICE Indoor Un-Conditioned Air Alert 1: Alert 2: Alert 3: Alert 4: Index<90 Index 90-103 Index 104-127 Index >127 Normal Practice 5min break every 45-50mins 5min break every 30-35mins NO PRACTICE Lightning Safety Policy • • • • The responsibility for removing a team or individuals from an athletic site in the event of dangerous or eminent lightning activity is the responsibility of the head coach. Whenever possible, the certified athletic training staff will advise the coach supervising the activity as to the perceived threat from lightning. It will be the responsibility of the head coach to remove the team or individuals from the field or event site. The Athletic Trainer will advise the coach if lightning is within six miles and the field should be cleared until the Lightning Tracking Service issues a lightning clear signal. Emergency Action Plan Conditions that may warrant emergency care • Heat illness • Head injury • Neck or spine injury • Respiratory difficulties • Fractures, dislocations • Severe bleeding • Shock • Sickle Cell Trait Collapses • Cardiac Arrest Communication in Emergency • Contact Athletic Training Room, or, if not available, • Activate EMS for emergency transport to hospital.  Identify and decide that emergency transportation is warranted.  Remains with athlete to administer necessary first aid & sends someone else to call 911. What to say when calling EMS: “We have an emergency situation at ________________________. The emergency is __________________________. We request assistance at _______________________ through the entrance __________________.” • • • Person making the call waits for ambulance at the designated entrance. The person who identified and activates emergency action plan decides who shall go in the ambulance with the athlete. Basic first aid & CPR should continue to be administered until EMS relieves person of their responsibility to the student-athlete. Drug Testing Institutional Testing: • Testing may occur at any day or time • Testing for NCAA banned substances, as well as, but not limited to any illicit drug (i.e. marijuana, synthetic drugs, Adderall, any controlled substance w/o valid prescription, etc.) First positive: • Notification of student-athlete, head coach, sport administration, parents/legal guardian, • Education program. • Student-athlete subject to reasonable suspicion testing at any time Second positive: • Notification of student-athlete, head coach, sport administration, parents/legal guardian • Intervention program • Suspension of 20% of competition immediately • Student-athlete subject to reasonable suspicion testing at any time Third positive: • Permanent removal from roster and possible financial aid Coaches may enforce a stricter policy. Speak with Sport Administrator regarding this. NCAA Testing: • May occur at any time or day • Athlete notified the day before testing and given time and location to report • Failure to report results in positive test First Positive: 1 year suspension from competition Second Positive: Permanent ban from competition HIPAA HIPAA is a federal law that requires that all medical records are confidential and will only be released pursuant to our student-athlete’s authorization. No medical information is to be released without written consent from the student-athlete. This includes any form of medical information written or spoken. Every effort should be made to keep this information private and confidential. Act in good faith. Never release anything that could be used against a student. Failed Drug Tests: “Violation of team rules.” NC State University Sports Medicine Sickle Cell Trait Notification (Coach) _______________________(sport) The Sports Medicine Staff would like to make you aware that as of _______________________(date) the following student-athletes have been identified as having sickle cell trait: 1. ______________________________________________ 2. ______________________________________________ 3. ______________________________________________ 4. ______________________________________________ 5. ______________________________________________ 6. ______________________________________________ 7. ______________________________________________ 8. ______________________________________________ 9. ______________________________________________ 10.______________________________________________ Please understand that seven college student-athletes with sickle cell trait, died during conditioning activities between 2000-2009. This is a high risk group that should be monitored appropriately. Activity should be stopped immediately if any of these athletes experiences muscle pain and/or a cramping sensation, abdominal weakness, abnormal fatigue, or breathlessness. Never restrict water. Contact EMS and/or your Athletic Trainer when any athlete is in distress. NC State University Sports Medicine Sickle Cell Trait Notification (Coach) Athlete’s name: _________________________________________ Team: ___________________________ Coach’s name: __________________________________________ Date: _____ / _____ / _____ Introduction: Sickle Cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. This trait gives red blood cells a sickle or “half -moon” shape that should normally be round. This trait can make red blood cells stick to vessel walls and also gives them poor oxygen carrying capacity compared to normal red blood cells. During exercise, these sickled red blood cells can accumulate in the bloodstream. The accumulation of sickled red blood cells can lead to ischemic rhabdomyolysis, the rapid breakdown of muscle cells possibly causing death if not treated. Sickling can occur within 2-3 minutes of intense all –out exercise. Heat, dehydration, altitude, asthma, and other medical conditions may increase the risk. Characteristics of a Sickling Collapse: • Sickling collapse has been mistaken for cardiac collapse or heat collapse. But unlike sickling collapse, cardiac collapse tends to be “instantaneous”, and the athlete (with Ventricular fibrillation) who hits the ground no longer talks. A sickling collapse often occurs with-in the first half hour on field, as during wind sprints as opposed to heat collapse which tends to happen after prolonged periods of exercise. (NATA Consensus) • Sickling does not have muscle twinges as compared to heat cramps; • Heat cramping pain is more severe than sickling; • Heat cramps lock up the athlete, sickling players slump to the ground in muscle weakness; • Heat cramping athletes tend to yell in pain with muscle contractions, while sickling athletes lie fairly still with normal tension in their muscles; • Sickling athletes can recover quickly if caught early and treated effectively Precautions and Treatment: • Build up in training slowly with paced progressions, allow for longer rest and recovery periods. These athletes should be involved in year round and preseason strength and conditioning to enhance their preparedness. • Consider excluding athletes with sickle cell trait from participation in performance test such as mile runs or serial sprints. • Give alternative exercises for performance testing especially if the standards are not specific to the sport • Stop all activity with onset of symptoms (the sensation of muscle “cramping”, pain, swelling, weakness, tenderness; inability to “catch breath”, fatigue). • The athletic trainer will have the ability to pull a sickle cell trait athlete out of activity. • Allow sickle cell trait athletes to set their pace. • Athletes with sickle cell trait that perform repetitive high speed sprints and/or interval training that induces high levels of lactic acid should be allowed extended recovery between repetitions if needed. • Allow athletes to seek evaluation once signs and symptoms arise. These athletes also should not be harassed for sitting out. • Encourage proper hydration. Never restrict water to any athlete. • Understand that asthma, heat illness, and altitude can increase the likelihood of sickling. • Sickle cell trait athletes should not participate in extreme exercise sessions when they are ill or have a fever. • Educate the student-athlete about the signs and symptoms and encourage them to report these symptoms. • Coach should contact ATC or EMS if sickling is suspected. By signing below I am stating that I have been notified of my student-athlete’s positive sickle cell trait test by NC State Sports Medicine, that I have received education on sickle cell trait, and that I have also been instructed on the proper precautions and treatment of sickle cell trait. Coach’s Signature: ____________________________________________________________________ Date: _____ / _____ / _____ Athletic Trainer’s Signature: ____________________________________________________________ Date: _____ / _____ / _____ NC State University Sports Medicine Sickle Cell Trait Notification (S&C Coach) Athlete’s name: _________________________________________ Team: ___________________________ Coach’s name: __________________________________________ Date: _____ / _____ / _____ Introduction: Sickle Cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. This trait gives red blood cells a sickle or “half -moon” shape that should normally be round. This trait can make red blood cells stick to vessel walls and also gives them poor oxygen carrying capacity compared to normal red blood cells. During exercise, these sickled red blood cells can accumulate in the bloodstream. The accumulation of sickled red blood cells can lead to ischemic rhabdomyolysis, the rapid breakdown of muscle cells possibly causing death if not treated. Sickling can occur within 2-3 minutes of intense all –out exercise. Heat, dehydration, altitude, asthma, and other medical conditions may increase the risk. Characteristics of a Sickling Collapse: • Sickling collapse has been mistaken for cardiac collapse or heat collapse. But unlike sickling collapse, cardiac collapse tends to be “instantaneous”, and the athlete (with Ventricular fibrillation) who hits the ground no longer talks. A sickling collapse often occurs with-in the first half hour on field, as during wind sprints as opposed to heat collapse which tends to happen after prolonged periods of exercise. (NATA Consensus) • Sickling does not have muscle twinges as compared to heat cramps; • Heat cramping pain is more severe than sickling; • Heat cramps lock up the athlete, sickling players slump to the ground in muscle weakness; • Heat cramping athletes tend to yell in pain with muscle contractions, while sickling athletes lie fairly still with normal tension in their muscles; • Sickling athletes can recover quickly if caught early and treated effectively Precautions and Treatment: • Build up in training slowly with paced progressions, allow for longer rest and recovery periods. These athletes should be involved in year round and preseason strength and conditioning to enhance their preparedness. • Consider excluding athletes with sickle cell trait from participation in performance test such as mile runs or serial sprints. • Give alternative exercises for performance testing especially if the standards are not specific to the sport • Stop all activity with onset of symptoms (the sensation of muscle “cramping”, pain, swelling, weakness, tenderness; inability to “catch breath”, fatigue). • The athletic trainer will have the ability to pull a sickle cell trait athlete out of activity. • Allow sickle cell trait athletes to set their pace. • Athletes with sickle cell trait that perform repetitive high speed sprints and/or interval training that induces high levels of lactic acid should be allowed extended recovery between repetitions if needed. • Allow athletes to seek evaluation once signs and symptoms arise. These athletes also should not be harassed for sitting out. • Encourage proper hydration. Never restrict water to any athlete. • Understand that asthma, heat illness, and altitude can increase the likelihood of sickling. • Sickle cell trait athletes should not participate in extreme exercise sessions when they are ill or have a fever. • Educate the student-athlete about the signs and symptoms and encourage them to report these symptoms. • Coach should contact ATC or EMS if sickling is suspected. By signing below I acknowledge that I have been notified of my student-athlete’s positive sickle cell trait test by NC State Sports Medicine, that I have received education on sickle cell trait, and that I have also been instructed on the proper precautions and treatment of sickle cell trait. S&C Coach’s Signature: _______________________________________________________________ Date: _____ / _____ / _____ Athletic Trainer’s Signature: ____________________________________________________________ Date: _____ / _____ / _____ NC State University Sports Medicine Sickle Cell Trait Notification (Student-Athlete) Name: _________________________________ Date: _____ / _____ / _____ Team: ___________________________ Introduction: Sickle Cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. This trait gives red blood cells a sickle or “half- moon” shape that should normally be round. This trait can make red blood cells stick to vessel walls and also gives them poor oxygen carrying capacity compared to normal red blood cells. During exercise, these sickled red blood cells can accumulate in the bloodstream. The accumulation of sickled red blood cells can lead to ischemic rhabdomyolysis, the rapid breakdown of muscle cells possibly causing death if not treated. Sickling can occur within 2-3 minutes of intense all –out exercise. Heat, dehydration, altitude, asthma, and other medical conditions may increase the risk. Characteristics of a Sickling Collapse: • Sickling collapse has been mistaken for cardiac collapse or heat collapse. But unlike sickling collapse, cardiac collapse tends to be “instantaneous”, and the athlete (with Ventricular fibrillation) who hits the ground no longer talks. A sickling collapse often occurs with-in the first half hour on field, as during wind sprints as opposed to heat collapse which tends to happen after prolonged periods of exercise. (NATA Consensus) • Sickling does not have muscle twinges as compared to heat cramps; • Heat cramping pain is more severe than sickling; • Heat cramps lock up the athlete, sickling players slump to the ground in muscle weakness; • Heat cramping athletes tend to yell in pain with muscle contractions, while sickling athletes lie fairly still with normal tension in their muscles; • Sickling athletes can recover quickly if caught early and treated effectively Precautions and Treatment: • Athletes should be involved in preseason strength and conditioning to enhance preparedness. • Alternative exercises may be used in place of initial performance tests such as mile runs or serial sprints. • Stop all activity with onset of symptoms (the sensation of muscle cramping, pain, swelling, weakness, tenderness, inability to catch breath, fatigue). • Athletes with sickle cell trait that perform repetitive high speed sprints and/or interval training that induces high levels of lactic acid should talk to their coach in advance to discuss the possibility of needing more recovery time between repetitions. • Athletes need to stay properly hydrated. • Asthma, heat illness, and altitude can increase the likelihood of sickling. • Sickle cell trait athletes should not participate in strenuous sessions when they are ill (vomiting or diarrhea) or have a fever. • Sickling athletes should recognize their symptoms and report them immediately. • Athletes with positive test results, family medical history, or other indicators of sickle cell trait should share their test results and relevant medical information with their primary care physicians, family, and sports medicine staff. By signing below, I acknowledge that I have tested positive for sickle cell trait. NC State University Sports Medicine has provided me with educational materials relating to sickle cell trait and that I have also been instructed on the proper precautions and treatment of sickle cell trait. I also understand the risk of my involvement in athletic activity. NC State University Sports Medicine has answered all of my questions regarding sickle cell trait to my satisfaction. I also agree to inform my personal physician and parent/guardian. I further attest that I will notify a member of the NC State University sports Medicine Team immediately should I begin to exhibit any of the signs or symptoms noted above without fear of repercussion. Athlete’s Signature: ___________________________________________________________________ Date: _____ / _____ / _____ Physician’s Signature: _________________________________________________________________ Date: _____ / _____ / _____ Athletic Trainer’s Signature: ____________________________________________________________ Date: _____ / _____ / _____ North Carolina State University Department of Athletics Licensed Athletic Trainer Protocol I. PREVENTION A. Organization and implementation of pre-participation physical examinations and screening procedures under physician supervision B. Physical conditioning C. Fitting and maintenance of protective equipment D. Application of taping and special pads and braces E. Monitor and control environmental risks F. Identification and correction of common risk factors and conditions predisposing the athlete to increased risk of injury G. Development and implementation of preventative maintenance rehabilitation program II. RECOGNITION, EVALUATION AND IMMEDIATE CARE A. Conducts a thorough initial evaluation of injuries sustained by the athlete and formulates an impression of the injury for the purpose of: 1. Administering proper first aid and emergency care 2. Making appropriate physician referral for diagnosis and medical treatment B. Obtain a history from athlete C. Observe and inspect the involved area D. Perform special testing procedures such as strength, range of motion, stability and functional testing E. Determine the appropriate course of action with physician involvement F. In the event of a serious injury, appropriate care will be rendered. This may include: 1. Calling 911 and activating EMS if appropriate 2. When it is safe and reasonable to do so, contact the team physician to make him aware of the situation to insure his involvement in the process at the appropriate time period III. REHABILITATION AND RECONDITIONING A. Development and implementation of comprehensive rehabilitation programs including the determination of therapeutic goals and objectives, selection of therapeutic modalities and exercise, methods of evaluating and recording rehabilitation progress and development of criteria for progression and return to competition B. Inform parents, staff, coaches, athletes about the rehabilitation process using direct communication in order to enhance rehabilitation IV. V. HEALTH CARE ADMINISTRATION A. Maintain the health care records of the athlete B. Coordinate a plan which includes emergency, management, and referral systems specific to the setting by involving appropriate health care professionals in order to facilitate proper care PROFESSIONAL DEVELOPMENT AND RESPONSIBILITY A. Enhance one’s knowledge of sports medicine issues by participating in educational and clinical activities in order to improve skills B. Adhere to ethical and legal statues, rules and guidelines which define the proper role of the licensed athletic trainer C. Serve as a resource in order to enhance awareness of the roles and responsibilities of the licensed athletic trainer The undersigned physician and athletic trainer agree to abide by this protocol: William Jacobs M.D. Print or Type Name of Physician Print or Type Name of Athletic Trainer Signature of Physician Signature of Athletic Trainer 3521 Haworth Drive Physician’s Address 2500 Warren Carroll Dr. Box 8502 Employment Address Raleigh, NC 27609 City, State, Zip Code Raleigh, NC 27695 City, State, Zip Code (919) 782-1806 Business Telephone (919) 515-2111 Business Telephone 2014-2015 SPORTS MEDICINE Rob Murphy Director Sports Medicine MSOC Diana Nguyen Nutrition Amanda Poppleton Nutrition Michelle Joshua Sport Psychology Tetsuo Yamanaka Football Justin Smith Football Alyse King Football Andy Wood Football Alyssa Schramm MSOC, W Tennis Cheer Josh Geruso Ryan Holleman Baseball, Tennis Abby Whiteside WSOC, SWIM Wes Bell M Tennis Cheer Men’s Basketball Will Conlon Wrestling Colleen Levinson Swimming Cheer Bianca Broughton Track Blake Wickerham Track Cheer Jennifer O’Donoghue Gymnastics, Golf Kristen Mostrom VB, Cheer, Rifle Casi Dailey WBKB, SB Amber Gast Softball Cheer Glenda May Insurance Coord Angela Hardee Admin Assist NORTH CAROLINA STATE UNIVERSITY SPORTS MEDICINE STUDENT-ATHLETE MEDICAL HISTORY PERSONAL DATA Name: ______________________________ _____________________________ __________________________ Last First Middle NCSU ID#: _____________________ Date of Birth: ________________ Age: __________ Cell Phone: __________________ (MM/DD/YYYY) Gender:  Male  Female Sport(s):__________________________________________________________ GENERAL MEDICAL FAMILY HISTORY: Have you or anyone in your immediate family been diagnosed with the following? YES NO Please Explain (Family Member, Age, Etc.): Sudden Death (Before age 50) Heart Disease/Heart Attack Heart Murmur Abnormal Heart Rate/Palpitation High Blood Pressure/Hypertension Diabetes Marfan Syndrome Epilepsy Blood Disorder Mental Disorder Stroke Drug and/or Alcohol Dependency PERSONAL MEDICAL HISTORY: Have you ever had or do you currently have any of the following conditions? If yes, please explain in the space provided below. YES NO DATE YES NO DATE Pneumonia/Frequent Respiratory Anemia/Low Blood Counts Infections Appendicitis Recurrent Ear Infections Asthma/Breathing Problems Sexually Transmitted Disease Chicken Pox Sickle Cell Disease Constipation/Diarrhea/Hemorrhoids Sinus Infection/Nasal Polyps/Nose Diabetes Fracture DVT/ Blood Clots Skin Infection/Disease Headaches/Migraines Spleen/Liver Injury Hearing Impairment/Loss Stomach Problems (bleeding, ulcers) Hernia Stress Fracture Hepatitis/Liver Problems/Jaundice Thyroid Disorder Kidney Disease/Stones/Injury Tuberculosis Meningitis Tumor/Growth/Cyst Urinary Problems (blood in urine, infections, etc.) Mononucleosis “Mono” Motion/Air/Car Sickness Please Explain:____________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Student-Athlete Medical History Page 1 of 7 Updated: Nov 2014 PLEASE LIST YOUR CURRENT FAMILY PHYSICIAN: ________________________________________________________________________________________________________________ NAME ____________________________________________________________________________________________________________________________________________________ ADDRESS CITY STATE ZIP ____________________________________________________________________________________________________________________________________________________ PHONE FAX Recent Tetanus Immunization: ______/______/______ CURRENT MEDICATIONS/SUPPLEMENTS: (list all prescription & over-the-counter medications, vitamins, nutritional supplements and their doses) 1.____________________________________ 2.____________________________________ 3.____________________________________ 4.____________________________________ 5.____________________________________ 6.____________________________________ Please check the most appropriate space according to YOUR use of the following items Alcohol Tobacco Vitamins Nutritional Supplements Anti-inflammatories Laxatives Sleeping Pills Other: Never DIETARY HABITS: Have you ever met with a nutritionist, dietitian, etc? Are you interested in meeting with a nutritionist? Do you regularly consume meat? (1-2 times a day) Are there certain foods/food groups you avoid eating? Please list Do you have any special dietary needs? (Lactose/Gluten intolerant) Do you have any food allergies? Have you ever been treated for anemia? Do you feel pressured by anyone to be at a specific weight? What do you consider your ideal weight? Are you happy with your current weight? Do you worry about your weight or body composition? Does your weight affect how you feel about yourself? How many times do you eat during a typical day? Have you ever tried to control your weight with:  Vomiting?  Laxatives?  Diuretics?  Diet Pills?  Fasting?  Excessive Exercise?  Other Supplements or Medications? Rarely (1-2 x/week) YES NO Occasionally (3-6 x/week) Daily Please Explain: List the weight List the weight Include meals and snacks INTERNAL/SURGICAL HISTORY: YES NO Were you born WITHOUT a complete set of paired organs (eyes, kidneys, ovaries/testes, etc.)? Have you ever had to repair/remove any organ (hernia, tonsils, appendix, spleen, etc.)? Please explain: _____________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Student-Athlete Medical History Page 2 of 7 Updated: Nov 2014 ALLERGIES: Aspirin/Anti-Inflammatories Codeine Hay Fever Insect Stings/Bites Latex YES NO YES Penicillin Sulfa Any Foods: Any Drugs: Other: NO Please explain: _____________________________________________________________________________ _______________________________________________________________________________________ CARDIAC HISTORY: Have you ever had/currently have any of the following conditions? YES NO Rheumatic Heart Disease High blood pressure/Hypertension Seen a cardiologist Low blood pressure/Hypotension Had an echocardiogram/EKG Irregular heart beat/Palpitations Had a stress test Felt dizzy/Light-headed/Passed out during Heart murmur or after exercise Chest pain/Tightness/Discomfort with exercise YES NO __________________________________________________________ _______________________________________________________________________________________ Please explain (Dates, Physician Names, etc.): HEAT ILLNESS HISTORY: Have you ever: Become dehydrated? Had heat cramps? Had heat exhaustion? YES NO YES Had heat stroke? Received IV fluids? Had intolerance to heat? NO _____________________________________________________________________________ _______________________________________________________________________________________ Please explain: PSYCHOLOGICAL/NEUROLOGICAL HISTORY: Have you ever been diagnosed, evaluated, or treated for: YES NO ADD/ADHD Eating Disorder (Anorexia, Bulimia, etc.) Alcohol Abuse/Addiction Epilepsy/Seizure Disorder Anxiety/Depression Learning Disability Bipolar or Schizophrenia Disorder Sleeping Disorder (Apnea, Narcolepsy, etc.) Drug Abuse/Addiction Stress Management Have you ever met with a Psychologist/Psychiatrist? Are you interested in meeting with a Sport Psychologist or Psychiatrist? VISION HISTORY: Have you ever/do you currently: YES Had an eye injury? Wear glasses/contacts/protective eyewear? Are you color blind? NO YES YES NO NO DENTAL HISTORY: Have you ever/do you currently: YES Had a tooth knocked out/loose/chipped? Wear a dental/orthodontic appliance? Wear a protection device? NO Please bring a current prescription from your physician if applicable Please explain: _____________________________________________________________________________ _______________________________________________________________________________________ Please describe any other general medical problems that have not been represented above. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Student-Athlete Medical History Page 3 of 7 Updated: Nov 2014 ORTHOPEDIC PLEASE LIST YOUR ORTHOPEDIC DOCTOR/SURGEON: ________________________________________________________________________________________________________________ NAME ____________________________________________________________________________________________________________________________________________________ ADDRESS CITY STATE ZIP ____________________________________________________________________________________________________________________________________________________ PHONE FAX ORTHOPEDIC HISTORY:  Explain any “YES” answers in the spaces provided by describing location (left/right), nature of injury/illness, and dates.  Please attach any medical documents regarding any previous injuries to this form. Medical documents may include, but are not limited to: X-rays, MRI’s, CT Scans, Bone Scans, surgical notes, physician notes, etc. HEAD INJURY: Have you ever had/currently have: YES NO Concussion Knocked Out/Unconscious “Bell-rung” Recurrent headaches/Migraines Face or skull fracture Hospitalization/Surgery X-ray/CT/MRI Missed practice/game time Other YES NO _____________________________________________________________________________ _______________________________________________________________________________________ Please explain: CERVICAL SPINE/NECK: Have you ever had/currently have: YES NO Injury/Sprain/Strain Disc injury Pinched nerve/Stinger/Burner Fracture/Dislocation Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO _____________________________________________________________________________ _______________________________________________________________________________________ Please explain: SHOULDER/UPPER ARM: Have you ever had/currently have: YES NO Injury/Sprain/Strain Bursitis/Tendinitis Dislocation/Subluxation Shoulder A-C Joint Separation Numbness/Weakness in arm Fracture Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO _____________________________________________________________________________ _______________________________________________________________________________________ Please explain: ELBOW/FOREARM: Have you ever had/currently have: YES NO Injury/Sprain/Strain Dislocation Bursitis/Tendinitis Fracture Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO _____________________________________________________________________________ _______________________________________________________________________________________ Please explain: Student-Athlete Medical History Page 4 of 7 Updated: Nov 2014 WRIST/HAND/FINGER: Have you ever had/currently have: YES NO Injury/Sprain/Strain Dislocation Fracture Brace/Cast/Splint Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO Please explain: _____________________________________________________________________________ _______________________________________________________________________________________ SPINE/LOWBACK: Have you ever had/currently have: YES NO Injury/Sprain/Strain Nerve/Disc injury Numbness/Weakness in leg Radiating pain in leg Fracture Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO Please explain: _____________________________________________________________________________ _______________________________________________________________________________________ RIBS/CHEST: Have you ever had/currently have: YES NO Injury/Sprain/Strain Fracture Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO _____________________________________________________________________________ _______________________________________________________________________________________ Please explain: HIP/GROIN: Have you ever had/currently have: YES NO Injury/Sprain/Strain Bursitis/Tendinitis Dislocation Fracture Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO _____________________________________________________________________________ _______________________________________________________________________________________ Please explain: THIGH: Have you ever had/currently have: YES Injury/Sprain/Strain Fracture Hospitalization/Surgery NO X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO Please explain: _____________________________________________________________________________ _______________________________________________________________________________________ KNEE: Have you ever had/currently have: YES Injury/Sprain/Strain Bursitis/Tendinitis Dislocation/Subluxation Torn cartilage/Meniscal Injury Swelling Locking/Giving away NO Fracture Brace/Cast/Splint Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO _____________________________________________________________________________ _______________________________________________________________________________________ Please explain: Student-Athlete Medical History Page 5 of 7 Updated: Nov 2014 ANKLE/LOWER LEG: Have you ever had/currently have: YES NO Injury/Sprain/Strain Bursitis/Tendinitis Dislocation Instability/Weakness Stress Fracture/Shin Splints Fracture Brace/Cast/Splint Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO Please explain:_____________________________________________________________________________________________________ _________________________________________________________________________________________________________________ FOOT/TOE: Have you ever had/currently have: YES Injury/Sprain/Strain Bursitis/Tendinitis Dislocation Weakness Fracture NO Brace/Cast/Splint Hospitalization/Surgery X-ray/CT/MRI/Bone Scan Missed practice/game time Other YES NO Please explain:______________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Please describe any other orthopedic problems that have not been represented above. _______________________________________________________________________________________ _______________________________________________________________________________________ Please list any supportive/protective equipment that you currently wear while competing in your sport (braces, splints, orthotics, etc.) _______________________________________________________________________________________ _______________________________________________________________________________________ WOMEN’S HEALTH HISTORY: Is your menstrual cycle regular? Have you ever gone more than 2 months without a menstrual cycle? Is heavy bleeding ever a problem? Do you ever have bleeding between periods? Do you ever experience any unusual discharge? Are cramps a frequent problem during your period? Do you have frequent urinary tract infections? Have you ever had an abnormal pap smear? Have you ever had a blood clot in your veins? Do you perform breast self examination? Have you ever been pregnant or given birth? YES NO Comments: Age of your first period? Date of your last period? Interval between periods? Number of periods in 12 months? Duration of period (# of days)? What brand and dose of birth control do you take (if applicable)? Date of your last gynecological exam? Date of your last pap smear? Please describe any other women’s health issues that have not been represented above. _______________________________________________________________________________________ _______________________________________________________________________________________ Student-Athlete Medical History Page 6 of 7 Updated: Nov 2014 Student-athlete, please read carefully. The undersigned, hereby: 1. Affirms that all answers and information contained within this document is correct and true, and that no answers or information have been withheld. 2. Understands his/her having passed the physician examination does not necessarily mean he/she is physically qualified to engage in athletics, but only that the examiner did not find any medical reason to disqualify him/her. ______________________________________________________ ______________________________ Student-Athlete Printed Name Date ______________________________________________________ Student-Athlete Signature Did you include your MRI’s, x-rays, EKG’s, medical notes, and prescriptions with your packet?  Yes  No REQUIRED: Please read carefully. The parent, guardian and/or bearer of primary insurance, will serve to verify information provided. The undersigned, hereby: 1. Affirms that the information contained within this document has been reviewed and is correct and true, and that no answers or information have been withheld. ______________________________________________________ ______________________________ Parent/Guardian Printed Name (REQUIRED) Date ______________________________________________________ Parent/Guardian Signature (REQUIRED) For internal NCSU use and review. Please do not write below this line. Thank you. The undersigned, hereby: Serving as the assigned staff Athletic Trainer, I affirm that the information contained within this document has been reviewed and is complete. The undersigned, hereby: Serving as the Facility Supervisor, and/or assigned Supervising Athletic Trainer, I affirm that the information contained within this document has been reviewed and is complete. ______________________________________ NCSU Staff Athletic Trainer (Print) ______________________________________ NCSU Supervising Athletic Trainer (Print) ______________________________________ NCSU Staff Athletic Trainer (Signature) ______________________________________ NCSU Staff Athlete Trainer (Signature) ______________________________________ Date of affirmation ______________________________________ Date of affirmation Student-Athlete Medical History Page 7 of 7 Updated: Nov 2014 Student‐Athlete Physical Exam    Name:__________________________________      Sport:_______________  Date:_____/_____/_____   General Medical Examination  Height:  _____________  Weight:  _____________  Eyes:  R 20/_____  Blood Pressure:    ______/______  Pulse:  _____________    L 20/_____  Corrected:  Y/N ______      Are there abnormalities? Eyes  Ears  Nose  Throat  Neck Adenopathy    ADD/ADHD medications?  Concussion history?  Other medications?  Y / N  Y / N  Y / N  Y / N  Y / N  Y / N  Y / N  Y / N  Heart  Lungs  Abdomen  Femoral Pulse  Other  Y / N  Y / N  Y / N  Y / N  ____________________  If yes, list:__________________________________________________  If yes, explain:______________________________________________  If yes, list and explain:________________________________________    Comments:______________________________________________________________________________ _______________________________________________________________________________________    Provider:  __________________________________________________ Date:  _____/_____/_____    Orthopaedic Examination      Participate in full activities without restrictions     Participate in activities with the following restrictions:________________________________________ ____________________________________________________________________________________   Participate in full activities pending   X‐rays       MRI/CT     Other__________    Not able to participate in any sport activities    Provider:  __________________________________________________ Date:  _____/_____/_____    Participation Certification  This is to verify that the above referenced patient is under the care of NC State Sports Medicine.  According  to his/her examination, the following instructions were given:      Participate in full activities without restrictions     Participate in activities with the following restrictions:________________________________________ ____________________________________________________________________________________   Participate in full activities pending   X‐rays       CT/Echo     Other__________    Not able to participate in any sport activities    Comments:______________________________________________________________________________ _______________________________________________________________________________________  Allergies   Sickle Cell Trait   Asthma   Cardiac   Anemia   Skin Issue    Provider:  _________________________________    Date:  _____/_____/_____  NC STATE UNIVERSITY SPORTS MEDICINE Shared Responsibility and Assumption of Risk Shared Responsibility and Assumption of Risk: Participation in intercollegiate athletics involves inherent dangers and physical risks. The inherent dangers and physical risks involved in these activities are such that that no amount of care, caution, instruction or expertise can eliminate, and can result in injuries, permanent disabilities, or even death. Examples include, but are not limited to:           Sudden death, heart attack, respiratory failure Paralysis, spinal cord damage, nerve damage Head injuries, concussions, brain damage, Chronic Traumatic Encephalopathy Dental injuries, tooth fractures, loss of teeth, facial disfigurement Broken bones, joint damage, arthritis Eye injury, vision loss Loss or injury to vital organs Muscle and ligament damage, sprains, ruptures Menstrual irregularities and complications Psychological distress, depression, anxiety Reasonable precautions should be made by all participants, coaches, staff, and administrators to minimize this risk. Each sport has its own set of safety rules and regulations which should be adhered to at all times. To rely on officials to enforce compliance with the rulebook is as insufficient as to rely on warning labels to produce compliance with safety guidelines. As a student-athlete, it is your responsibility to take appropriate steps to prevent injuries when possible by following the rules of the game and wearing all recommended and required protective equipment and braces. Additionally, it is your responsibility to provide timely and accurate information regarding all injuries and illnesses (whether the injury pertains to yourself or a teammate) to the appropriate Sports Medicine staff member and coaches and to comply with their directions. By signing below, I acknowledge that I fully understand and accept the RISKS associated with my participation in athletics at NC State, and these activities are such that that no amount of care, caution, instruction or expertise can eliminate. If I have any further questions regarding the risks inherent to my sport, I understand that it is my responsibility to ask a member of the NC State Sports Medicine Staff. I assume responsibility for all risks, known and unknown, involved to me in the aforementioned activities, and I am voluntarily participating in reliance upon my own judgment and knowledge of my own experience and capabilities. To minimize my risk, I agree to follow and play within the rules of this sport. I agree to report all injuries/illnesses in a timely manner to the Sports Medicine Staff. Additionally, I have provided an accurate medical history and I will update my records as needed. I understand that having passed a physical examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the evaluator did not find a medical reason to disqualify me at the time of the evaluation. _____________________________ Student-Athlete’s Name (Print) _____________________________ Signature of Student-Athlete ______________ Date _____________________________ Parent’s Name (Print) _____________________________ Signature of Parent ______________ Date (If student athlete is under 18) University of Notre Dame Sports Medicine Department Intercollegiate Athletics Concussion Management Plan Purpose: Head injuries can pose a significant health risk for student-athletes competing in intercollegiate athletics. The University of Notre Dame is committed to promoting the safety of its studentathletes. In light of this commitment and developing research on the symptoms and effects of head injuries, Notre Dame has taken steps to prevent, identify, evaluate, and manage head injuries in a comprehensive and consistent manner. The Notre Dame Athletic Department, in accordance with NCAA bylaw 3.2.4.17, has implemented this Concussion Management Plan (“the Plan”) to establish guidelines and procedures for assessing intercollegiate student-athletes who have or may have suffered a head injury. The Plan covers the education, recognition, emergency care, long-term care, and returnto-play of student-athletes who exhibit concussion-like symptoms. The Notre Dame Sports Medicine Department recognizes that each head injury and each student-athlete is unique. Therefore, in certain cases, modifications to this protocol may be deemed appropriate by Notre Dame team physicians and sports medicine staff. Definitions: Concussions are the most common form of head injury suffered by student-athletes. A uniform definition of a concussion does not exist because of the complexity of concussions. A concussion can be caused by a direct or indirect blow to the head or elsewhere on the body resulting in an impulsive force being transmitted to the head. A concussion may cause impaired neurologic function, which may or may not involve loss of consciousness. The exact recovery periods from these types of head injuries are uncertain timeframes and will often vary from student-athlete to student-athlete. Throughout this policy, team physician means a university physician with experience in the evaluation and management of concussions. Signs/Symptoms: A concussed student-athlete may exhibit a variety of symptoms or very few symptoms. Despite popular belief, most concussions do not involve student-athletes losing consciousness. One important factor to take into consideration is that, while some symptoms appear immediately, others may take time to appear. Additionally, symptoms and the severity of symptoms will vary among student-athletes. Signs and symptoms of concussions include, but are not limited to: Symptoms:  Dizziness  Nausea/Vomiting  Confusion  Irritability  Headaches  Ringing in ears  Fatigue  Light headedness  Disorientation  Seeing bright lights/stars  Depression  Feeling of being stunned  Pressure in head  Neck pain Signs:           Difficulty concentrating Reduced attention Decreased playing ability Cognitive dysfunction Vacant stare Personality change Loss of consciousness Slurred/incoherent speech Delayed verbal or motor responses Sleep disturbances Education/Responsibilities: 1. Student-Athletes: Notre Dame student-athletes must be truthful and forthcoming about symptoms of illness and injury, both at the time of an injury as well as upon the emergence of any reoccurring or new symptoms. In conjunction with the annual preparticipation physical, student-athletes will sign a questionnaire in which they acknowledge their responsibility to be truthful and forthcoming about symptoms of illness and injury. Each year, the sports medicine staff will educate Notre Dame student-athletes specifically about concussions. As part of that education, each student-athlete will receive the NCAA Concussion Fact Sheet (Appendix A) and will sign the Student-Athlete Concussion Responsibility Form (Appendix B). In signing the form, student-athletes will acknowledge that: a. they have received and reviewed the NCAA Concussion Fact Sheet for Student- Athletes and participated in education related thereto; and b. they accept the responsibility for truthfully and promptly reporting their illnesses and injuries to the sports medicine staff, including any signs or symptoms of a concussion, regardless of whether any such illnesses, injuries, signs, or symptoms are related to participation in intercollegiate athletics. 2. Coaches: All Notre Dame coaches (and appropriate athletics administrators) will receive the NCAA Concussion Fact Sheet for Coaches (Appendix C) and will sign the Coach’s Concussion Responsibility Form (Appendix D), acknowledging that: a. they have received and reviewed the NCAA Concussion Fact Sheet for Coaches and participated in education related thereto; 2 b. they will encourage their student-athletes to report their illnesses and injuries to sports medicine staff, especially any signs or symptoms of a concussion; c. they will refer any student-athlete whom they suspect of sustaining a concussion to the proper medical authority; and d. they have read and understand the Notre Dame Concussion Management Plan, including the fact that team physicians (and, in their absence, athletic trainers) have unchallengeable authority to withhold a student-athlete from practice or competition, and that team physicians have unchallengeable authority to determine concussion management, return-to-play, and medical clearance. 3. Sports Medicine Staff: The Notre Dame Sports Medicine staff will undergo at least annual training sessions on the diagnosis and treatment of head injuries and this Concussion Management Plan. Baseline Assessment: At the beginning of each new season, Notre Dame sports medicine staff shall administer a baseline assessment for all student-athletes The baseline assessment includes an evaluation of brain injury and concussion history, symptom evaluation, and balance evaluation. The team physician will then determine pre-participation clearance. Recognition and Evaluation: 1. If a student-athlete reports or displays signs, symptoms, or behaviors that a Notre Dame athletics staff member believes are consistent with a concussion, the Notre Dame athletics staff member shall inform the student-athlete’s coach, as well as the studentathlete’s team physician and/or athletic trainer. The student-athlete shall be removed from any practice or competition then underway, and will be evaluated by a team physician or athletic trainer, who will make a determination of whether there is a basis for a suspected concussion. 2. A student-athlete with a suspected concussion shall be withheld from practice or competition and shall not return to athletic activity for the remainder of that day. The team physician or athletic trainer making such decision should notify the coaching staff that the student-athlete will not return to athletic activity for the remainder of the day. 3. A treating athletic trainer or team physician shall have the authority to require that a student-athlete be continuously monitored during a period that the student-athlete, in the judgment of the athletic trainer or team physician, is acutely symptomatic. 4. A student-athlete with a suspected concussion will be evaluated by a team physician for a diagnosis as soon as possible in accordance with the severity of the symptoms. Such evaluation will generally include follow-up testing (which may include but is not limited to SCAT III testing); the timing and nature of any follow-up testing are in the discretion of the treating team physician. 3 5. Student-athletes and/or sports medicine staff may not be able to recognize the possibility of a concussion until hours or days after the precipitating event. Under these circumstances, once a student-athlete reports or displays signs, symptoms, or behaviors that a Notre Dame athletics staff member believes are consistent with a concussion, the athletics staff member shall inform the student-athlete’s coach, as well as the student athlete’s team physician and/or athletic trainer, and the team physician or athletic trainer shall initiate normal evaluation and return-to-play procedures. 6. If a student-athlete sustains a potential concussion outside of participation in intercollegiate athletics, the student-athlete is responsible for truthfully and promptly reporting the injury to the sports medicine staff, including any signs or symptoms of a concussion, at which point the potential concussion will be managed in the same manner as potential concussions sustained during participation in intercollegiate athletics. 7. Visiting team student-athletes evaluated by Notre Dame sports medicine staff will be managed under the same guidelines as Notre Dame student-athletes while under the evaluation of Notre Dame sports medicine staff. 8. If a Notre Dame student-athlete reports or displays signs, symptoms, or behaviors that a Notre Dame athletics staff member believes are consistent with a concussion while away from campus in connection with team activities and a team physician is not present, the athletics staff member shall inform the student-athlete’s coach and the student athlete’s athletic trainer. The Notre Dame athletic trainer shall manage the student-athlete under the guidelines set forth in this Plan, and should consult with a local physician experienced in the evaluation and management of concussions, if deemed necessary by the athletic trainer. Regardless, the student-athlete will be evaluated by a team physician as soon as possible upon return to campus. Emergency Referrals: In the event that a student-athlete displays one or more of the following symptoms during an initial evaluation, a team physician and/or athletic trainer should consider activation of the applicable Medical Emergency Response Procedures and/or immediate referral to the Emergency Room: • • • • • • Prolonged loss of consciousness Deteriorating level of consciousness Suspicion of spine or skull injury Seizure activity Evidence of hemodynamic instability/deteriorating of vital signs Repetitive vomiting 4 Monitoring/Follow-Up Care: 1. Due to the need for ongoing monitoring for deterioration of symptoms, when an athletic trainer or team physician determines that a student-athlete who displays signs, symptoms, or behaviors consistent with a concussion or who is diagnosed with a concussion may be released from immediate care, the student-athlete should be accompanied by an individual who can provide reliable supervision (such as a roommate, parent/guardian, coach, member of residence hall staff or a teammate). In the alternative, such studentathletes should be liberally referred to University Health Services at Saint Liam’s for observation. 2. Upon release from immediate care, the student-athlete and the individual who accompanies him/her will be provided with verbal or written instructions, which may include monitoring, limitation of certain activity, and additional assessments (see Concussion Take-Home Instructions in Appendix E for an example of information typically provided upon discharge). 3. As appropriate, the sports medicine staff should communicate with Academic Services for Student-Athletes to assist in managing the return-to-learn protocol; Residence Hall or other Student Affairs staff to assist in managing supervision and other issues; and coaches and other Notre Dame athletics staff to assist in managing athletics-related issues. 4. Student-athletes with a prolonged recovery shall be evaluated by a physician to consider additional diagnoses (e.g., post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, mood disorders, or ocular or vestibular dysfunction) and proper management options. Return to Play Guidelines: 1. When the treating University physician determines that it is appropriate for the studentathlete to be evaluated for return to play, the evaluation will follow the sports medicine staff supervised process set forth below. 2. The following steps will typically take place over several days. In select settings in which student athletes have minimal concussive symptomology and no other modifiers that may prolong recovery, the return-to-play protocol may be modified. In contrast, in studentathletes with increased symptom burden and duration, the progression for return-to-play may be more conservative and each stage may take more than a day. 3. If symptoms do arise during the stage-to-stage progression, the student-athlete will return to the previous asymptomatic level. Stage Requirement Rehabilitation Stage 5 Functional Exercise at Each Stage Objective 1 No activity 2 Light aerobic exercise Sport-specific exercise (noncontact) 3 Completion of Stage 2 4 Completion of Stage 3 Non-contact training drills 5 Completion of Stage 4 Full-contact practice 6 Completion of Stage 5 Return to play Stage Complete physical and cognitive rest Recovery Increase heart rate Non-contact simple movement patterns specific to sport Progression to more complex training drills Following medical clearance, participate in normal activities Add movement Exercise, coordination, and cognitive load Restore studentathlete’s confidence and coaching staff assess functional skills Normal game play 4. No student-athlete can return to full activity, practice or competition until they are medically cleared to do so by a team physician. 5. Team physicians shall have unchallengeable authority to determine concussion management, return-to-play and medical clearance. In the absence of a team physician, athletic trainers have unchallengeable authority to withhold a student-athlete from practice or competition. 6. Any member of the Notre Dame Sports Medicine staff must report any attempt to interfere with proper concussion protocol to a member of the Executive Committee in the Department of Athletics. Return-to-Learn Guidelines 1. The athletic trainer and team physician will serve as the primary contacts to assist a student-athlete who is diagnosed with a concussion on return-to-learn issues. The athletic trainer and team physician will work with campus partners as appropriate, including but not limited to counselors from Academic Services for Student-Athletes, other academic advisors, the Faculty Athletics Representative, the student-athlete’s course instructors, the Office for Students with Disabilities, the University Counseling Center, coaches and athletics administrators. Implementation of the return-to-learn protocol must be in compliance with the Americans with Disabilities Act (ADA). 6 2. Each student-athlete who is diagnosed with a concussion shall have an individualized plan that generally includes: a. No classroom activity on the day the concussion is sustained; b. Relative cognitive rest that minimizes potential cognitive stressors such as school work, video games, reading, texting and watching television; c. Remaining at home if the student-athlete cannot tolerate light cognitive activity; d. A gradual return to classroom and academic activities that may include modification of schedule or other academic accommodations for up to two weeks. 3. At any point during the return-to-learn protocol, a physician shall re-evaluate the studentathlete if he or she becomes symptomatic. For any student-athlete who is symptomatic for more than two weeks, the athletic trainer and/or team physician shall work with the Office for Students with Disabilities and other campus partners to create a plan consistent with the ADA. Reducing Exposure to Head Trauma The University of Notre Dame will take steps to reduce student-athlete exposure to head trauma and otherwise act in the best interest of student-athlete health and safety, including adherence to the Inter-Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines. The above policy was adopted by the University of Notre Dame Department of Athletics effective July 1, 2014, revised July 31, 2015, and is adapted in part from The University of North Carolina at Chapel Hill Sport Concussion Policy. 7 Prevention and Care of Injuries and Illness Concussions and Head Injuries The following guideline pertains to EDUCATION AND TREATMENT OF CONCUSSIONS. There is an increasing awareness surrounding the seriousness of student-athletes sustaining concussions with potential short term and/or long term consequences. Within the overarching goal of maximizing the student-athlete experience while at The Ohio State University, the Department of Athletics is committed to: - minimizing potential concussion complications in our student-athletes, both immediate and long term. - minimizing the negative impact of concussion on the student-athlete’s academic career. “The NCAA Concussion Policy and Legislation mandates that institutions implement the following: 1. An annual process that ensures student-athletes are educated about the signs and symptoms of concussion; 2. A process that ensures a student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from athletics activities and evaluated by a medical staff member with experience in the evaluation and management of concussion; 3. A policy that precludes a student-athlete diagnosed with concussion from returning to athletic activity for at least the remainder of that calendar day; and 4. A policy that requires medical clearance for a student-athlete diagnosed with a concussion to return to athletic and cognitive activity as determined by a physician or the physician’s designee. ANNUAL EDUCATION Student-Athletes - Student-athletes will receive concussion education material prior to the start of each academic year. Student-athletes are provided the NCAA “Fact Sheet for Student-Athletes” form. Each student-athlete will sign an acknowledgement (form titled “Concussion Acknowledgement and Release Form” that they have read and understand the information provided. The education outlines the causes, symptoms and possible consequences of concussion and head injury. This education also outlines their responsibility for reporting these injuries to the medical staff. The signed acknowledgement forms will be retained in the respective student-athletes’ medical charts. Coaches - All head coaches and assistant coaches will receive concussion education material via PowerPoint at the start of each academic year. Coaches are provided the NCAA “Fact Sheet for Coaches” form in addition to the PowerPoint education. Each coach will sign an acknowledgement at the conclusion of the PowerPoint that they understand the concussion management plan, their role within the plan and that they have received education about concussions. Education will outline the causes, symptoms and possible consequences of a concussion. The Director of Sport Performance will ensure that each coach has completed this education and will document the completion dates of the training sessions. Team Physicians - All team physicians will receive concussion education annually at a staff retreat, date to be determined by the Head Team Physician. This education will be provided via PowerPoint. At the conclusion of the PowerPoint, each Team Physician will sign an acknowledgement (form titled “Physician Concussion Education Acknowledgement”) that they understand the concussion management plan, their role within the plan and that they have received education about concussions. Education will outline the causes, symptoms, treatment and possible consequences of a concussion. The Head Athletic Trainer and Team Physician will retain copies of the signed acknowledgement forms. These forms will be placed in the main copy of the Standard Operating Procedures Manual. Certified Athletic Trainers - All certified athletic trainers (AT) will receive concussion education annually at a staff meeting, date to be determined by the Head Athletic Trainer. This education will be provided via PowerPoint. At the conclusion of the PowerPoint, each AT will sign an acknowledgement (form titled “AT Concussion Education Acknowledgement”) that they understand the concussion management plan, their role within the plan and that they have received education about concussions. Education will outline the causes, symptoms, treatment and possible consequences of a concussion. The Head Athletic Trainer and Team Physician will retain copies of the signed acknowledgement forms. These forms will be placed in the main copy of the Standard Operating Procedures Manual. Director of Athletics and Sport Administrators - The Director of Athletics and Sport Administrators that oversee athletics programs will receive concussion education annually at a staff meeting, date to be determined by the Director of Athletics. At the conclusion of the PowerPoint, the Director of Athletics and each Sport Administrator will sign an acknowledgement (form titled “Administration Concussion Education Acknowledgement”) that they understand the concussion management plan, their role within the plan and that they have received education about concussions. The Director of Sport Performance will ensure that each administrator has completed this education and will document the completion dates of the training sessions. PRE-PARTICIPATION ASSESSMENT: - All varsity student-athletes at The Ohio State University will undergo a series of baseline evaluations and questions. Testing will consist of the following: o Incoming Health History Questionnaire: Section “Head Injuries/ Illnesses and Concussions.  Brain Injury and Concussion History o ImPact Baseline Testing  Baseline Symptom Scale  Attention Span  Working Memory  Sustained and selective attention time  Response variability  Non-verbal problem solving  Reaction time o SCAT3 Baseline Testing  Glasgow Coma Scale  Maddocks Score  Cognitive Assessment with SAC Delayed Recall  Baseline Symptoms Evaluation  Neck Examination  Balance and Coordination Evaluations - The AT for each sport will ensure these tests are completed in conjunction with the incoming student-athlete preparticipation evaluation. The team physician will review the Incoming Health History Questionnaire for concerns regarding a student-athlete’s history of head injury. If concerns arise during this evaluation, the team physician will review the ImPact Test and SCAT3 Evaluation to determine participation or need for additional consultation or testing. - New baseline concussion assessments should be considered for student-athletes with complicated or multiple concussion history. This will be determined by the Team Physician. RECOGNITION AND DIAGNOSIS OF A CONCUSSION: - Any student-athlete that experiences concussion-like symptoms will be withdrawn from practice/competition and will be evaluated by the sport specific AT and/or team physician. Under no circumstance should a student-athlete return to participation on the same calendar day if concussion is confirmed. - Upon confirmation of concussion diagnosis, the student-athlete should undergo an evaluation by the AT and/or Team Physician that consists of symptom assessment, SCAT3 evaluation, and clinical evaluation for cervical spine trauma, fractures and/or intracranial bleeding. - If no medical personnel are available at practice or competition, any student-athlete displaying symptoms of a concussion should be withheld from activities by the supervising adult. • If medical personnel are available in the athletic training room (ATR), the student-athlete will be sent to the ATR for evaluation. • If medical personnel are not available and the student-athlete sustains a head injury, an attempt should be made to contact the medical staff. If medical personnel are not available, and head injury symptoms are significant, the student-athlete should be taken to the emergency department for evaluation. The medical team will assume their role in the concussion management plan after emergency department care has been rendered. • The medical staff should be notified of the situation in a timely fashion. • Concussions that occur from a non-athletic cause will be managed in the same fashion. POST-CONCUSSION MANAGEMENT: - Should the student-athlete display major concussive symptoms the Emergency Action Plan should be activated. Refer to document “Emergency Action Plan” for detailed information regarding activation of EMS. Emergency Action Plans are posted in conspicuous locations at every Ohio State athletics facility. - Major Concussive symptoms include: • Glasgow Coma Scale < 13 • Prolonged loss of consciousness • Focal neurological deficit suggesting intracranial trauma • Repetitive Emesis • Persistently diminished/ worsening mental status or other neurological signs/symptoms • Suspected spinal injury - If major concussive symptoms are not present, and the student-athlete undergoes evaluation per the AT and/or Team Physician as stated above, the AT will discharge the student-athlete with the form “Head Injury Discharge Instructions”. This form will be reviewed with the student-athlete and another responsible adult. The form should be signed by the student-athlete. The original copy should be given to the student-athlete as discharge instructions and a copy should be made for the student-athlete’s medical chart. - A daily symptom scale will be completed by the student-athlete until the score returns to ‘baseline’. • If the student-athlete is asymptomatic within 14 days and the post-injury neurocognitive function is back to baseline, the student-athlete will undergo a graded cardiovascular workout challenge under supervision of the medical team. The medical team may progress activity if the student-athlete remains asymptomatic. • If symptoms persist greater than 14 days or if the student-athlete has a return of symptoms during the return to play progression, a neurocognitive assessment and balance re-assessment will be performed. If symptoms or progression become complicated, an evaluation/consult with neuropsychology specialist(s) should be considered.  If symptoms persist greater than 14 days or become complicated, the student-athlete should have follow-up consultation with the Team Physician to consider additional diagnoses including, but not limited to; post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression, or ocular/vestibular dysfunction.  As each student-athlete and situation vary, the medical team will determine the best course of evaluation and treatment, and will utilize additional resources as deemed necessary, to make the appropriate decisions in the student-athletes best interest. RETURN TO PLAY: - After symptoms return to baseline, a SCAT3 will be performed (preferably by the same individual who conducted the initial injury SCAT3, for consistency). ImPact will be utilized at the team physician’s discretion. If deemed back to baseline by the team physician, the student-athlete can initiate a supervised return-to-play progression as follows in a step-wise fashion:  Light aerobic exercise with no resistance training  Intense aerobic activity with non-contact sport drills (including weight training)  Controlled practice (non-contact)  Full practice (may include contact)  Game/competition participation Any student-athlete withheld from activity due to concussion symptoms will be cleared by a team physician before returning to athletic activity. The final authority for resuming athletic activity shall reside with the team physician or the physician’s designee. RETURN TO LEARN: - Consideration will be given for academic implications following concussion. The student-athlete should not return to cognitive activity on the same day as a concussion diagnosis. - Cognitive instruction should be given as part of the “Head Injury Discharge” form. This plan will be individualized based on the needs of the student-athlete. It should be advised that no classroom activity should be resumed if the student-athlete cannot tolerate light cognitive activity. A gradual return to classroom activity will be initiated as tolerated by the studentathlete. - The medical staff will provide written documentation and communication to the student-athletes academic counselor. The academic counselor specific to the student-athletes sport will be considered the point-person for progression back into academic and team cognitive activities. - For student-athletes with prolonged symptoms of concussion lasting greater than 14 days the student-athlete should follow-up with the Team Physician and an academic management team will be aligned consisting of the following individuals: Medical Staff (appropriate individuals may include the team physician, athletic trainer, psychologist, neuropsychologist, etc.) • Academic Counselors • Course Instructors • Sport Administrators • Office of Disability Services representative • Coaching Staff • Compliance Office (as classwork may effect eligibility) Modifications and schedule accommodations will be made for student-athletes that experience concussion symptoms for up to 14 days, with assistance from the student-athletes academic counselor. If symptoms persist greater than 14 days or symptoms worsen with academic challenges, the student-athlete should be re-evaluated by the Team Physician. For persistent symptoms, the academic counselor will engage campus resources (consisting of learning specialists, the Office of Disability Services, and/or the ADAAA office) for prolonged cases. • - REDUCING EXPOSURE TO HEAD TRAUMA: - Education should be provided to sport coaches on recommendation to minimize head trauma. The Ohio State Medical Services team should ensure adherence to the education provided. This PowerPoint education to coaches involves the recommendation to eliminate unnecessary contact during practice sessions and teaching proper technique to studentathletes where appropriate for their respective sports. - The AT and sport coaches should work in conjunction to reduce gratuitous contact during practice sessions. When appropriate for respective sports, coaches and student-athletes should be educated regarding safe play and proper technique for head injury reduction. DOCUMENTATION OF CONCUSSION MANAGEMENT After diagnosis of a concussion, the managing AT will include the form titled “Concussion Quality Assurance Monitor” in the studentathlete’s medical chart. - The AT will document on this form as each step is completed. - At the resolution of the concussion, the AT will make a copy of all documentation as it pertains to the concussion. - The documentation will be provided to the Facility Supervising AT for inspection that all steps were followed per the concussion management policy. After the Supervising AT ensures documentation is complete, the copied packet will be provided to the Head Team Physician at the end of each academic year. The head team physician will review each packet to ensure thoroughness and proper education. References to Support Guidelines: 1. NCAA and CDC Educational Material on Concussion in Sport. Available online at: www.ncaa.org/health-safety 2. NCAA Sports Medicine Handbook 2014-2015. Guideline 2l; Sport-Related Concussion (Revised July 2014). 3. National Athletic Trainers’ Association Position, Consensus, Official and Support Statements. Reference Series, 2008. 4. NCAA Football Practice Guidelines: Year-Round Football Practice Contact Guidelines; Inter-Association Consensus, 2014. 5. NCAA Independent Medical Care Guidelines: Independent Medical Care for College Student-Athletes Guidelines; InterAssociation Consensus, 2014. Prevention and Care of Injuries and Illness Concussion Safety Protocol: Athletics Director – Certificate of Compliance THE OHIO STATE UNIVERSITY ATHLETIC TRAINING AND MEDICAL SERVICES Concussion Safety Protocol This Certificate of Compliance form is to be completed by the DIRECTOR OF ATHLETICS. By signing below, each party acknowledges the Concussion Safety Protocol as established in the policy titled “Concussion and Head Injury” above. This policy must be reviewed and updated annually. This should be kept on file by the Head Athletic Trainer, the Head Team Physician and the Director of Athletics. By completing this form, the DIRECTOR OF ATHLETICS and HEAD TEAM PHYSICIAN certifies that The Ohio State University Athletic Department is compliant with the concussion education standards and treatment protocols as established in the “Concussion and Head Injury” policy. The policy maintains that all individuals associated with Athletics (i.e. Medical Staff, Coaches, Athletics Director and Sport Administrators) have been educated on concussions and head injuries. This also maintains that the Athletic Training and Medical Staff will follow the policy and procedures outlined in the “Concussion and Head Injury” Policy. Director of Athletics (Print Name) Director of Athletics (Sign Name) Date University of Oklahoma Concussion Safety Protocol EDUCATION  Student-athletes in each sport will be presented with NCAA concussion fact sheets and educational material on concussions through a combination of pre-season meetings and/or ACS prior to practice or competition.  Student-athletes should review the material with the understanding that they accept responsibility for reporting all of their injuries and illnesses to the medical staff, including signs and symptoms of concussions.  Coaches, Sport Oversight Administrators, and the Athletics Director will be educated about concussions and the Concussion Safety Protocol as follows: Concussion education will be provided to coaches, Sport Oversight Administrators and the Athletics Director at the beginning of the academic year during a Compliance or roundtable meeting and/or through ACS. Coaches should understand their responsibility for helping to identify student-athletes exhibiting potential signs, symptoms or behaviors consistent with a concussion and getting them evaluated by the Athletic Trainer and/or Team Physician.  Team Physicians will be provided concussion education material annually and will sign acknowledgement of receipt, reading and understanding.  Athletic Trainers and Physical Therapists will be provided annual concussion education and submit signed acknowledgement upon completion.  Acknowledgement will be documented that student-athletes have read and understand concussion facts and that coaches, Sport Oversight Administrators and the Athletics Director have read and understand both concussion facts and the institution’s Concussion Safety Protocol.  Reducing head trauma exposure may be difficult to quantify. However, it is important to emphasize ways to minimize head trauma exposure. Examples include, but are not limited to: o Adherence to Inter-Association Consensus: Year-Round Football Practice Contact Guidelines. o Adherence to Inter-Association Consensus: Independent Medical Care Guidelines.  Athletics health care providers are empowered with unchallengeable autonomous authority to determine medical management and return-to-play decisions of student-athletes. o Reducing gratuitous contact during practice. o Taking a ‘safety first’ approach to sport. 00029357-1 1 April 2015  Coaches will be advised and understand that the Athletic Trainer and/or Physical Therapist, in conjunction with the Team Physician, has the FINAL say regarding when or if a student-athlete will return to practice and/or competition. PROCESS Pre-participation:  All student-athletes, prior to initial participation, shall complete a baseline concussion assessment:  Brain injury and concussion history.  Symptom evaluation.  Cognitive assessment.  Balance evaluation.  A Team Physician determines clearance for sport participation and/or additional specialty consult or baseline testing. Recognition and Diagnosis of Concussion:  A student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by an Athletic Trainer, Physical Therapist and/or Team Physician.  Student-athletes diagnosed with a concussion shall not return to activity for the remainder of that calendar day and until final medical clearance has been provided, as explained below.  Differential diagnosis in acute concussion assessment must include, but is not limited to: central nervous system disorders, trauma, and spine injury.  Student-athletes diagnosed with a concussion will be serially assessed by an Athletic Trainer, Physical Therapist, and/or Team Physician with clinical evaluation, symptom assessment, physical and neurological examination, cognitive assessment and balance testing. Prior to discharge following acute concussion diagnosis, a written home care plan [Appendix A] shall be provided to both the student-athlete and another responsible adult, (e.g., parent or roommate). Post-Concussion Management:  Indications for implementing the Emergency Action Plan, including transportation for further medical care, in post-concussion management are: o Glasgow Coma Scale < 13. o Prolonged loss of consciousness. o Focal neurological deficit suggesting intracranial trauma. o Repetitive emesis. 00029357-1 2 April 2015 o Persistently diminished/worsening mental status or other neurological signs/symptoms. o Spine injury.  Concussions will be serially evaluated on a scheduled basis until asymptomatic or a return to baseline. Return to Play progressions are then commenced.  The Athletic Medicine Staff will document the incident, evaluation, continued management and clearance of any student-athlete who has suffered a concussion.  Student-athletes with prolonged recovery from concussion will be referred to a Team Physician for a review of management options and differential diagnoses, including but not limited to: o Academic accommodation o Post-concussion syndrome. o Sleep dysfunction. o Migraine or other headache disorders o Mood disorders such as anxiety and depression o Ocular or vestibular dysfunction Return to Play:  Medical clearance following concussion for participation in academics and/or sport will be determined by the Team Physician, or by an Athletic Trainer or Physical Therapist in consultation with a Team Physician.  Each student-athlete with concussion must undergo a supervised stepwise progression:  Student-athlete physical and cognitive activity (as described below) will be restricted until he/she is asymptomatic or has returned to baseline, then progresses with each step below without worsening or new symptoms: 1. Light aerobic exercise without resistance training. 2. Sport-specific exercise and activity without head impact. 3. Non-contact practice with progressive resistance training. 4. Unrestricted training. 5. Return to competition. Return to Competition:  The Head Team Physician is the FINAL medical authority regarding all medical eligibility, including management and return-to-play of any ill or injured student-athlete. Return to Learn: As with return-to-play, the first step of return-to-learn is relative physical and cognitive rest. Relative cognitive rest involves minimizing potential cognitive stressors, such as academic work, video games, reading, texting and watching television. 00029357-1 3 April 2015  No academic obligations on same day as concussion onset.  The gradual return to academics should be individualized and based on the absence of concussion symptoms following cognitive exposure. o If the student-athlete cannot tolerate light cognitive activity, he/she should remain at home. o Once the student-athlete can tolerate cognitive activity without return of symptoms, he/she should return to the classroom, often in graduated increments.  At any point, if the student-athlete becomes symptomatic, (i.e., more symptomatic than baseline), or scores on clinical/cognitive measures decline, the Team Physician should be notified and the student-athlete’s cognitive activity reassessed.  A student-athlete with concussion symptoms greater than two (2) weeks warrants re-evaluation by the Team Physician and members of the multi-disciplinary team as appropriate.  The student-athlete’s athletics academic advisor will navigate return-to-learn with the studentathlete per medical direction. o The extent of academic adjustments, as warranted, may be decided by a multidisciplinary team that may include the Team Physician, Athletic Trainer, Faculty Athletics Representative or other faculty representative, coach, individual teachers, neuropsychologist and psychologist/counselor.  00029357-1 Campus resources are compliant with ADAAA and include Athletics learning specialists and tutors as well as the Disability Resource Center. 4 April 2015 Home Care Instructions sustained a concussion today, . Please follow the following important recommendations: 1. must report to the athletic training facility on at AM PM for a follow-up evaluation. 2. If any of the symptoms below develop before the follow-up visit, please call at or, call 911.      Decreasing level of consciousness Increasing confusion Increasing irritability Loss of or fluctuating level of consciousness Repeated vomiting     Seizures Slurred speech or inability to speak Inability to recognize people or places Worsening headache Otherwise, you can follow the instructions outlined below: It is OK to  Use acetaminophen (Tylenol) for headaches  Use ice pack on head and neck as needed for comfort  Eat a carbohydrate-rich diet  Go to sleep  Rest o Minimize physical activity to daily living needs o Minimize mental activity, i.e. no academics, video games, computer, etc. There is NO need to  Check eyes with a flashlight  Wake up frequently (unless otherwise instructed)  Test reflexes  Stay in bed Do NOT  Drink alcohol  Drive a car or operate machinery  Engage in physical activity (e.g. exercise, lift weights, sport activity)  Engage in mental activity (e.g. school, homework, computer games, etc.)  Engage in social media Other recommendations: Recommendations provided to: Please feel free to contact me if you have any questions. I can be reached at Recommendations provided by: Signature: 00029357-1 Date: 5 April 2015 OKLAHOMA STATE UNIVERSITY Concussion Safety Protocol PURPOSE: Provide a stepwise process in the evaluation and management of sports-related head injuries from an athletic trainer’s and team physician’s perspective. PRE-SEASON EDUCATION: 1) Oklahoma State University has provided to student-athletes, coaches, team physicians, athletic trainers, and athletic directors (Form 5 & 6) the NCAA concussion fact sheet as well as a consent form stating that the material has been read and understood. The above parties will provide a signed acknowledgement of having read and understood the concussion educational and management material. PRE-PARTICIPATION ASSESSMENT: 1) Every student-athlete will be required to have a pre-season baseline assessment for head injury/concussion as it pertain to prior history of head injury/concussion. 2) Baseline assessments will include; a) Brain injury and concussion history. b) Graded concussion symptom scale checklist (SC) (Form 1), in which the student athlete will rate a series of symptoms based on a 0-6 scale. c) Balance Error Scoring System (BESS) (Form 2), used to assess the student-athletes balance, which will be compared pre vs. post injury. d) Standardized Assessment of Concussion (SAC) (Form 3), used to measure immediate neuro-cognitive effects of the head injury, which includes orientation, immediate memory, concentration and delayed memory. e) ImPACT, a computerized neuropsychological test will be administered to obtain baseline measures of memory, reaction time, etc, in order to assist in the evaluation of a head injury/concussion, and tracking for a safe return to play. f) Baseline testing will be conducted for all new athletes (including transfers) by the respective athletic trainers, with test scores being filed in the student-athlete’s medical chart, and kept with the athletic trainer for easy access at home and away practices/competition. g) All baselines will be reviewed by the Team Physician as part of their PPE, and the Team Physician will subsequently clear each individual student-athlete for participation. 1 RECOGNITION AND DIAGNOSIS OF CONCUSSION: 1) In the case of a known head injury, or a suspected concussion based on the athlete exhibiting concussion-like symptoms, the student-athlete will immediately be administered a postconcussion SC, SAC and BESS test, along with Cranial nerve testing (Table 1). a) If the student-athlete is within 90% of his/her baseline values on the SAC, BESS and SC, the student-athlete will be considered for return to play only if they remain asymptomatic after a reasonable time of complete assessment and inactivity. However, prior to returning to activity/sport the student-athlete is required to partake in some type of exertional exercises (Table 2). i) If symptoms do not return, the student-athlete is allowed to return to play. ii) If symptoms do return, the student-athlete is not allowed to return and further testing/evaluation will be administered. b) If the student-athlete is not within 90% of his/her baseline values directly after the injury, and does not reach those values after a reasonable time of being monitored during inactivity, the student-athlete will not be allowed to return to competition. Also, if the student-athlete has any loss of consciousness the student-athlete will not be allowed to return to competition, no matter what their scores indicate. POST-CONCUSSION MANAGEMENT: 1) Any student-athlete diagnosed with a concussion shall not return to activity for the remainder of that day. Final medical clearance and any return to activity will be determined by the Team Physician, Dr. Val Gene Iven, in conjunction with the certified athletic trainer involved with the management of his/her concussion. Upon initial evaluation of injured student-athlete, Oklahoma State University’s Emergency Action Plan (EAP) will be instituted for any of the following conditions: Glasgow Coma Scale <13; prolonged loss of consciousness; focal neurological deficit suggesting intracranial trauma; repetitive emesis; persistently diminished worsening mental status or other neurological signs/symptoms; spine injury. This EAP is coordinated effort with Sports Medicine staff, paramedics, and Stillwater Medical Center emergency medicine personnel. Notification of parents/guardians of event will occur as deemed necessary. a) If the student-athlete is unable to return to competition, he/she will be administered the post-concussion symptom checklist prior to going home. Student-athlete and any individuals that live with that student-athlete will also be given specific instructions for the care of the student athlete’s injury (Form 4 & 5). i) If the student-athlete lives alone, a staff athletic trainer, graduate assistant athletic trainer, student athletic trainer, and/or another teammate will be assigned to the athlete to monitor his/her status overnight. Student-athlete will be provided with contact information for both his/her Athletic Trainer or Team Physician. b) The first day following the injury, the student-athlete will be re-evaluated by certified athletic trainer, as well as the Team Physician. The athlete will be administered the symptom checklist and ImPACT neuropsychological testing. If the student-athlete is symptom free and within 90% of baseline values of all concussion tests, the studentathlete is allowed to start the return to play exertional testing protocol (Table 2). If the 2 c) d) e) f) student-athlete does not meet the baseline values on both tests, he/she is not allowed to will not initiate the exercise component of the return to play protocol. i) If the student athlete is unable to take the neuropsychological testing the next day due to a road game, the certified athletic trainer will test him/her using non-computer tests (i.e. SC, BESS, and SAC) to determine his/her return to play status. ii) When the student-athlete’s scores of a particular test are within 90% of baseline scores, they will not be required to repeat that particular test on a daily basis. The second day post-injury, and each subsequent day, the student-athlete will only be administered the symptom checklist. The student-athlete will not be administered any additional tests until the symptom checklist has returned to baseline values. If the student-athlete has returned to baseline values, they will be administered the SAC and BESS tests. Each of these tests will be administered every day until the values are within 90% of baseline. Once the symptom checklist, SAC and BESS are within 90% of baseline, the studentathlete will then be administered the ImPACT test. If the student-athlete has no significant changes on ImPACT testing from baseline values as interpreted by the Team Physician and certified athletic trainer, they will be allowed to start the return to play protocol. If values have not returned to anticipated levels as expected the student-athlete is not allowed to start return to play protocol and will be re-tested each day until scores return to normal. All recorded values and test scores should be recorded daily as the student athlete progresses through the protocol using the Sports Related Head Injury Incident Report Sheet (Form 7). If student athlete fails to show signs of expected, progressive recovery – the Team Physician will determine need for further management. Such cases may include further imaging studies and/or referral to Neurology. RETURN TO PLAY: 1) Classifying the injury with reference to any of the many established concussion diagnostic guidelines will allow the Team Physician and Athletic Trainer to optimally manage a return to play protocol more effectively. Again, guidelines are only guidelines and clinical experience by the Team Physician or certified athletic trainer will be considered foremost when making a return to play decision. 2) Head trauma suspected concussive event without loss of consciousness a) Remove student-athlete from contest. Examine immediately for abnormal cranial nerve function, impaired cognition, incoordination or other post-concussive symptoms at rest and with exertion. May return to contest if examination is normal and asymptomatic for a reasonable time frame. If any symptoms reoccur, return that day is not permitted b) If the student-athlete is removed from contest/practice and develops symptoms during the sideline evaluation, daily evaluations are necessary. Student-athlete may begin restricted participation when asymptomatic at rest and after successful completion of tests. Unrestricted participation is allowed if asymptomatic during exertional testing and neuropsychological and balance testing normal. 3) Head trauma suspected concussive event with loss of consciousness a) Remove the student-athlete form contest and prohibit return that day. Examine immediately and at 5 min intervals for evolving intracranial pathology. Further diagnostic 3 tests for suspected intracranial pathology will then be considered. Reexamine daily. May return to restricted participation when Athletic Trainer and Team Physician are assured the student-athlete has been asymptomatic at rest and with prescribed and supervised exertional testing. Unrestricted participation if remains asymptomatic and performing restricted activities normally and comfortably. All neuropsychological assessment and balance testing have returned to normal. 4) The goal in managing an athlete with a concussion should be to prevent further catastrophic outcome, to return the athlete to safe, unrestricted competition in a manner that minimizes both the possibility of second-impact syndrome and/or a more severe head injury leading to lingering symptomology and further time away from training/competition. 5) The potential of long term effects of repetitive head injury will be discussed with any student athlete sustaining any such head injury by the Team Physician. REDUCING EXPOSURE TO HEAD TRAUMA: 1) Oklahoma State University is committed to reducing exposure by the following: i) Adhering to reducing the number of contact practices ii) Providing coaches, athletic training staff and student athlete’s with education regarding safe play and proper technique iii) Recognition of unchallengeable autonomy of medical staff in determining medical management and return to play decisions of student-athletes. RETURN TO LEARN: 1) Provide guidelines for initiating cognitive rest following sports-related concussion and establishing a process to guide the transition of return to the academic classroom/setting. “Return-to-learn” is a parallel concept to “return-to-play”. The foundation of return-to-learn includes: Management of a return-to-learn should a stepwise program that fits the needs of the individual. Return-to-learn guidelines acknowledges that both physical and cognitive activities require brain energy utilization, and that such brain energy is not available or may be limited for physical and cognitive exertion due to the concussion-induced brain energy crisis. The “hallmark” of return-to-learn is cognitive rest immediately following concussion, just as the “hallmark” of return-to-play is physical rest. Cognitive rest refers to avoiding potential cognitive stressors such as school work, video games, reading, texting and watching television, as well as team meetings and instruction. Current evidence suggests that providing both physical and cognitive rest allows the brain to heal more quickly, providing the beneficial effect of cognitive rest on ultimate concussion recovery. a) When a student athlete sustains a head injury/concussion and cognitive rest is suggested either by the Team Physician and/or Athletic Trainer, the Associate Athletic Director in Academic Affairs Marilyn Middlebrook will be notified. Academics will then notify appropriate instructors and the Office of Disability Services on campus. b) Cognitive rest following concussion involves avoiding the classroom for at least 24 hours. The following descriptive models will be referred to when assessing concussive injury and outlining a “return-to-learn” plan. i) Academic Adjustment - a student-athlete’s academic schedule requires some modification in the first one to two weeks following concussion. In this case, full 4 recovery is anticipated, and the student-athlete will not require any meaningful curriculum or testing alterations. ii) Academic Accommodation - the student-athlete has persistent symptoms for more than two weeks following concussion. Because the student-athlete has not recovered in the anticipated period of time, he or she may require a change in the class schedule and special arrangements may be required for tests, term papers and projects. At this point, the student athlete with the direction of Team Physician will meet with the Office of Disability Services to develop a University approved plan. Although there is no fixed timeline for academic accommodation, this generally applies to studentathletes who have more prolonged concussion symptoms, or who may be suffering with post-concussion syndrome. iii) Academic Modification - a more difficult scenario in which the student-athlete suffers prolonged cognitive difficulties, which thereby requires a more specialized educational plan constructed by the multidisciplinary team including the potential of withdrawing from classes for that given semester. c) If the student-athlete cannot tolerate the amount of time required to participate in a class requiring light cognitive activity, he or she should remain at home or in the residence hall. i) For example, once the student-athlete can tolerate 30-45 minutes of cognitive activity without return of symptoms, he/she should return to the classroom in a step-wise manner. Such return should include no more than 30-45 minutes of cognitive activity at one time, followed by at least 15 minutes of rest. 2) Return-to-learn recommendations are based on consensus statements, with a paucity of evidence-based data to correlate with such consensus recommendations. 3) Return-to-learn recommendations should be made within the context of a multi-disciplinary team that includes both Sports Medicine and Academic Student Services personnel. a) The levels of adjustment needed should be decided by a multi-disciplinary team that includes Sports Medicine and Students Services personnel, including but not limited to the Team Physician Val Gene Iven, Director of Athletic Training John Stemm, Athletic Trainer of respective sport and Associate Athletic Director in Academic Affairs Marilyn Middlebrook, Faculty Athletic Representative Meredith Hamilton, Licensed Clinical Psychologist Trevor Richardson, and any individual professors deemed appropriate. The level of multi-disciplinary involvement should be made on a case-by-case basis. 4) A process that ensures the gradual return to cognitive activity is based on the absence of concussion symptoms following cognitive exposure. References McCrory P et al: Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47:250-258. Harmon KG et al: American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013: 47:15-26. Schneider KJ et al: The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports med 2013; 47:304-307. 5 Table 1. Cranial Nerve Testing Cranial Nerve I III,IV,V V VII X XI XII Test Sense of smell Eye tracking and pupil reactivity Biting down Facial expressions Swallowing Shoulder shrug Protrusion of the tongue 6 Table 2. Exertional Testing Protocol Student-athlete reports to athletic trainer symptom free Step 1 Student-athlete performs a 20 minute bicycle workout with interval sprinting, stopping if symptoms return. If no symptoms: Step 2 Student-athlete performs individual sport skills without threat of contact. If symptoms return, student-athlete must stop and revert to step 1 the following day. If no symptoms: Step 3 Student-athlete may return to practice with limited contact. Level of involvement depends on the sport and position of the student-athlete. If symptoms return, student-athlete must stop. **If no symptoms, student-athlete should be seen by physician for clearance to participate in all activities the following day** • • In some cases, steps 1 and 2 could be completed on the same day between AM and PM sessions No student-athlete can return to full activity until they are asymptomatic with limited, controlled exertion and full contact activities and cleared by the team physician. 7 Form 1: Concussion Symptom Scale Checklist Name:______________________ Sport:________________ Date:______________ Circle one: Baseline Test or Post-Concussion Test: D_____ For Baseline Tests: Only score items that you experience on a regular/consistent basis (3-4 days per week, during the season). All other items should be scored “0” Symptoms None Mild Moderate Severe 1. Headache 0 1 2 3 4 5 6 2. Nausea 0 1 2 3 4 5 6 3. Vomiting 0 1 2 3 4 5 6 4. Balance Problems/Dizziness 0 1 2 3 4 5 6 5. Fatigue 0 1 2 3 4 5 6 6. Trouble Sleeping 0 1 2 3 4 5 6 7. Sleeping More Than Usual 0 1 2 3 4 5 6 8. Drowsiness 0 1 2 3 4 5 6 9. Sensitivity To Light 0 1 2 3 4 5 6 10. Blurred Vision 0 1 2 3 4 5 6 11. Sensitivity To Noise 0 1 2 3 4 5 6 12. Sadness/Depressed 0 1 2 3 4 5 6 13. Irritability 0 1 2 3 4 5 6 14. Numbness/Tingling 0 1 2 3 4 5 6 15. Feeling Like “In A Fog” 0 1 2 3 4 5 6 16. Difficulty Concentrating 0 1 2 3 4 5 6 17. Difficulty Remembering 0 1 2 3 4 5 6 18. Neck Pain 0 1 2 3 4 5 6 Column Total Score 0 Overall Total Score 8 Form 2: Balance Error Scoring System (BESS) Scorecard Name:_____________________________ Sport:_____________________ Examiner:__________________ Date:____________ Time:____________ Circle one: Baseline Test Position or Post-Concussion Test: D_____ Firm Surface # of Errors Foam Surface # of Errors Double-Leg Stance Single-Leg Stance Tandem Stance Total Errors Total Score Instructions: 1. Student-athlete first stands with both feet narrowly together, both hands on iliac crests, and eyes closed. 2. Student-athlete holds this stance for 20 seconds while the ATC records the number of balance errors. a. A balance error is operationally defined as: • Opening the eyes • Hands coming off of hips • Taking a step • Moving hips into 30º or more abduction • Lifting the forefoot or heel • Remaining out of testing position for more than 5 seconds 3. The test is repeated with a single-leg stance using the non-dominant foot and again using a heel-to-toe stance with the non-dominant foot in the rear. 4. All three tests are performed on a firm surface and on a medium density foam surface. 5. The numbers of errors on each of the six tests are added for a total BESS score. 9 Form 3: Standardized Assessment of Concussion (SAC) Name:_______________________________ Sport:______________________ Examiner:__________________ Date:______________ Time:_____________ Circle one: Baseline Test or Post-Concussion Test: D_____ Introduction I am going to ask you some questions. Please listen carefully and give your best effort. Orientation What month is it? What is the date today? What is the day of the week? What year is it? What time is it right now? (Within 1 hr) 0 0 0 0 0 Immediate Memory I am going to test your memory. I will read you a list of words and when I am done, repeat back as many of the words as you can remember, in any order. List Trial 1 Trial 2 Trial 3 Elbow 0 1 0 1 0 1 Apple 0 1 0 1 0 1 Carpet 0 1 0 1 0 1 Saddle 0 1 0 1 0 1 Bubble 0 1 0 1 0 1 Total Trials 2 & 3: I am going to repeat that list again. Repeat back as many words as you can remember in any order, even if you said the word before. Concentration 1 1 1 1 1 /5 /15 I am going to read you a string of numbers and when I am done you repeat them back to me in the reverse order of how I read them to you. For example if I say 7-1-9, you would say 9-1-7. If correct go to next string length. If incorrect, read trial 2. Stop after incorrect on both trials. Trial 1 Trial 2 Score 4-9-3 6-2-9 0 1 3-8-1-4 3-2-7-9 0 1 6-2-9-7-1 1-5-2-8-6 0 1 7-1-8-4-6-2 5-3-9-1-4-8 0 1 Now tell me the months of the year in reverse order, starting with the last month. 1 pt for sequence /5 Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan Delayed Recall Tell me as many words as you can remember from the list I read earlier, in any order. 1 pt each Elbow Apple Carpet Saddle Bubble /5 TOTAL SAC SCORE 10 / 30 Form 4: OKLAHOMA STATE UNIVERSITY ATHLETIC TRAINING ROOM HEAD INJURY PROTOCOL This is a medical follow-up sheet regarding concussion management for your health and safety. Often times signs of a traumatic head injury do not appear immediately after the injury itself. The purpose of this fact sheet is to alert you to the symptoms of significant head trauma that may occur several hours after you leave the training room. It is important that the injured student-athlete go home and rest. This includes: No TV / Movies No video games No loud music No alcohol No medications not approved by the athletic trainer or team physician If you experience one or more of the following symptoms following a head injury, seek medical attention 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. Difficulty remembering recent or meaningful events. 2. Severe headache, particularly at a specific location. 3. Extreme stiffening of the neck. 4. Bleeding or clear fluid dripping from the ears or nose. 5. Mental confusion, strangeness or irritability. 6. Nausea or vomiting. 7. Dizziness, poor balance or unsteadiness. Weakness in either arm or leg. Abnormal drowsiness or sleepiness. Convulsions/twitching. Unequal pupils. Loss of appetite. Persistent ringing of the ears. Slurring of speech. Unable to be aroused. Change in respiration / difficulty breathing. The appearance of any of the above symptoms should not be taken lightly and are signs/symptoms that are consistent with a significant head injury that immediate requires medical attention. If any of the symptoms appear, immediately contact your Team Physician (Dr. Val Gene Iven), Certified Athletic Trainer, or John Stemm, Head Athletic Trainer at 405742-7463(cell), 405-332-4035 (home), or go to Stillwater Medical Center’s Emergency Room. Oklahoma State University Athletic Training Staff 11 M. 0020C mm_OZ .P 354. mImE. Tum Emm ET?hu. ?an mp Eran-IE? .nlf?ll an?n? - I HEB nElmF-h?an?nu aim?H EB run nah?u Elw?rn?i? Ehr 3min. roan?Hug anu nE-Hmn ?riq?nwnl??nnELanrr ?nub ?annm?nn E3 5513. - manna: imaging E. . ?nu Egn?ni??iawi gain-HIE nub: h. n?zncm??D?sd HIE lum- u?n .Hl an. Hana?? ?Sula?m?! au?inn? . Un. Ha." EWEH Anna-?? rung. TE. in :Em?n I Run: and Iran?Ban. i .123; .H. Finn Fin. Lr?ir amalgam. nE. a. nrnn._n.E.m In. Ema?Hanna. n?ma?n?. 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OCH Mann?noun Hum. 335 inn ?1.51 Shar?g?i Em?.n?n?unannunh.3u. . ah nil. a. .. . mini? 0 35:3 3 mania ll?iinnilin Elignlqiniin?ii Giana?14E 5 Form 6: OSU Student-Athlete Injury & Illness Responsibility Statement I, the undersigned athlete at Oklahoma State University, acknowledge the NCAA requirement that student-athletes at OSU accept the responsibility for reporting their personal injuries and illness to the OSU Athletic Training Staff, which may include, but is not limited to, signs and symptoms of concussions. Furthermore, I acknowledge that I have received the NCAA concussion education materials. • Headaches • “Pressure in head” • Nausea or vomiting • Neck pain • Balance problems or dizziness • Blurred, double, or fuzzy vision • Sensitivity to light or noise • Feeling sluggish or slowed down • Feeling foggy or groggy • Drowsiness • Change in sleep patterns • Amnesia • “Don’t feel right” • Fatigue or low energy • Sadness • Nervousness or anxiety • Irritability • More emotional • Confusion • Concentration or memory problems (forgetting game plays) • Repeating the same question/comment If you notice any symptoms of concussion: • Tell your athletic trainer and/or coach • Appears dazed • Vacant facial expression • Confused about assignment • Forgets plays • Is unsure of game, score, or opponent • Moves clumsily or displays incoordination • Answers questions slowly • Slurred speech • Shows behavior or personality changes • Can’t recall events prior to hit • Can’t recall events after hit • Seizures or convulsions • Any change in typical behavior or personality • Loses consciousness • Do not return to participation in a game, practice, or other activity until you have been cleared to return to activity by a medical professional. • If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion which may result in a severe brain injury and can change your life. 13 I have received and reviewed the concussion fact sheet; I accept the responsibility for reporting my injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions Printed Name: __________________________________________ Sport: ____________________________ ____________________________________________ Date: _________________ Signature ____________________________________________ Date: _________________ Signature of parent or guardian if student athlete is under age 18. 14 Form 7: SPORTS-RELATED HEAD INJURY INCIDENT REPORT SHEET Name_________________ Sport______ (# of Previous Head Injuries_______ Date of Injury__________ Date of Last Head Injury________) Return to Play Date__________ TESTS DOI D1 D2 Grade of Current Injury_________ D3 D4 CN TEST SX CHECK SAC BESS COMP(VERB) COMP(VIS) REACT TIME MOTOR SPEED 15 D5 D6 D7 WK2 WK3 WK4 BASELINE Concussion Management Plan Pre-season Education All University of Oregon student athletes will read the NCAA Concussion Fact Sheet. They will then sign the attached statement acknowledging that they understand the material and that they accept responsibility for reporting their injuries, including any signs and symptoms of concussion. The athletic trainer for each sport will coordinate the educational session and signing of the necessary documents. These signed documents will be stored in the student athlete’s medical file. All University of Oregon coaches will read the NCAA Concussion Fact Sheet. They will sign the attached statement acknowledging that they understand the material, will encourage athletes to report their symptoms of concussion, and will accept the responsibility for referring student athletes to the medical staff if a concussion is suspected. The Director of Athletic Medicine will coordinate the educational session and signing of the necessary documents. These documents will be kept in the compliance office. All University of Oregon team physicians, athletic trainers, and graduate assistant athletic trainers will read the University’s Concussion Management Plan and the NCAA Concussion Fact Sheet. Each party will provide a signed acknowledgement of having read and understood the concussion materials. These documents will be kept by The Director of Athletic Medicine. The Director of Athletic Medicine will coordinate an annual meeting with Athletic Medicine staff to review the Concussion policy and any changes. Pre-participation Prior to participation in practice or competition all intercollegiate student athletes will complete a baseline evaluation. This evaluation will include a neuropsychological test (Impact), a graded symptom checklist, a Standard Assessment of Concussion (SAC), a balance evaluation (tandem gate), and complete a questionnaire to determine prior history of concussion. A team physician will review the evaluation and determine pre-participation clearance and/ or the need for additional testing. Assessment Student athletes exhibiting signs, symptoms, or behaviors consistent with concussion are immediately removed from practice or competition. An athletic trainer or physician with concussion management experience will assesses the student athlete. The initial suspected concussion evaluation will include a graded symptom checklist, a physical and neurological exam, a Standard Assessment of Concussion (SAC), a balance exam (tandem gait), clinical assessment for cervical spine trauma, skull fracture, and intracranial bleed. If a concussion is confirmed the student athlete will be removed from practice/ play for that calendar day. Management Any student athlete diagnosed with a concussion shall not return to activity for the remainder of the day. A student athlete diagnosed with a concussion is not allowed to return to practice, competition, or any other physical activity until cleared for participation by a physician. The emergency action plan is initiated by the attending physician or athletic trainer to transport the student athlete for further medical care if any of the following are present: Glasgow Coma Scale<13, prolonged loss of consciousness, focal neurological deficits suggesting intracranial trauma, repetitive emesis, worsening mental status, or suspected spinal cord injury. If a physician is not present during the event the athletic trainer will notify the physician to develop an evaluation and treatment plan. Student athletes who exhibit concussive symptoms and another responsible adult are given written and verbal instructions regarding activities to avoid as well as progressive symptoms requiring further emergency medical intervention. A management plan is made for the concussed student athlete to receive serial evaluations. This will typically consist of an initial exam, a follow up 1-3 hours post injury, and then every 24 hours. Return-to-Learn The concussed student athlete will be given a concussion awareness letter by the athletic trainer or physician to use to notify his/her professors that they are being treated for a concussion. No classrooms activity will take place on the day of injury. The concussed student athlete will follow up daily to complete a graded symptom checklist. The student athletes certified athletic trainer will function as the point person within athletics to help the student athlete navigate the return to learn process; and will collaborate with the team physician, coaches and academic advisor to create a plan for academic recovery. An individualized plan will be developed to assist the concussed student athlete to progress from cognitive rest to gradual return to the classroom/ studying. If the student athlete reports worsening symptoms with academic activity the physician will reevaluate. If a concussed student athlete has a prolonged return to symptom free academics the multidisciplinary team may be expanded to include, but not limited to: team physician, athletic trainer, clinical counselor, neuropsychologist, academic advisor, course director, college administrators, office of disability services representatives, and coaches. The concussed student athletes schedule may be modified for up to two weeks as needed. If the student has not returned to normal academic activity within two weeks the student athlete will be reevaluated by the team physician and members of the multidisciplinary team as appropriate. Any concussed student athlete with a prolonged recovery will be reassessed by a physician in order to consider additional diagnosis and best management options. Campus resources will be engaged by the student athlete’s academic advisor for cases that cannot be managed through schedule modification / academic accommodations. Such resources will be consistent with ADAAA and include one of the following: learning specialists, office of disability, ADAAA office. Return to Play The concussed student athlete will have daily follow up with their certified athletic trainer to assess their symptoms. Once the student athlete’s symptom checklist score returns to baseline for 24 hours, while performing full academic activity, the student athlete will begin the return to play process. Initially the student athlete will perform an aerobic exertion test on a stationary bike (20min at 12-15 MPH) If the student athlete has any return of concussion-like signs /symptoms, the activity will be terminated, and the student athlete will continue resting and not proceed to any additional testing. Retesting may not occur until the student athlete is once again asymptomatic for a minimum of 24 hours while engaged in full academic responsibilities. If the athlete is asymptomatic during the aerobic exertion test they will undergo additional testing including a Standardized Assessment of Concussion (SAC), neuropsychological evaluation (Impact), and a balance test (tandem gait) Once additional testing is completed the student athlete will have a follow up evaluation by a physician to review their testing in relation to their baseline scores. If the student athlete is thought to be recovered by the treating physician they may begin a graduated exertion protocol. The student athlete is monitored by the certified athletic trainer during these steps to assess if any concussion- like symptoms /signs occurs during or after the activity. The student athlete may not progress to the next step until they can complete the activity symptom free. If symptoms recur during the graduated exertion protocol the student athlete is referred back to the physician for reassessment. The graduated exertion protocol allows a gradual increase in volume and intensity. Depending on individual assessment, a student athlete may complete Steps 1-3 on the same day. However Step 3, Step 4, and Step 5 must occur on separate days after insuring no return of symptoms following each exercise session. Step 1: Aerobic conditioning and body weight strength conditioning Step 2: Aerobic conditioning including high intensity intervals and full strength training Step 3: Noncontact sport specific drills Step4: Limited, controlled noncontact practice Step 5: Full practice No athlete can return to full activity or competition until they are asymptomatic in limited, controlled and full-contact activities, and cleared by the team physician. Reducing Exposure to Head Trauma Intercollegiate sports at the University of Oregon will be taught and practiced in a 'safety first' approach. Measures to make sport safer will include but are not limited to: Adherence to Inter-Association consensus guidelines Reducing gratuitous contact during practice Taking the head out of contact Coaching and student-athlete education regarding safe play and proper technique CONCUSSION AWARENESS LETTER The University of Oregon Athletic Medicine and Student Services/Academic Counseling Departments would like to inform you that _________________________________ sustained a concussion on __/__/__. He/ she will undergo additional concussion testing. A concussion or mild traumatic brain injury can cause a variety of physical, cognitive, and emotional symptoms. Concussions range in significance from minor to major, but they all share one common factor — they temporarily interfere with the way your brain works. We would like to inform you that during the next few weeks this athlete may experience one or more of these signs and symptoms. Headache Balance Problems Diplopia- Double Vision Photophobia-Light Sensitivity Misophonia-Noise Sensitivity Feeling Sluggish or Groggy Difficulty Concentrating Nausea Dizziness Confusion Difficulty Sleeping Blurred Vision Memory Problems Personality Changes As a department, we wanted to make you aware of this injury and the related symptoms that the student athlete may experience. Although the student is attending class, please be aware that the side effects of the concussion may adversely impact his/her academic performance. Any consideration you may provide academically during this time would be greatly appreciated. We will continue to monitor the progress of this athlete and anticipate a full recovery. Should you have any questions or require further information, please do not hesitate to contact us. Thank you in advance for your time and understanding with this circumstance. Gregory Skaggs, M.D. Director of Athletic Medicine 541-346-4529 gskaggs@uoregon.edu Concussion Symptom Inventory Name: Date of injury: Name of academic advisor:__________________________________________ Score is on a 0 – 6 scale (6 being the worst) Symptom Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems Total Symptom Score Athlete Initials Athletic Trainer Initials Date of last concussion: Date: Date: Date: Date: Date: Date: Date: University of Oregon Student-Athlete Concussion Statement I understand that it is my responsibility to report all injuries and illness to my athletic trainer and or team physician. I have read and understand the NCAA Concussion Fact Sheet. I am aware of the following information: (initial each line) _______ A concussion is a brain injury, which I am responsible for reporting to my athletic trainer or team physician. _______A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. _______Some concussion symptoms may be present right away; others may not show up for hours or days after the injury. ______If I suspect a teammate has a concussion, I am responsible for reporting the injury to my athletic trainer or team physician. ______I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion like symptoms. ______Following a concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. ______In rare cases, repeat concussions can cause permanent brain damage, and even death. __________________________ Signature of the Student Athlete __________________________ Printed name of the Student Athlete University of Oregon Coaches Concussion Statement I have read and understand the University of Oregon Concussion Management Policy. I have read and understand the NCAA Concussion Fact Sheet. I am aware of the following information: (initial each line) _______ A concussion is a brain injury, that athletes must report to the medical staff. _______A concussion can affect the athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. _______Some concussion symptoms may be present right away; others may not show up for hours or days after the injury. ______If I suspect an athlete has a concussion, it is my responsibility to insure the athlete is evaluated by medical staff. ______I will encourage athletes to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussion. ______I will not knowingly allow an athlete to return to play in a game or practice if she/he has received a blow to the head or body that results in concussion- like symptoms. ______Athletes shall not return to play in a game or practice on the same day that they are suspected of having a concussion. ______Following a concussion the brain needs time to heal. Concussed athletes are much more likely to have a repeat concussion if they return to play before their symptoms resolve. In rare cases repeat concussions can cause permanent brain damage, and even death. ______I am aware that all athletes must complete a baseline testing process prior to engaging in sport at the University of Oregon. ______I am aware that athletes diagnosed with a concussion will be cared for by the medical staff and will follow a graduated return to play protocol following full recovery of neurocognition and balance. __________________________ ______________ __________________________ Signature of the Coach Date Printed name of Coach University of Oregon Medical Provider Concussion Statement I have read and understand the University of Oregon Concussion Management Policy. I have read and understand the NCAA Concussion Fact Sheet. I am aware of the following information: (initial each line) _______ A concussion is a brain injury, that athletes must report to the medical staff. _______A concussion can affect the athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. _______Some concussion symptoms may be present right away; others may not show up for hours or days after the injury. ______If I suspect the athlete has a concussion, it is my responsibility to have the athlete see the appropriate medical staff. ______I will encourage the athletes to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussion. ______I will not knowingly allow the athlete to return to play in a game or practice if she/he has received a blow to the head or body that results in concussion- like symptoms. ______Athletes shall not return to play in a game or practice on the same day that they are suspected of having a concussion. ______Following a concussion the brain needs time to heal. Concussed athletes are much more likely to have a repeat concussion if they return to play before their symptoms resolve. In rare cases repeat concussions can cause permanent brain damage, and even death. ______I am aware that all athletes must complete a baseline testing process prior to engaging in sport at the University. ______I am aware that athletes diagnosed with a concussion will be cared for by the medical staff and will follow a graduated return to play protocol following full recovery of neurocognition and balance. __________________________ _______________ ______ ______________________ Signature of Medical Provider Date Printed name Medical Provider Oregon State University Sports Medicine Concussion Management Plan Purpose: The Oregon State University Sports Medicine staff recognizes that concussions are serious injuries that require a comprehensive and carefully measured approach to management. This plan was created with the understanding that each concussion, as well as each student-athlete, is unique. Individualizing concussion management, considering each student athlete’s complete medical history, and close physician involvement are the hallmarks of this concussion plan and are essential for the safety of our student-athletes. All members of OSU’s athletic department are responsible for supporting, administering, and adhering to this plan. Failure to follow this plan may lead to disciplinary action up to and including termination from employment. This concussion plan is based on prevailing current knowledge and inter-association guidelines for concussion evaluation and management and is intended to be an evolving document. Introduction: Concussion management in athletics is a dynamic and individual process. Each athlete will experience trauma to the head in a different manner, with differing recovery paths and timeframes. Concussions are complicated by several factors, including but not limited to previous head injury, dehydration, medical conditions, Attention Deficit Hyperactivity Disorder (ADHD), and medications. International experts have convened in attempts to develop guidelines and consensus statements and have concluded that no single approach is applicable to all concussions however a general framework has been established as an accepted approach to concussion care (InterassociationGuidelines). Definition: Concussion is defined as a complex pathophysiological process affecting the brain and induced by traumatic biomechanical forces. It is most commonly characterized by the rapid onset of a constellation of symptoms or cognitive impairment that is self-limited and resolves spontaneously. Concussion Education: Due to the severe nature of a concussion, Oregon State University believes in a conservative, twopronged approach for treatment. First, student-athletes are responsible for self-reporting his or her symptoms after suffering a concussion. Self-reporting of symptoms plays an integral role in tracking the severity and subsequent recovery of a concussion. Therefore, the student-athlete is responsible for reporting his or her signs and symptoms completely and honestly to the staff Certified Athletic Trainer and/or Team Physician as soon as they present and each day following the injury. {00395187;1} 4/30/14 1 Oregon State University Sports Medicine Concussion Management Plan In an effort to reinforce the importance of self-reporting and ensure that student athletes know what to report, student-athletes will be annually presented with educational materials that provide information about the mechanisms of head injury, signs and symptoms of a concussion, and the dangers associated with an unreported concussion. Subsequently, it will be required that all student-athletes sign the Oregon State University Student-Athlete Concussion, Injury and Illness Agreement to Self-Report, a statement certifying that the student athlete has received and understood the educational material presented, and are accepting responsibility for truthfully reporting of his or her injuries and illnesses, including signs and symptoms of a concussion. Second, all OSU athletic department members are responsible for reporting any signs or symptoms of a concussion that he or she witnesses to the OSU sports medicine staff. As such each coach (including volunteer coaches, athletic trainer, physician, sport administrators, strength coaches, athletic directors at Oregon State University must undergo concussion education annually so that they are better prepared to be able to identify and respond to a concussion. Each individual who completes the concussion process must sign a statement of compliance which will be kept on file within the compliance office. Baseline Assessment: Every student-athlete will have a pre-participation physical exam with a team physician. Prior to that encounter, the student athlete must complete a health history physical questionnaire, which includes a history of previous concussions, learning issues and ADHD. Each physical exam should include a brief neurological assessment with attention paid to those athletes with previous concussion histories. As part of the pre-participation physical process, and before clearance for team activities, all athletes participating in NCAA sports must have a baseline neurocognitive exam, such as IMPACT, and must also complete a balance testing evaluation, such as BESS. More extensive neuropsychological evaluation may also be considered and ordered by the team physician as needed. Additionally, those athletes who suffer a concussion after initial clearance must have a repeat baseline evaluation that must occur after a minimum interval time of 6 months. Evaluation: Recognition is the first step in the evaluation and management of concussion. The athletic trainer is most often the initial evaluator of concussions and is responsible for knowing the various categories of possible signs and symptoms of concussion. If the team physician is present, he/she must participation in the evaluation process. {00395187;1} 4/30/14 2 Oregon State University Sports Medicine Concussion Management Plan Possible signs and symptoms of a concussion include, but are not limited to, the following: 1. Cognitive symptoms a. Level of consciousness, Confusion, Orientation b. Amnesia - Post-traumatic, Retrograde (less common) c. Concentration, Registration 2. Physical symptoms (headache, dizziness, nausea, fatigue) 3. Cranial Nerve Findings a. Pupils → Need to be equal, and reactive to light b. Diplopia, nystagmus, photophobia, phonophobia 4. Balance abnormalities (Gait, Romberg) 5. Mood Related Symptoms (insomnia, irritability, sadness) When a student-athlete self-reports or otherwise exhibits signs and symptoms that raise a concern for a concussive event, the athlete must be removed from participation in their sport and must be evaluated by a certified athletic trainer or team physician. The evaluator must perform a symptom assessment, physical and focused neurological exam including brief tests to assess neurocognitive function, such as memory and attention, balance exam and clinical assessment for cervical spine trauma, skull fracture and intracranial bleed. SCAT 3 may be used as a tool to assist in part of this evaluation process. The athletic trainer will document all pertinent information surrounding the evaluation and management of any suspected concussions, including but not limited to the following: 1. 2. 3. 4. 5. 6. 7. 8. Mechanism of injury. Initial signs and symptoms assessment. State of consciousness. Findings on serial testing of symptoms, neurocognitive function, and balance. a. Noting deficits compared with baseline. Instructions given to the athlete, parent or roommate. Recommendations given by the physician. Graduated RTP progression a. Including dates and specific activities involved in the athlete’s return. Relevant information regarding the athlete’s history of prior concussion & recovery pattern. Immediate & Home Care: {00395187;1} 4/30/14 3 Oregon State University Sports Medicine Concussion Management Plan If it is determined by the team physician (or if he/she is not present, the athletic trainer) that a concussion has occurred or cannot be reasonably excluded, the athlete must be removed from play and or competition and must not be returned to play in the same day. The emergency action plan must be followed, including transportation for further medical care, for any of the following: Glasgow Coma Scale < 13, Prolonged loss of consciousness, Focal neurological deficit suggesting intracranial trauma, Repetitive emesis, Persistently diminished/worsening mental status or other neurological signs/symptoms or possible spine injury. The team physician should be notified if he/she is not present during the immediate post-concussion care. The athletic trainer must develop a mechanism for serial monitoring of symptoms and if symptoms worsen, the team physician must be contacted by phone or in person. Once on home care, if the student athlete experiences any of the following, he/she must contact the team physician (or, if unreachable, the athletic trainer): Stumbling/Loss of Balance Weakness in one arm/leg Blurred or Tunnel Vision Increased Irritability Worsening Headache Repeated Vomiting Decreasing Level of Consciousness Dilated, Unreactive or Unequal Pupils Increased Confusion An overnight contact (typically a roommate, friend, or significant other) must be established to assist in monitoring the condition of the concussed student-athlete over the first 24 hours. An instructional form for home care of the concussion has been developed and must be provided and explained to both the student-athlete and the overnight contact before the concussed student-athlete is allowed to leave the venue. This instruction must include special attention paid to warning signs that would warrant that the student-athlete seek immediate medical attention. A follow-up with Oregon State University Sports Medicine staff must be scheduled within 24 hours of the injury and recorded on the home care instruction form. The athletic trainer must make a copy of the completed home care instruction form to be kept with the medical records. Physician Referral &Neurocognitive Testing: All athletes with suspected concussion must be referred to the team physician for evaluation and diagnosis within the first 24 hours of injury whenever possible. In the event that a concussion occurs {00395187;1} 4/30/14 4 Oregon State University Sports Medicine Concussion Management Plan while the team on out of town or the team physician is unavailable for any other reason, the physician must be informed of the injury by phone by the athletic trainer. A post-injury neurocognitive test will be conducted by ATC staff when directed by the team physician, or when the athlete’s symptom score returns to baseline levels. Repeat neurocognitive testing without physician approval should not occur. There is rarely a need to test more than twice post-injury. The more frequently the test is done, the less reliable are the results. Post-Concussion Course: 1. Expected or “Typical” Course a. Symptoms typically include headache, along with sensitivity to light and sound, nausea, dizziness, blurry vision, confusion, memory and concentration problems, among others. Typically there is a gradual resolution of symptoms over a few days, with a fairly predictable decrease in the number and severity of symptoms. Balance issues usually resolve first. Headache is often the last symptoms to resolve, which can often be worsened with exertion (valsalva) and movement. 2. Prolonged symptoms a. A student athlete who has prolonged symptoms in the recovery process must be reevaluated by a physician if the symptoms continue past a seven day period. The physician will perform an assessment and evaluation of the student athlete to include consideration for additional diagnosis or problems such as Post- concussion syndrome, Sleep dysfunction, Migraine or other headache disorders, Mood disorders such as anxiety and depression, and Ocular or vestibular dysfunction. Best management options for these concomitant diagnosis will be initiated. Return to Play: The student-athlete must be re-evaluated periodically by the sports medicine staff with experience in concussion management to assess recovery of the concussion. Any future return to play decisions will be made by the team physician based on the initial evaluation and follow-up assessments of the sports medicine staff and must follow the outline below: {00395187;1} 4/30/14 5 Oregon State University Sports Medicine Concussion Management Plan 1. The athlete may only start his/her return to activity after a physician evaluates the athlete and determines that the athlete is ready to begin the return to play procedure,, unless otherwise approved by the physician. A concussion symptom score must be recorded every 24 hours, as medically necessary. 2. After being determined ready to begin the return progression, the student athlete may begin his/her return to activities as follows. Unless otherwise approved by the team physician, each stage in the progression must take a minimum of 24 hours, and be clearly documented and provided for the physician upon follow-up. a. Stage 1 – No activity – physical & cognitive rest. b. Stage 2 – Light Aerobic Exercise i. Stationary bike for 15 minutes at <70% MHR. ii. No resistance training. c. Stage 3 – Sport Specific Cardiovascular Exercise i. Progressive conditioning drills specific to the sport, no resistance training. ii. For example, bike sprint intervals half gassers. d. Stage 4 – Non-contact Training Drills i. Progress to more complex sport specific training drills, begin resistance training. ii. For example, passing drills in football, agilities. e. Stage 5 – Unrestricted Training i. Following clearance by team physician, may participate in full practice activities or full workouts. f. Return to Competition may occur after the team physician releases the athlete. 3. Monitor for changes in symptoms or mental status by Sports Medicine Staff. a. If the athlete develops any symptoms during or after any of the exercise sessions, he/she must stop and rest for the remainder of the day. He/she may not return to exercise again until Sports Medicine Staff determine the athlete is asymptomatic. He/she may then return to the previous attempted level of exercise, and continue to graduate along the protocol. b. Challenge balance pre- & post-exercise at each stage (i.e. modified BESS). 4. The physician will determine if an additional neurocognitive test should be completed. It must not be taken within 3 hours of strenuous physical activity. This neurocognitive test must be reviewed by the physician prior to clearing the student athlete to return to practice activities in stage 4. If the student athlete has successfully completed stages 1-4, along with a normal neurocognitive test (as determined by the physician), he/she may then be cleared for full participation. {00395187;1} 4/30/14 6 Oregon State University Sports Medicine Concussion Management Plan Academics and Return to Learn: A concussion, no matter how mild it may seem at the time, causes disruption in the normal brain activity and metabolism. After concussion any mental demand can bring about worsening symptoms and potentially a delay of healing from a concussion. Therefore when a student-athlete is diagnosed with a concussion the student-athlete will be removed from academics and no return to class shall occur the same day of the concussion. Much as in return to play a stepwise progression will occur for student athletes return to learn in the post-concussion period with respect to mental and learning challenges. The student athlete will be aided in the navigation of the return to learn protocol by the Faculty Athletics Representative (FAR). In the event the FAR is not available, the head of academic support for student athletes will assist the student athlete. The student athlete is responsible for contacting their professors to notify them of the injury and also for communicating with the FAR all academic obligations they currently have at the time surrounding the injury. Unlike return to play when an athlete must be completely back to baseline and able to progress through several challenges, the student need not be 100% symptom free to begin the return to learn process as long as the necessary accommodation are in place for the student. This process should be multidisciplinary and involve several key individuals: Faculty Athletic Representative, Team Physician, Instructors, Academic Advisor, Dean of Student Life representative and the Office of Disability Access Services (DAS) among others. The process will comply with all applicable state and federal laws. The steps in return to learn that will be followed are: 1. No return to class room or study groups the day of the concussion 2. The appointed person may assist the athlete in contacting Dean of Student Life representative and the student athlete’s professors to inform them of the concussive episode. 3. At home or in their normal living environment the student will attempt short mental challenges the following day. • If the student is able to concentrate on mental activity for up to 20 minutes at a time without worsening of symptoms then they are encouraged to study and work on academic challenges in 20 minute intervals with breaks in between. This time duration may be progressed as the student is able. {00395187;1} 4/30/14 7 Oregon State University Sports Medicine Concussion Management Plan • If symptoms prevent the student from concentrating on mental activity or worsen, rest is required. The student should be kept on mental rest with no (or very limited) television, texting, reading, homework. 4. When symptoms allow the student to concentrate on mental activity for up to 40 minutes at a time, the student may return to the lecture arena. It is important to note that sequential timing of classes should be avoided if possible. 5. If symptoms do not permit return to classroom and academic work within 5-7 days after the concussion occurred, or the symptoms are progressing, the student athlete will be reevaluated by the team physician. 6. The Faculty Athletics Representative will work with the Dean of Student Life representative, the professors and the athlete in determining if any schedule and academic accommodations are needed during the first 14 days. The FAR may rely on the input from the student, physician, mental health provider, student athlete academic advisor, Dean of Student Life representative, or any others necessary in determining if any changes need to be made. 7. In the event the student athlete’s symptoms progress beyond 14 days to the point it prevents the student athlete from fully participating in the academic realm, a multidisciplinary team will meet to help navigate the more complex cases. • The multi-disciplinary team may consist of any combination of the following that best helps the student athletes unique situation: i. Team physician. ii. Athletic trainer. iii. Psychologist/counselor. iv. Neuropsychologist consultant. v. Faculty athletic representative. vi. Academic counselor. vii. Course instructor(s). viii. College administrators. ix. Dean of Student Life. x. Office of Disability Access Services representative 8. The resources available on campus that may be engaged in student athletes cases where they are unable to continue in their normal learning progression for any class or term. • Office of Disability Access Services • Office of Equity and Inclusion • Academic Advisor {00395187;1} 4/30/14 8 Oregon State University Sports Medicine Concussion Management Plan • Department of the Registrar Reducing Exposure to Head Trauma: The sports medicine staff, team physicians, and athletics administration understand and support the initiatives of the NCAA and other organizations in their efforts to reduce exposure to head and facial trauma. As such coaches and athletics staff members should adhere to the Inter-Association Consensus: Year-Round Football Practice Contact Guidelines. Furthermore, as members of the Pac-12 the football staff should follow the Pac-12 rules on contact practices which state 1. Football Practice Policies. Proper football technique and mechanics, especially when blocking and tackling are involved, should be the priority at every football practice. The core, upper body and lower body should be utilized for contact and players should be taught to avoid using the helmet to initiate contact. Players initiating contact should neither utilize their helmet in play-making, nor target the recipient of a block or tackle above the shoulders. a. NCAA Rules. Except where expressly limited below, Pac-12 institutions shall continue to abide by the football practice rules and regulations outlined in the annual NCAA Division I Manual. b. Definition of "Full Contact". The Pac-12 shall define "full contact" as any live tackling, live tackling drills, scrimmages or other activities where players are generally taken to the ground. Full contact shall not include "thud" sessions or drills that involve "wrapping up" where players are not taken to the ground and contact is not aggressive in nature. c. Fall/In-Season Practices. Pac-12 institutions shall limit full contact practices to two (2) per week during the regular football season [the period between the first regular-season game and the last regular-season game or Pac-12 Champion­ ship Game (for participating institutions)]. d. Preseason Practices. For days during which Pac-12 institutions schedule a two-a-day practice, full contact shall be allowed in one practice (the other practice is limited to helmets and shoulder pads). If full contact practices are scheduled consecutively around one of the two-a-day full contact practices, only one of those practices shall be more than 50 percent full contact. (e.g., if a morning session of a two-a- day practice is full contact. that morning session practice or the preceding one-a-day practice would be limited to no more than 50 percent full contact. e. Spring Practices. Pac-12 institutions shall schedule spring practices so that of the eight (8) permissible full contact practices, only two (2) of those full contact practices occur in a given week. (NCAA rules define these eight practices as practices involving "tackling.") This rule will be subject to instances where inclement weather or other unforeseen circumstances have constricted or otherwise altered a previously finalized spring schedule that complied with this rule. {00395187;1} 4/30/14 9 Oregon State University Sports Medicine Concussion Management Plan 2. Reducing Exposure to Head Trauma in Sports other than Football. All coaches and teams should take attempts to reduce gratuitous contact during practice and embody a philosophy of taking a ‘safety first’ approach to sport. Head Coaches are expected to instruct their coaches and student-athletes regarding safe play and proper techniques so as to reduce potential exposure to unnecessary head trauma. Any athletics staff member or other individual who feels that a safety first approach is not being taken can inform the Director of Sports Medicine or the Athletics Director of their concerns. All situations that are brought forward will be investigated and corrective action will be taken as necessary. 3. Independent Medical Care It is always important to emphasize the Inter-Association Consensus: Independent Medical Care Guidelines which state that the Institutional medical line of authority should be established independently of a coach, and in the sole interest of student-athlete health and welfare. Medical line of authority is transparent and evident at Oregon State University, and collaborative interactions with the medical director and primary athletics health care providers (defined as all institutional team physicians and athletic trainers) exist so that the safety, excellence and wellness of student-athletes is evident in all aspects of athletics and are student-athlete centered. Our sports medicine staff, including athletic trainers and physicians, are expected to communicate and intervene anytime they feel there is unreasonable risk to the health of the student athlete. They are empowered by unchallengeable autonomous decision making in regards to return to play and removal from play of our student athletes in regards to health and safety of the student athlete at Oregon State. {00395187;1} 4/30/14 10 THE STA TE UNIVERSITY Concussion Policy: Mission Statement The Pennsylvania State University Department of Intercollegiate Athletics and Department of Sports Medicine are committed to the health and well-being of every student athlete. Part of that commitment is the safe participation in sport. The Penn State Concussion Policy is designed to provide the student athlete with a comprehensive approach to the clinical management of sports related mild traumatic brain injury or concussion. This policy is in accordance with all aspects of ‘NCAA Concussion Management Requirements’, the ‘Big Ten Concussion Management Policy’ as well as ‘Evidence Based International Guidelines’ for the prevention, management and care of student athletes recovering from concussion. i Table of Contents Concussion Policy: Mission Statement ……………………………………………………….………………i Procedures for Education about Concussion……………………………………………………………….1 Procedures for Reducing Exposure to Head Injury……………..……………………………………….3 Concussion Management Policy: Procedures for Baseline Testing………………………………………………………………………………….5 Emergency Procedures for on / off field diagnosis and management…………………………6 Return to Academics Procedures ……………………………………………………………………………….7 Return to Play Procedures …………………………………………………………………………………………8 Concussion Policy Review Procedures ………………………………………………………………………10 Research Initiatives: Penn State Sports Concussion Research & Service Lab ……………………………………………..11 APPENDICES Appendix A: NCAA Constitution 3.2.4.17………………………………………………………….12 Appendix B: Head Exposure Reduction Initiatives ……………………………………………13 Appendix C: CDC, NCAA Educational Handouts…………………………………….………….14 Appendix D: B1G & PSU Concussion Self-Reporting Acknowledgement Form & Concussion Post Injury Instruction Form………………………………………………………….15 Appendix E: B1G Concussion Acknowledgement Form – Coaches..………………….18 Appendix F: B1G Concussion Acknowledgement Form – Athletic Director………19 Appendix G: B1G Concussion Acknowledgement Form – Sports Medicine………20 Appendix H: SCAT 3 Form…..……………………………………………………………………………21 Appendix I: Return to Academics – Academic Restriction Form…..………………….25 Appendix J: Certificate of Compliance – Athletic Director……………………………….26 Concussion Education Athletic Trainers will be responsible for coordination of all ‘Concussion Education’ materials to be presented to their student athletes and coaches at their respective team meeting or designated time prior to participation in college athletics. Athletes, Coaches, Athletic Administration and Sports Medicine personnel education may include the following materials: 1. CDC & NCAA Concussion Education Handout (See Appendix C) – This form is provided to the student athletes, coaches, athletic administration and sports medicine personnel. It is a short review of what a concussion is and the common ‘Signs and Symptoms’ of a concussion. In addition, it provides a summary of the recommended management steps for athletes recovering from concussion. 2. ‘Self-Reporting Acknowledgement Form’ (See Appendix D) - This form will be presented to the student athletes. This form acknowledges that they have received a copy of the educational materials outlined above and provided by their athletic trainer. The signature of the student athlete acknowledges this receipt as well as the student athlete’s responsibility to self-report concussive symptoms as well as to report teammates that are suspected of having a concussion based on the information discussed in the educational meeting. 3. ‘Concussion Post-Injury Instruction Form’ (See Appendix D) – This form will be discussed during the meeting and will be specifically addressed / given to any student athlete recovering from a concussion. This form gives the student athlete information on what to expect in the acute stage following their injury as well as instructions for short term management. 4. ‘Return to Academics’ Policy following concussion (See Page 6.) – This process will be mentioned during the educational meeting and will be specifically addressed with any student athlete recovering from a concussion. This form gives the student athlete information regarding their injury as well as what they can expect from their healthcare provider. 5. ‘Return to Practice’ and competition following concussion (See Page 7.) – This process will be mentioned in the educational meeting but will be specifically addressed with any athlete recovering from concussion. It should be noted that the ‘Return to Play’ procedure is a minimal standard guideline and can be modified by their healthcare provider based on their history, symptoms etc. 1 6. ‘B1G Concussion Acknowledgement Form(s)’ (See Appendix E, F & G) – These forms are reviewed by the coaching staff, athletic director, team physicians and athletic trainers and are presented by the Director(s) of Sports Medicine & Athletic Training. All groups listed above will be given the CDC & NCAA Concussion Educational Material as well as Penn State’s Concussion Management Policy Manual and asked to review these materials. They will then acknowledge they have received a copy of the ‘Concussion Management Policy Manual’ and will be expected to report any athlete suspected of receiving a concussion. Signature of this document will acknowledge their understanding of the information provided. 2 Reducing Exposure to Head Injury Reducing exposure to head Injury is part of the overall prevention strategy for attenuating sports related concussion. Penn State Sports Medicine takes an active role in the overall reduction of exposure to head injury on a daily basis using the following strategies: 1. Prevention: a. Education: Annual education of the student-athletes, coaches and sports administration on the signs, symptoms, diagnosis and management of concussions is performed by the Sports Medicine staff. Education remains a critical component in helping a student athlete recognize when they may have potentially sustained a concussion. Early recognition and management can help prevent the deleterious effects of secondary brain injury if left unrecognized by the student athlete. b. Technique: Proper coaching and instruction on safe techniques are paramount to reducing head injury risk in sports. One example of specific instruction in the sport of football is outlined by the Heads Up Tackling™ technique instruction provided by the USA Football organization (See Appendix B). c. Maintenance & Inspection of Protective Gear: Protective equipment is designed to mitigate injurious forces and reduce overall injury to the student athlete participating in sport. Regular inspection of protective equipment is performed by athletic training staff and/or equipment staff to ensure equipment deemed necessary for the sport meets performance standards. Properly fitted and maintained protective equipment can reduce the likelihood of head injury. d. Research: i. Penn State University Sports Medicine is committed to understanding all aspects involved in sport related concussion and its effects and impact on the student athlete. In keeping with this Penn State Sports Medicine is highly involved in research in association with the Center for Sports Concussion Research and Service lab (http://concussion.psu.edu/) at Penn State University in the College of Health and Human Development. This laboratory is one of the nation’s leading facilities focused on traumatic brain injury in athletics. An enhanced understanding of the physiologic underpinnings of concussion can broaden our understanding of the injury and lead to a reduced risk of repeat injury with the advanced diagnosis and management performed by the lab. 3 2. Post-Injury Management: a. ‘Return to Play’: A cautious approach to the diagnosis and conservative management of athletes recovering from concussion can help prevent patient risk of serious injury from repeated head trauma. A multidisciplinary diagnosis and management team can help detect any residual abnormalities and monitor their recovery before allowing the athlete to follow the ‘Return to Play’ protocol. Conservative management of the brain injured athlete will help reduce repeat exposure to head injury. 4 Concussion Baseline Testing & Follow-Up Testing 1. Baseline Neuropsychological Testing - Current concussion management guidelines recommend the use of Neuropsychological (NP) baseline testing for student athletes participating in collegiate athletics. All athletes will utilize computerized baseline NP testing using ImPACT®. Baseline computerized NP measurements will be taken prior to participation in college athletics. In addition, in-coming student athletes with a disclosed history of mTBI may be referred for formal clinical neuropsychological evaluation by the supervising team physician to a licensed clinical neuropsychologist. Further, any student athlete suspected of / or diagnosed with a learning disability, history of mental illness or migraines may also be considered for formal clinical neuropsychological cognitive baseline testing. 2. Balance Testing - In accordance with evidence based management guidelines, all student athletes will perform baseline clinical balance measures using the balance error scoring system (BESS) as outlined in the SCAT3 (See Appendix H). Baseline clinical balance measures will be taken prior to participation in college athletics. 3. Repeating Computer Based / Clinical NP Testing (Post-Injury): All athletes suffering a concussion will retake computer based NP testing prior to full clearance back to competitive sport. The timeline that the testing is performed may vary. Typically computer based NP testing will be performed after the patient is asymptomatic. There are some cases, when directed by the team physician, that computer based NP testing should be repeated earlier to help document severity of injury. In difficult or inconclusive cases, the evaluation by other formalized NP testing or additional expert consultation may be utilized when directed by the team physician. 5 Emergency Action Procedures for On / Off Field Recognition and Management: On the field emergency management of athletes suspected of sustaining a concussion will be coordinated by the supervising sports medicine personnel in accordance with the medical chain of command as outlined in the Penn State Emergency Action Plan. Recognition and management will occur as follows: Athlete demonstrates signs & symptoms of a head or neck injury and suspected concussion NO YES Does the Athlete Demonstrate any of the following: -Serious Cervical / Spine Injury -Glasgow Coma Scale < 13 -Prolonged Loss of Consciousness -Focal Neurological Deficit – Intracranial Trauma -Repetitive emesis -Diminishing/Worsening ‘Mental Status’ or other neurological signs/symptoms FOOTBALL ONLY: ‘Neutral Observer’ sends feedback to the ‘Field of Play’ about suspected head injured athlete Consider Alternative Diagnosis YES NO Sideline Evaluation: Self-Reported Symptoms, Positive Indicators on SCAT 3, Altered Mental Status, Altered Postural Stability Testing Diagnosed with Concussion. Complete remainder of assessment tools to determine injury baseline - - Activate E.M.S. Removal of athlete using appropriate stabilization / immobilization techniques. Transportation of the Athlete to a Level 1 Trauma Center. Remove from Competition / Practice Observe for deterioration of injury status Initiate Follow-Up Care: - Cognitive / Physical Rest Period - Activate ‘Return to Learn’ Chain of Command - Determine NP testing follow-up - When appropriate initiate physician guided ‘Return to Play’ procedures (Adapted from) Scorza et.al. Current Concepts in Concussion Evaluation and Management American Family Physician, 2012 Jan 15; 85(2): 123-132. Once it has been determined that a student athlete has sustained a concussion, that athlete is not eligible to return to athletic participation the same day. The athlete must then be evaluated as soon as possible (preferably within 24 hours) by the supervising team physician or a physician trained in sports related concussion management. A plan for follow-up care will be determined and initiated by the supervising team physician and athletic trainer. 6 Post-Concussion Injury Management 1) Return to Academics: Concussion initiates a complex pathophysiologic injury cascade in the brain which adversely affects neural homeostatic mechanisms. Return to Academic guidelines assumes that both physical and cognitive activities require brain energy utilization, and that after a concussion, brain energy may not be available due to the complex pathophysiologic injury cascade. Return to learn should therefore be managed in a stepwise program that fits the needs of the individual and gradually introduces cognitive stress. Development of this individualized academic progression is done within the context of a multi-disciplinary team that may include 1) Supervising team physician, 2) Supervising athletic trainer, and 3) Academic advisor. In cases where recovery from concussion is complicated this team may also include 1) Psychologist/Counselor, 2) Learning Specialist 3) Neuropsychologist and/or 3) Neurologist. As the athlete recovers from their concussion they are exposed to a sub-symptom threshold cognitive stimulus. As such, the supervising team physician will indicate when the student athlete can initiate a stepwise ‘Return to Academics’ progression. An example of one such progression is provided in the table below. It is meant as a template for cognitive progression and not a rigid guideline. The athlete may be progressed faster or slower through cognitive exposure based on the presence or absence of symptoms. Rehabilitation Stage 1. No Activity Cognitive Exposure at Each Stage of Recovery Complete Cognitive Rest — No school, no homework, no reading, no texting, no video games, no computer work. Relax previous restrictions on activities and add back for short periods of time (515 minutes at a time). 2. Gradual Reintroduction of Cognitive Activity 3. Homework at Homework in longer increments (20-30 minutes at a time). home 4. School Re-entry Part day of school after tolerating 1-2 cumulative hours of homework at home. 5. Gradual Increase to full day of school Reintegration into school 6. Resumption of full Introduce testing, catch up with essential work. cognitive workload ** (Adapted from) Master et.al. Importance of ‘Return to Learn’ in Pediatric and Adolescent Concussion, Pediatric Annals September. 2012, 41:9, 1-6. ** 7 At any point, if the student-athlete becomes symptomatic (i.e., more symptomatic than baseline), or scores on clinical/cognitive measures decline, the team physician should be notified and the student-athlete’s cognitive activity reassessed. Supervising team physicians will give the student athlete an ‘Academic Restriction Form’ (See Appendix I). This form will be used to inform the student athlete’s professor and academic support staff of their recent head injury as they recover from concussion. All academic considerations are consistent with provisions provided to students with documented brain injury under the Americans with Disabilities Act Amendments Act (ADAAA) of 2008 and were developed in consultation with the Office for Disability Services (ODS) at Penn State University. Furthermore, academic support staff working with the student athlete will be contacted to inform them of any temporary or longterm absence from class participation and in order to facilitate any additional referral/academic support services as needed. Communication between the team physician, athletic trainer, student athlete, academic counseling and professors is an essential component to the safe return of a student athlete to academic demands. 2) Return to Play: The athlete may begin the ‘Return to Play’ protocol when cleared by the supervising team physician. The typical progression for a ‘Return to Play’ protocol is outlined by the chart below which is consistent with International Guidelines from the Concussion in Sport Group. Differences between sports will exist when participating in sports specific drills and training but the guidelines or objective for each ‘Rehabilitation Stage’ should be the same for all athletes, independent of sport. Return to Play Protocol: 24 hour minimum between stages outlined below Rehabilitation Stage 1. No Activity 2. Light Aerobic Exercise 3. Sports Specific Exercise 4. Non-Contact Training Drills 5. Full Contact Training 6. Game Play Functional Exercise at Each Stage of Recovery Complete physical and cognitive rest; Initiate ‘Return to Learn’ protocol when cleared by supervising team physician Walking, stationary cycling keeping intensity <70% MPHR); No resistance training Examples: Skating in hockey, running in soccer; No head impact activities Progression to more complex training drills (e.g. Passing drills in football and ice hockey). **Progressive resistance exercise allowed.(See ‘Strength Training Progression Table’) Following medical clearance participate in normal training activities Full clearance / Normal Game Play McCory et. al. Concensus statement on concussion in sport – the 4th International Conference on Concussion in Sport held in Zurich, November 2013. Clinical Journal of Sports Medicine. 2013 Mar: 23(2): 89-117) 8 3) Return to Strength Training: When cleared to participate in strength training, the advancement of the strength training progression will be at the discretion of the athletic trainer and/or the team physician. An example is found below: Strength Training Progression Table: 24 hour minimum between stages outlined below Rehabilitation Stage 1. Light Resistance 2. Moderate Resistance 3. Full Resistance Functional Exercise at Each Stage of Recovery Medicine Ball, Bands and Body Weight exercises Progress Med Ball Intensity, Continue Band work, Increase to 50% Body Weight or less of pre-injury training loads with ≥ 1 minute rest between sets. Full weight training based on strength phase that corresponds with training cycle. Cut volume down ½ to ⅓ of protocol workout. Load should be 50-75% or less training loads. Med balls, bands and body weight exercises still okay. Rest should be 1 minute between sets. *Note for all phases: Stop with any adverse signs or symptoms. Regular reps only (No forced reps/no SS-Negatives and no isometrics). Hydration / Flexibility (All Vertical) during rest periods with extra emphasis on proper breathing technique. 4) Prolonged Recovery: Some athletes that continue to have prolonged symptoms will be serially evaluated by their supervising team physician to measure/monitor the deterioration or improvement of their symptoms. The physician will then determine when referral is needed to diagnose the presence of additional pathology. Consultation may include but is not limited to neurologist(s), neurosurgeon(s), neuropsychologist(s) or therapist(s) trained in neural or vestibular rehabilitation. In addition, the physician and sports medicine staff will coordinate academic accommodations / considerations given the length of time the athlete may have been restricted from cognitive efforts. These academic considerations will be consistent with all rules and regulations outlined by Penn State’s Office of Disability Services and the Morgan Academic Support Center. A multidisciplinary approach to the diagnosis and management of these complicated patients are consistent with international guidelines for mild traumatic brain injury management. 9 Concussion Policy Review Procedures This Concussion Management Policy will be reviewed by a ‘Concussion Committee’ comprised of team physicians and athletic trainers on an annual basis appointed by the Director of Athletic Medicine and Assistant Athletic Director for Athletic Training Services. Renewed editions will be submitted and approved by the Director of Athletic Medicine and Assistant Athletic Director for Athletic Training Services before being finally reviewed and approved by the Director of Athletics for Penn State University in accordance with all NCAA and B1G mandates and requirements. (See Appendix J – Certificate of Compliance) All procedures must be completed prior to submission to the NCAA Concussion Safety Protocol Committee by May 1st annually. 10 Penn State Center for Sports Concussion Research & Service As part of our efforts to better understand the short and long term health effect of sports related concussion, Penn State Sports Medicine works closely with the Center for Sport Concussion Research and Service (http://concussion.psu.edu/) within the College of Health and Human Development. The research lab is currently home to one of the nation’s leading facilities focused on traumatic brain injuries in athletics lead by Dr. Semyon Slobounov (Director) and Dr. Peter Arnett (Co-investigator). Dr. Slobounov has developed the Virtual Reality (VR) facility which is designed to examine residual cognitive and motor abnormalities in patients suffering from concussion. Virtual reality is incorporated with brain imaging research (fMRI, DTI, MRS, EEG) to examine the alteration of brain functions/structures in concussed individuals. Dr. Arnett’s primary focus is on the role of clinical neuropsychology and recovery of function following concussion. This multidisciplinary research and service are focused on both collegiate athletics and pediatric populations. Student athletes participating in varsity & club level athletic teams are able to participate in research initiatives within the Center for Sports Concussion Research and Service lab and contribute to our growing body of knowledge on sports related concussion. The lab is currently conducting research in the areas of: • • • • The effects of concussion on academic performance. The effects of hypothermia on brain function in the concussed athlete. The effects of anti-oxidant supplementation on brain function in the concussed athlete. The effects of concussion on generalized brain function as measured using virtual reality, functional MRI and EEG analysis. • Neuropsychological predictors of outcome following concussion, including motivation at baseline, cognitive variability, premorbid personality characteristics, and cognitive reserve. • Genetic factors that predict concussion outcome. 11 Appendix A: NCAA Constitution By-Law 3.2.4.17 By-Law 3.2.4.17 Concussion Management Plan – An active member institution shall have a concussion management plan for its student athletes. The plan shall include, but is not limited to, the following: (a) An annual process that ensures student-athletes are educated about the signs and symptoms of concussions. Student-athletes must acknowledge that they have received information about the signs and symptoms of concussions and that they have a responsibility to report concussion-related injuries and illnesses to a medical staff member; (b) A process that ensures a student-athlete who exhibits signs and symptoms or behaviors consistent with a concussion shall be removed from athletics activities (e.g. competition, practice, conditioning sessions) and evaluated by a medical staff member (e.g. sports medicine staff, team physician) with experience in the evaluation and management of concussions; (c) A policy that precludes a student-athlete diagnosed with a concussion from returning to athletics activity (e.g. competition, practice, conditioning sessions) for at least the remainder of that calendar day; and (d) A policy that requires medical clearance for a student-athlete diagnosed with a concussion to return to the athletics activity (e.g. competition, practice, conditioning sessions) as determined by a physician (e.g. team physician) or the physician’s designee. 12 Appendix B: USA Football: Heads Up TacklingTM technique HEADS UP TACKLING TACKLE PROGRESSION The foundational starting point for all movements and drills. Technique for coming to balance and regaining breakdown position prior to contact. Correct body posture at moment of impact for safer tackling. Head and eyes are up using the front of shoulder as point of contact. The opening of the hips to generate power and create an ascending tackle. With head to the side and out of contact, throw double uppercuts and ?grab cloth? on the back of jersey to secure the tackle. @usafootball #HeadsUpFB lusafootball usafootball.com Download the free Main @jshallenbeck tiBetterSaferGame Heads Up Football app Appendix C: CDC NCAA Educational Handout CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A A concussion is a brain injury that: . Is caused by a blow to the head or body From contact with another player, hitting a hard surface such as the ground, ice or ?oor, or being hit by a piece of equipment such as a bat, lacrosse stick or ?eld hockey ball . Can change the way your brain normally works. . Can range from mild to severe. . Presents itself differently for each athlete. . Can occur during practice or competition in ANY sport. . Can happen even if you do not lose consciousness. HOW CAN I PREVENT A Basic steps you can take to protect yourself from concussion: . Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. . Avoid striking an opponent in the head. Undercutting, ?ying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. 0 Follow your athletics department?s rules for safety and the rules of the sport. . Practice good sportsmanship at all times. . Practice and perfect the skills of the sport. WHAT ARE THE OF A You can?t see a concussion, but you might notice some of the right away. Other can show up hours or days alter the injury. Concussion include: Amnesia. Confusion. . Headache. Loss of consciousness. 0 Balance problems or dizziness. 0 Double or fuzzy vision. . Sensitivity to light or noise. 0 Nausea (feeling that you might vomit). . Feeling sluggish, foggy or groggy. 0 Feeling unusually irritable. . Concentration or memory problems (forgetting game plays, facts, meeting times). 0 Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion (such as headache or tiredness) to reappear or get worse. WHAT SHOULD I DO IF I THINK I HAVE A Don?t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with The sooner you get checked out, the sooner you maybe able to retum to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal While your brain is still healing, you are much more likely to have a rept concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. For more information and resources, visit and wwvv.CDC.gov.If Concussion. Reference to any commercial entity orpruduct orsewr'ce on this page should not be construed as an endorsement by the Government ofthe con-puny or its products or services. 14 Appendix D: PSU Concussion Self-Reporting Acknowledgement Form THE PENNSYLVANIA STATE UNIVERSITY DEPARTMENT OF INTERCOLLEGIATE ATHLETICS STUDENT-ATHLETE CONCUSSION, INJURY AND ILLNESS SELF-REPORTING ACKNOWLEDGEMENT FORM About Concussions: • A concussion is a traumatic brain injury that is caused by a blow to the head or body, and results in an alteration in mental status, with or without loss of consciousness. • Concussions can range from mild to severe, and may present differently in each student-athlete. • Symptoms of concussion include: amnesia / loss of memory, confusion, headache, loss of consciousness, groggy, feeling irritable, concentration or memory problems, and slowed reaction time. Treatment and Reporting of Concussion and Other Injury or Illness: • A student-athlete who exhibits signs or symptoms of a possible concussion should be removed from practice or competition and assessed by a certified athletic trainer and/or team physician of the Penn State sports medicine staff. • A student-athlete who has suffered a concussion may not return to practice or competition until symptoms have resolved and he or she has received medical clearance. • The Penn State sports medicine staff cannot evaluate and treat a student-athlete who may have suffered a concussion, or any other type of injury or illness, unless the student-athlete discloses his or her symptoms. • Failure of a student-athlete to advise the sports medicine staff about symptoms of a head injury, concussion, or other injury or significant illness could result in serious and permanent harm. I hereby acknowledge: (1) that I have read and understand the above information; (2) that I have received educational materials about concussions and the opportunity to ask questions on the subject; and (3) that my participation in my sport may result in a head injury, concussion, or other injury or illness. I accept responsibility for reporting all head injuries, symptoms of concussion, injuries of any kind, and significant illness to the sports medicine staff. _________________________________________ Printed Name of Student-Athlete _____________________________ Sport __________________________________________ Signature of Student-Athlete Date: ____________________________ If Student-Athlete is under the age of 18, the signature of a parent or guardian is also required. I certify that I am the Student-Athlete’s parent or legal guardian, and that I have read this form, Understand the provisions hereof, and agree to be bound by the terms set forth herein, on behalf of the Student-Athlete and on my own behalf. __________________________________________ Printed Name of Parent or Guardian __________________________________________ Signature of Parent or Guardian Date: ____________________________ 15 Appendix D: B1G Injury and Illness Reporting Form Big Ten Injury and Illness Reporting Acknowledgement Form I, ________________________, acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the sports medicine staff of my institution (e.g., team physician, athletic training staff). I recognize that my true physical condition is dependent upon my accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at my institution. I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. I have been provided with education on head injuries and understand the importance of immediately reporting symptoms of a head injury/concussion to my sports medicine staff. By signing below, I acknowledge that my institution has provided me with educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. I, _____________________ have read the above and agree that the statements are accurate. Student-athlete’s name _______________________________ Signature of student-athlete ______________________ Date _________________________________ Name of person obtaining consent _ ________________________ Signature of person consenting 16 Appendix D: Concussion Post-Injury Instruction Form CONCUSSION POST-INJURY INSTRUCTION FORM Name: ____________________________ Date: ______________________ You have sustained a mild traumatic brain injury (concussion), which is a very serious injury and needs to be monitored. There are various signs and symptoms of a mild head injury that may show up immediately or several hours since initial injury. The following were signs and symptoms that you had during the initial evaluation: HEADACHE VOMITING FATIGUE ALTERED EMOTION/BEHAVIOR NUMBNESS/TINGLING FEELING IN A “FOG” DIFFICULTY REMEMBERING DELAYED VERBAL / MOTOR SKILLS SLOWING OF PULSE BLURRED VISION CLEAR FLUID DRAINAGE FROM EAR/NOSE AMNESIA (ANTEGRADE/RETROGRADE) BLOOD/FLUID FROM THE EARS OR NOSE VOMITING MORE THAN ONCE OR TWICE NAUSEA BALANCE PROBLEMS / DIZZINESS SENSITIVITY TO LIGHT / NOISE RINGING IN THE EARS FEELING SLOWED DOWN DIFFICULTY CONCENTRATING CONFUSION / DISORIENTATION SLURRED / INCOHERENT SPEECH CONVULSIONS / TREMORS SADNESS BREATHING DIFFICULTY CONTINUED DOUBLE VISION WEAKNESS IN EITHER ARM OR LEG UNCONTROLLABLE EYE MOVEMENTS Please remember to report back to the Athletic Training Room tomorrow morning at __________ for a follow up evaluation. Please review the marked symptoms above. **If these symptoms worsen, or if any of the additional symptoms appear, report them to the Athletic Trainer/Team Physician immediately. ** Otherwise, follow the instructions below: It is OK to: -Use Acetaminophen for headaches with approval from Team Physician. (No medications before your appointment) -Use ice pack on neck and/or head for comfort. - Go to sleep at a decent hour (8hrs sleep) - Cognitive and Physical Rest for the first 24 hours after injury. - After 24 hours: You can walk to and attend class, and do homework as permitted by the health care provider. DO NOT: -Take aspirin/Ibuprofen (Advil/Motrin) for headaches -Do any physical or cognitively strenuous activity -Drink alcohol -Drink more caffeinated beverages than normal -Stay up late -Watch TV, play video games, sit at a computer or listen to loud music for long periods of time -Text/play on your phone -Drive vehicle when impaired -Attend large group functions or parties Emergency Phone Numbers Department of Public Safety Athletic Trainer On Call Physician (814) 337-6911 ____________ (814) 865-3566 17 Appendix E: B1G Concussion Education Acknowledgement Form Big Ten Coaches Concussion Acknowledgement Form I, ________________________, acknowledge that as a member of the athletic department at, Pennsylvania State University, I accept responsibility for supporting our sports medicine department’s policy on concussion management. I understand that my student-athletes may have a risk of head injury and/or concussion. I also understand the importance of them reporting any such symptoms of a head injury/concussion to the sports medicine staff (e.g., team physician, head athletic trainer). I also accept responsibility for reporting to the sports medicine staff any signs or symptoms that I may witness. By signing below, I acknowledge that my institution has provided me with educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. I, _________________have read the above and agree that the statements are accurate. _______________________________ Signature of Coach ______________________ Date __________________________________ Name of person obtaining acknowledgement ________________________ Signature of such person 18 Appendix F: B1G Concussion Education Acknowledgement Form B1G Concussion Acknowledgement Form I, ________________________, acknowledge that as Director of the Athletic Department at, Pennsylvania State University, I accept responsibility for supporting our Sports Medicine Department’s ‘Concussion Management Policy’. I understand that my student-athletes may have a risk of head injury and/or concussion. I also understand the importance of them reporting any such symptoms of a head injury/concussion to the sports medicine staff (e.g., team physician, head athletic trainer). By signing below, I acknowledge that Pennsylvania State University has provided me with educational materials on what a concussion is and given me an opportunity to ask questions about areas that are not clear to me on this issue. I, _________________have read the above and agree that the statements are accurate. _______________________________ Signature of Director of Athletics ______________________ Date __________________________________ Name of person obtaining acknowledgement ________________________ Signature of such person 19 Appendix G: B1G Concussion Education Acknowledgement Form B1G Concussion Acknowledgement Form – Sports Medicine I, ________________________, acknowledge that as a member of the Sports Medicine department at, Pennsylvania State University, I accept responsibility for supporting our Sports Medicine Department’s ‘Concussion Management Policy’. I understand that my student-athletes may have a risk of head injury and/or concussion. I also understand the importance of them reporting any such symptoms of a head injury/concussion to our sports medicine staff (e.g., team physician, head athletic trainer). By signing below, I acknowledge that Pennsylvania State University has provided me with educational materials on what a concussion is and given me an opportunity to ask questions about areas that are not clear to me on this issue. I, _________________have read the above and agree that the statements are accurate. _________________________________ Signature of Sports Medicine Personnel ______________________ Date __________________________________ Name of person obtaining acknowledgement ________________________ Signature of such person 20 1 Appendix H: SCAT 3_Forn_1 Hm @?Er Sport Concussion Assessment Tool 3rd Edition For use by medical protessionals only Name DatefTime of Injury: Date of Assessment: What is the The SCAT3 is a standardized tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older. It supersedes the orig? inal SCAT and the SCATZ published in 2005 and 2009ir respectively?. For younger persons, ages 12 and under, please use the Child SCATB. The SCAT3 is designed for use by medical professionals. If you are not quali?ed, please use the Sport Concussion Recognition Tool". Preseason baseline testing with the SC AT3 can be helpful for interpreting post-injury test scores. Speci?c instructions for use of the SCAT3 are provided on page 3. If you are not familiar with the SEATS, please read through these instructions caretully. This tool may be freely copied in its current form for distribution to individuals, teams, groups and organizations. Any revision or any reproduction in a digital form re- quires approval bythe Concussion in Sport Group. NOTE: The diagnosis of a concussion is a clinical judgment, ideally made by a medical professional. The SCAT3 should not be used solely to make, or exclude, the diagnosis of concussion in the absence of clinical judgement. An athlete may have a concussion even if their SCAT3 is "normal". What is a concussion? A concussion is a disturbance in brain tunction caused by a direct or indirectforce to the head. It results in a variety of non-speci?c signs andror {some examples listed below] and most often does not involve loss consciousness. Concussion should be suspected in the presence of any one or more of the foIiowing: headache), or Physical signs ie.g., unsteadiness}, or - Impaired brain function confusion} or Abnormal behaviour ie.g., change in personality). SIDELINE ASSESSMENT Indications for Emergency Management NOTE: A hit to the head can sometimes be associated with a more serious brain injury. Any of the following warrants consideration of activating emergency pro? cedures and urgent transportation to the nearest hospital: Glasgow Coma score less than Deteriorating mental status Potential spinal injury Prograsive, worsening or new neurologic signs Potential signs of concussion? If any of the following signs are observed after a direct or indirect blow to the head, the athlete should stop participation, be evaluated by a medical protes- sional and should not be permitted to return to sport the same day if a concussion is suspected. Any loss of consciousness? "If so, how long?" Balance or motor incoordination (stumbles, 51va laboured movements, etc)? Disorientation or confusion {inability to respond appropriately to questions}? Loss o?t memory: ?If so, how long?" ?Before or after the injury?? Blank or vacant look: Visible facial injury in combination with any of the above: SPORT CONCUSSION ASSESMENT TOOL 3 1 Examiner: Glasgow coma scale (GCS) Best response No opening opening in response to pain opening to speech Eyes opening spontaneously th?n Best verbal response {if} No verbal response Incomprehensible sounds Inappropriate words Confused Oriented Best motor response (Mi No motor response Extension to pain Abnormal ?exion to pain Flexionrwithdrawal to pain Localizes to pain obeys commands moisture.- Giasgow Coma score (E @105. 6C5 should be recorded for all athletes in case of subsequent deterioration. Maddocks Score3 ?i am going to ask you a few questions, please listen carefully and give yourbest effort. Modified Maddocks questions point for each correct answer] What venue are we at today? Which halic is it now? Who scored last in this match? What team did you play last weekfgame? Did your team win the last game? Maddoclcs score Maddocks score is validated forsidelvnediagnosis ofconcussion only and is not used forserial testing. Notes: Mechanism of Injury i'tell me what happened?): Any athlete with a suspected concussion should be REMOVED FROM PLAY, medically assessed, monitored for deterioration shou id not be left alone) and should not drive a motor vehicle until cleared to do so by a medical professional. No athlete diag- nosed with concussion should be returned to sports participation on the day of Injury. I9 2013 Concussion in Sport son 21 BACKGROUND Name: Date: Examiner: Sportrr team? school: Date .ftime of injury: Age: Gender: Years of education completed: Dominant hand: right left How many concussions do you think you have had in the past? nenher When was the most recent concussion? How long was your recovery from the most recent concussion? Have you ever been hospitalized or had medical imaging done for a head injury? Have you ever been diagnosed with headaches or migraines? Do you have a learning disability, dyslexia, Have you ever been diagnosed with depression, anxiety or other disorder? Has anyone in your family ever been diagnosed with any of these problems? Are you on any medications? If yes, please list: SEATS to he done in resting state. Bestdone or more minutes post excercise. EVALUATION How do you feel? "You should score yourself on the following based on how you now?. none mild modemtie Headache ?Pressure in head" Neck Pain Nausea or vomiting Diainess Blurred vision Ba lance problems Sensitivity to light Sensitivity to noise Feeling slowed down Feeling like "in a fog" Don?t feel rig ht? Dif?culty concentrating Dif?culty remembering Fatigue or low energy Confusion Drowsiness Trouble falling asleep More emotional Irnta bility Sadness Houdu?oqxu?umogxquumag Nervous or Anxious Total number of [Maximum possible 22} severity score [Maximum possible 132] Do the get worse with physical activity? Do the get worse with mental activity? self rated self rated and clinician monitored clinician interview self rated with parent input Overall rating: if you know the athlete well prior to the injury, how different is the athlete acting compared to hislher usual self? Please circle one response: no different very different unsure NM. Scoring on the 5CAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete's readiness to return to competition after concussion. Since siting and man: evolve over tin-re. it: is imnartant tn COGNITIVE 3r PHYSICAL EVALUATION 1 __ll r. yr- -.. .va - . Cognitive assessment Standardized Assessment of Concussion Orientation point for each correct answer) What month is it? 0 1 What is the date today? 9 1 What is the day of the week? 0 1 What year is it? 1 What time is it right now? [within 1 hour] 0 1 Orientation score of 5 Immediate memory List Trial 1 Trial 2 Trial 3 Alternative word list elbow 1 1 0 1 candle baby ?nger apple 0 1 1 t] 1 paper monkey penny carpet 1 1 t] 1 sugar perfume blanket saddle 1 1 1 sandwich sunset lemon bubble 1 1 0 1 wagon iron insect Total Immediate memory score total of'ts Concentration: Digits Backward List Trial I Alternative cigit list 4?9?3 0 1 5?2?9 5?2?5 4?1?5 3-8?1-4 1 3?2?19 13?9?5 4?9?6-8 1 1-5-2?8-5 3?8?5?2?7 5?1?8-4?3 T??l 6?2 1 5?3?9?1 4?3 8?3-1?9? 6?4 Total of 4 Concentration: Month in Reverse Order [1 pt. for entire sequence correct} 1 Concentration score of 5? Neck Examination: Range of motion Tenderness Upper and lower limb sensation Findings: Balance examination Do one or both of the following tests. Footwear{shoes, barefoot, braces, tape, etc] Modified Balance Error Scoring System testing5 Which foot was tested (Le. which is the non-domin ant foot] Left Flight Testing surface {hard floor, ?eld, etc.} Condition Double leg stance: Errors Single leg stance {non-dominant foot}: Errors Tandem stance [non-dominant foot at back]: Arid r' Or Tandem gait? Time [best of 4 trials): seconds Coordination examination Upper limb coordination Which arm was tested: Left Right Coordination score SAC Delayed f-tecall?l Delayed recall score ofg-S' INSTRUCTIONS Words in italics throughout the SCAT3 are the given to the athlete by the tester. Scale "You should score yourself on the following basedon how you feel now". To be completed by the athlete. in situations where the scale is being completed after exercise, it should still be done in a resting state, at least 10 minutes post exercise. For total number of maximum possible is 22. For severity score, add all scores in table, maximum possible is Elx? 132. Immediate Memory "l am going to tstyour memory. ready-bu a list ofworcb and when lam done, repeat badcas many words asyou can remember, in anyordec? Trials 2 E: 3: "lam going to repeat the same list again. Repeat baclr as manyworoh as you can remember in any circle: even ify-ou said the word befme.? Complete all 3 trials regardless of score on trial 3:2. Flead the words at a rate of one per second. Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the athlete that delayed recall will be tested. Concentration Digits bac lcvvard "l am going to readyou a string ofnumbers and when lam done, you repeat them back to me backwards, in reverse order of how read them toyou. For example, iflsay you would say 9-1-2? If correct, go to next string length. If incorrect, read tnal 2. One point possible for each string length. Stop after in correct on both trials. The digits should be read at the rate of one per second. Months in reverse order "Now tell me the months of the year in reverse order Start with the last month and go backward. So you?ll say December, November Go ahead" I pt. for entire sequence correct Delayed Recall The delayed recall should be performed after completion of the Balance and Coor- dination Examination. "Do you remember thatlist of wordsl reada few times earlier? Tellmeas many words from the list asyou can remember in any order.? Score 1 pt. for each correct response Balance Examination Modified Balance Error Scoring System testing5 This balance testing is based on a modi?ed version of the Balance Error Scoring System A stopwatch orwatch with a second hand is required for this testing. "l am nowgoing to test your balance. Please talce your shoes off roll up yourpant legs above anlcle {if applicablel, and remove any' anlrle taping tifapplicable}. This tart will consist of three twenty second tie-ls with differentstances." Double leg stance: "The first stance is standing your feet together with your hands on your hips and with your closed. You should try to maintain stability in that position for 20 seconds. i will be counting the number of time: you more out of this position. will start timing when you are setand have closed your ey-Bfr [It] Single leg stance: "if you were to kick a ball, which foot wouki you use?I lThis will be the dominant motl l'low stand on your non-dominant foot The dominant leg should be held in approicin'tarely 30 de- gre? of hip flexion and 45 degrees of knee flexion. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. will be counting the number of timesyou move out of this position. liyou stumble out of tia'sposit'on, open your eyes and return to the star'tposition and continue balancing. i-trillstart timing when you are setand hale closed your eyes.? Tandem stance: "Nos-vstand heel-to?toe with your non-domrnant foot in back. Your weight should be evenly distributed acmss both feet. Again, you should try' to maintain stability for 20 seconds with your hands on your hips and your eyes closed. i will be counting the number of tim? you move out of this position. lfyou stumble out of this position, open your and return to the start m'tion and continue balancing. willstart timing when you areset and have closed Balance testing types of errors 1. Hands lifted off iliac crest 2. Opening eyes 3. Step, stumble, or fall 4. Moving hip into 30 degrees abduction S. Lifting forefoot or heel E. Remaining out of test position a 5 sec Each of the 20?second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the athlete. The examiner will begin counting errors only after the individual has assumed the proper start position. The modi?ed BESS is calculated by adding one error point for each error during the three ZB-seoond tests. The maximum total number of errors for any single con- dition is 10. If a athlete commits multiple errors simultaneously, only one error is recorded but the athlete should quickly return to the testing position, and counting should resume once subject is set. Subjects that are unable to maintain the testing procedure for a minimum of five seconds at the start are assigned the highest possible score, ten, for that testing condition. OPTION: For further assessment, the same 3 stances can be performed on a surface of medium density foam leg, approximately 50cmx40cmx6cml. Tandem Gait"-T Part'cipams are instructed to stand with their feet together behind a starring the [the test is best done with footwear removed). Then, they walk in a fort-vard direction as guidcly and as accurately a possible along a 38mm wide (sports tapel, 3 meter line with an alternate foot heel?to?toe gait ensun'ng that they approximate their heel and toe on eaoh step. Once they cross the end of the 3m line; they turn lBt'J degres and retum to the starting pointusing the same gait. A total of4 trials are done and the bat time is retained. Attila-ts should complete the tart in seconch. Athletes fail the testiftheystep off the line, hate a separationbetween their heel and toe, or ifthey touoh or grab the examineror an obliect. in this case, the time is not recorded and the trial repeated, if appropriate. Coordination Examination Upper limb coordination Finger?to?nose {Fm} task: ?i am going to tart your coordination now. Please sit comfortably on the chair with youreyes open andyour arm {either r'ightorlei'tjl outstetched {shoulder flexed to Wdegrea and elbow and ?ngers extendeo?l, pointing in front ofyou. When lgive a start o'gnal, i would like you to perform live successive finger to nose repet'tions using your index ?nger to touch the tip of the nose, and then return to the starting position, as quickly and as accuratelyaspossible." Scoring: 5 correct repetitions in ll seconds :1 Note for testers: Adrietes fail the test ifthey do not touch their nose, do not fully extend their elbow or do not perform ?ve repetitions. Failure should he scored as 0. Re fe re nces 8.: Footnotes 1. This tool has been developed by a group of international experts at the 4th ln? ternational Consensus meeting on Concussion in Sport held in Zurich, Switzerland in November 2012. The full details of the conference outcomes and the authors of the tool are published in The BJSM Injury Prevention and Health Protection, 2013, Volume Issue 5. The outcome paper will also be simultaneously cor?published in other leading biomedical yo urnals with the copyright held by the Concussion in Sport Group, to allow unrestricted distribution, providing no alterations are made. 2. McCrory et al., Consensus Statement on Concussion in Sport the 3rd lnter? national Conference on Concussion in Sport held in Zurich, November 2008. British Journal of Sports Medicine 2009, 43: 3. Maddocks, Dicker, Saling, MM. The assessment of orientation following concussion in athletes. Clinical Journal oi Sport Medicine. 1995, Eli}: 32?3. 4. McCrea l'v'l. Standardized mental status testing of acute concussion. Clinical Jour? nal of Sport Medicine. 2001; 11: 5. Guskiewicz KM. Assessment of postural stability following sport?related concus- sion. Current Sports Medicine Reports. 2003; 2: 24?30. I5. Schneiders, AG, Sullivan, S.J., Gray, A, Hammond?Tooke, G.&McCrory, P. Normative values for 16-32 year old subjects for three clinical measures of motor performance used in the assessment of sports concussions. Journal of Science and Medicine in Sport. 2010; 13l2}: 196?201. 2. Schneiders, A.G., Sullivan, 5.1., J.K., Disson, M., Yden. TErMarshall, SW. The effect of footwear and sports?surface on dynamic neurological screen? ing in sport-related concussion. Journal of Science and Medicine in Sport. 2010, 13(4): 382?386 ATHLETE INFORMATION Any athlete suspected of having a concussion should be removed from play, and then seek medical evaluation. Signs to watch for Problems could arise over the ?rst 24?48 hours. The athlete should not be left alone and must go to a hospital at once if they: Have a headache that gets worse Are very drowsy or can't be awakened lCan't recognize people or places Have repeated vomiting Behave unusually or seem confused; are very irritable Have seizures {arms and legs jerk uncontrollablyl Have weak or numb arms or legs Are unsteady on their feet, have slurred speech Remember. it is better to be safe. Consult your doctor after a suspected concussion. Return to play Athletes should not be returned to play the same day of injury. When returning athletes to play, they should be medically cleared and then follow a stepwise supervised program, w'rth stages of progression. For example: RehabiItati-on stage Functional ateodl slag-e Objective of each stage ct rehabitation No activity Physical and cognitive rest Recovery Light aerobic exercise Walking, swimming or stationary cycling Increase heart rate beeping intensity, in at: maximum oredicted heart rate. No resistanoe training Snort-speci?c exercise Skating drills in hockey. running drills in movement No head impact activities Exercise, coordination, and cognitive load Non-contact training drills Progression to more oomplex training drills, eg oassing drills in football and ice hockey. May start progressive resistance training Restore oontidence and assess functional skills by coaching staff Full oontact practice Following medical clearanoe participate in normal training activities Return to play Normal game play There should be at least 24 hours (or longer} for each stage and if recur the athlete should rest until they resolve once again and then resume the program at the previous stage. Resistance training should only be added in the later stages. If the athlete is for more than 10 days, then consultation by a medical practitioner who is expert in the management of concussion, is recommended. Medical clearance should be given before return to play. CONCUSSION INJURY ADVICE (To be given to the person monitoring the concussed athlete} This patient has received an injury to the head. A careful medical examination has been carried out and no sign of any serious complications has been found. Recovery time is variable across individuals and the patient will need monitoring for a further period by a responsible adutt. Your treating physician will provide guidance as to this timefra me. If you notice any change in behaviour. vomitingr dizzinessr worsening head- ache, double vision or excessive drowsiness. please contact your doctor or the nearest hospital emergency department immediately. other important points: Rest (physically and mentally), including training or playing sports until resolve and you are medically cleared No alcohol No prescription or non?p rescription drugs without medical supervision. Speci?cally: - No sleeping tablets - Do not use aspirin, anti-inflammatory medication or sedating pain killers Do not drive until medically cleared Do not train or play sport until medically cleared Clinic phone number Scoring Summary: Tat Domain Number of of 22 Severity Score of 132 Orientation of 5 Immediate Memory of 15 Concentration of 5 Delayed Recall of 5 suntan BESS (total errors} Tandem Gait {seconds} Coordination of 1 Notes: Patient's name Dateltime of injury Dateitime of medical review Score Date: Date: Date: Contact details or stamp Appendix I: Return to Academics – Academic Restriction Form Penn State University Concussion Program Patient Name: ______________________________ Date of Evaluation: ___________________ Please excuse the patient named above from school today due to a medical appointment. The student named above has suffered a concussion / mild traumatic brain injury and is currently under the care of this clinic. Individuals with this type of injury may suffer from physical symptoms such as headaches, fatigue, dizziness and light sensitivity. They may also have difficulty with cognitive functioning such as concentration, short term memory, problem solving and multi-tasking. In addition, some will have difficulty with mood such as poor impulse control, anger and anxiety and depression. Each injury needs to be individualized and the below recommendations are based on our evaluation. _______ No Physical Activity Class _______ Restricted Physical Activity Class: Student should not participate in activities that would place the student at risk for a head injury. Should not participate in team sports such as basketball, soccer, dodge ball, softball, floor hockey, volleyball, etc. and all racquet sports. May participate in fitness such as running, riding a stationary bike, swimming, aerobics and weight training. The student should stop activity immediately with any return of symptoms. ______ Consideration of the following academic accommodation to help mitigate symptoms:  Extended time on exams/quizzes  Permission to record lectures/note-taking assistance  Exams/quizzes in quiet location  Absence from class due to scheduled rest periods  Frequent breaks from class if symptomatic  Limit one exam per day  Due dates/assignment extensions  Late arrival or need to leave prior to the end of class  Use of a reader for exams/quizzes  Other: ____________________________________ ______ Documentation of current functional limitations/physical symptoms provided to Learning Specialist for referral to ODS. ______ Full Neuropsychological evaluation requested and referral has been made. Additional recommendations will be provided, as applicable, once report is completed. Please feel free to contact me with any questions. Thank you for your attention and consideration. ____________________________ Date: ____________ _______________________ Date: ____________ Player Signature Team Physician Signature _________________________________ Player Name - Printed _______________________________ Team Physician - Printed ____________________________ Date: ____________ Academic Advisor _________________________________ Academic Advisor - Printed 25 Traumatic Brain Injury (TBI) Assessment and Management Policies & Procedures Manual University of Pittsburgh Sports Medicine 1) Purpose: The purpose of this policies and procedures manual is to outline the proper assessment and management of student-athletes suffering from neuropsychological injuries in order to ensure proper care and promote the health and wellness of student athletes at the University of Pittsburgh. Athletics healthcare providers in this manual are empowered to have the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. 2) Definition: an injury involving an acceleration/deceleration or rotational force imparted to the head that result in temporary alteration in mental status. 3) Pre – Season Education a) NCAA concussion fact sheets or other applicable materials are provided annually to student-athletes, coaches, team physicians, ATCs and Directors of athletics. Each party provides a signed acknowledgement of having read and understood said material. 4) Recognition and Evaluation a) On-Field Assessment i) Rule out emergent life threatening conditions (i.e. spinal cord injury, cranial fracture, etc) ii) Remove athlete from participation b) Side Line Assessment (Performed by a certified athletic trainer and/or team physician) i) Recognize Signs and Symptoms (1) Headache (2) Tinnitus (3) Nausea (4) Dizziness (5) Altered Vision (6) Tenderness (7) Numbness (8) Weakness (9) Photophobia (10) Fatigue (11) Inappropriate Emotion (12) (This list is not all inclusive) c) Cranial Nerve Assessment i) ii) iii) iv) v) vi) Olfactory – Assess sense of smell Optic - Visual fields, pupillary reflex Oculomotor, Trochlear, Abducens –Nystagmus, PERRLA, visual tracking (H test) Trigeminal – Facial sensation, jaw clench Facial – Smile/Grimace If the athlete has significant deficiencies in any of the above cranial nerves, a possible intercranial hematoma is to be suspected, the athlete’s pulse and blood pressure is to be assessed, and transportation to the local emergency room is to be advised by the certified athletic trainer. d) Clinical assessment for cervical spine trauma, skull fracture and intracranial bleed e) Assess and Calculate Glascow Coma Scale as defined Appendix A f) Upper Quarter Dermatome/Myotome Assessment i) Cognitive Functioning (1) 3 Word Recall (2) Serial 7s (3) Months in Reverse Order (4) Serial Testing ii) Balance exam iii) Symptom Assessment g) Serial testing will be ongoing to assess any deterioration of long term and short term memory. h) Athlete is to undergo an initial evaluation on the side line and to undergo subsequent reevaluation every 5 minutes post-injury or until symptoms resolve 5) Physician Referral a) Emergency Room Evaluation i) Any student athlete displaying any of the following conditions should be immediately referred by the team physician and/or certified athletic trainer and transported to the closest emergency room for evaluation (1) Deterioration of neurological function (2) Decreases or irregularity in breathing (3) Unequal, dilated, or un-reactive pupils (4) Seizure Activity (5) Changes in mental status (6) Spine Injury (7) Glascow coma scale less than or equal to 13 (8) Decreasing level of consciousness (9) Decreases or irregularity in pulse (10) Any sign of blood or CSF (11) Drastic changes in BP (12) Repetitive Emesis b) Same Day Referral i) Any student athlete that does not qualify for the criteria listed for emergency room evaluation, but displays the following signs and/or symptoms will be evaluated by a physician on the day of initial injury. (1) (2) (3) (4) (5) (6) (7) (8) (9) LOC on the field Any amnesia or significant confusion Increase in BP Cranial Nerve deficits Vomiting Motor, sensory, balance deficits subsequent to on- field evaluation Post-concussion symptoms worsen Increase in the number of symptoms Athlete has reoccurrence of symptoms after returning to play 6) Return to Play a) Same Day/Event i) When a student-athlete shows any signs, symptoms or behaviors consistent with a TBI, the athlete shall be removed from practice or competition and evaluated by a certified athletic trainer and/or team physician with experience in the evaluation and management of concussion. ii) After a student-athlete is diagnosed with a TBI he/she shall be withheld from the competition or practice and not return to activity for the remainder of that day. b) Monitoring Over Time i) A team physician will be responsible for determining when it is safe for a student athlete to return to participation suffering from neuropsychological injuries. ii) A physician will evaluate student-athletes with prolonged recovery in order to consider additional diagnoses and best management options. Additional diagnoses include, but are not limited to: post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression, ocular or vestibular dysfunction. iii) See Appendix B for supervised stepwise progression management plan by health provider with expertise in concussion. 7) IMPACT Testing a) Baseline Testing i) All incoming freshmen and transfers participating in sports at the University of Pittsburgh are to have baseline testing on IMPACT. ii) Any incoming student-athlete with a prior history of concussions will also be baseline tested iii) The baseline assessment will consist of a symptoms checklist, standardized cognitive assessments and balance evaluation. iv) The team physician determines pre-participation clearance and/or the need for additional consultation or testing. b) Post-Physician Evaluation i) After each physician evaluation, each student athlete diagnosed with a TBI will complete IMPACT testing. ii) Each student athlete will complete a physical exam comprising of ocular motor/vestibular-ocular and balance screens Ocular Motor/Vestibular-Ocular: (a) (b) (c) (d) (e) Abnormal Pursuits? Abnormal Saccades? Abnormal Convergence (<6cm) Any observable nystagmus? Blurring/dizziness with VOR No Yes N/A No Yes N/A No Yes N/A No Yes N/A No Yes N/A Balance Screen: (f) (g) (h) (i) (j) (k) (l) Romberg Eyes Open <30 sec or unsteady Romberg Eyes Closed <30 sec or unsteady Tandem Romberg Eyes Open <30 sec or unsteady Tandem Romberg Eyes Closed <20 sec Compliant Foam Eyes Open <30 sec or unsteady Compliant Foam Eyes Closed <30 sec or unsteady Tandem gait unsteady No Yes N/A No Yes N/A No Yes N/A No Yes N/A No Yes N/A No Yes N/A No Yes N/A c) IMPACT Testing i) Post-concussive injury IMPACT test scores relative to baseline, symptomology, and physician’s decision will be used to determine an athlete’s return to participation. ii) IMPACT test scores are to be reviewed by a team physician and/or a neuropsychologist, to assist in determining when an athlete’s symptoms and cognitive abilities are such that it is deemed safe to return the student athlete to activity iii) Referral to Neuropsychologist (1) In addition to examination by a physician, a neuropsychologist should be consulted with any athlete suffering a significant or multiple concussive episodes 8) Special Considerations a) Athletic Training Students i) All athletic training students who suspect an athlete of having sustained a TBI are to initially act as first responders to rule out life threatening emergent situations, and immediately report such incidents to the supervising staff certified athletic trainer. ii) No athlete is to be allowed to participate until evaluated by a certified athletic trainer. iii) It will be the responsibility of the evaluating certified athletic trainer to decide if the athlete’s condition necessitates evaluation by a physician. b) Traveling i) Any athlete that is suspected of sustaining a head injury or concussion is to be evaluated by the attending physician at away events. The attending physician will be responsible for deciding if an athlete shall return to participation. ii) If no physician is available the staff athletic trainer is to follow the policies for return to play previously outlined in this document. iii) If the certified athletic trainer decides that the athlete shall not return to play, the host athletic trainer is to be contacted in order to facilitate evaluation by an on-call physician. If an on-call physician is not available a visit to the local hospital for evaluation is necessary. c) Home Care Instructions i) Each athlete suffering a concussive injury will be given home care instructions regarding proper actions to take while at their residence and warning signs of a worsening condition that necessitates a visit to the emergency room for evaluation by a physician. (See Appendix C) 9) Documentation a) Documentation of the incident, evaluation, continued management, and clearance of the student-athlete with a TBI shall be kept in the student-athlete’s medical files. 10) Return to Learn a) The team athletic trainer will be the point person within athletics who will navigate return-to-learn with the student-athlete b) Identification of a multi-disciplinary team* that will navigate more complex cases of prolonged return-to-learn: (1) Multi-disciplinary team may include, but not limited to: (a) Team physician (b) Athletic Trainer c) d) e) f) g) h) i) j) (c) Psychologist/counselor (d) Neuropsychologist consultant (e) Faculty athletic representative (f) Academic counselor (g) Course instructor(s) (h) College administrators (i) Office of disability services representatives (j) Coaches Compliance with ADAAA No classroom activity on same day as concussion Individualized initial plan that includes: i) Remaining at home/dorm if student-athlete cannot tolerate light cognitive activity Gradual return to classroom/studying as tolerated Re-evaluation by team physician if concussion symptoms worsen with academic challenges. Modification of schedule/academic accommodations for up to two weeks, as indicated, with help from the team athletic trainer Re-evaluation by team physician and members of the multi-disciplinary team, as appropriate, for student-athlete with symptoms > 2 weeks Engaging campus resources for cases that cannot be managed through schedule modification/academic accommodations i) Such campus resources must be consistent with ADAAA, and include at least one of the following: (1) Learning specialists (2) Office of disability services (3) ADAAA office 11) Reducing Exposure to Head Trauma a) Adherence to Inter-Association Consensus: Year-Round Football Practice Contact Guidelines b) Adherence to Inter-Association Consensus: Independent Medical Care Guidelines c) Reducing gratuitous contact during practice d) Taking a ‘safety first’ approach to sport e) Taking the head out of contact f) Coaching and student-athlete education regarding safe play and proper techniques (See Attached Documentation) *All recommendations are based on those outlined in the NATA’s Position Statement on Management of Sport Related Concussion, NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, Dr. Michael Collins and Dr. Mark Lovell, Sports Medicine Concussion Program, UPMC Center for Sports Medicine. Updated June 2015 Appendix A Glasgow Coma Scale Spontan eous??open with blinking atbaselin 4 ICJpensto verbal command, speech or shout 3 Best response (E) Opensto pain not appliedto face 2 None ?1 Oriented 5 Confused conversation, butableto answerduestions 4 Bestverbal response W) Inappropriate responseswords discernible 3 In compreb en sible speech 2 None '1 Obeys commandsfor movement ES Purposeful movementto painful stimulus 5 Bestmotor response (M) Withdraws?cmm Dam ?4 Abnormal (spasticlflexion decorticate posture 3 Extensorlrigid) response, decerebrate posture 2 None Appendix B UPMC SPORTS MEDICINE CONCUSSION PROGRAM (updated 3/27/08) Stage 1 Stage of Rehabilitation Target Heart Rate: 30-40% of maximum exertion * (Max HR – Rest HR X .30) + Rest HR Recommendations: exercise in quiet area (treatment rooms recommended); no impact activities; balance and vestibular treatment by specialist (prn); limit head movement/position change; limit concentration activities; 10-15 minutes of light cardio exercise. Stage 2 Target Heart Rate: 40-60% of maximum exertion * (Max HR – Rest HR X .40) + Rest HR Recommendations: exercise in gym areas recommended; use various exercise equipment; allow some positional changes and head movement; low level concentration activities (counting repetitions); 20-30 minutes of cardio exercise. (stage 1 exercises included, as appropriate) GUIDELINES FOR POST-CONCUSSION REHAB Physical Therapy Program - Very light aerobic conditioning - Sub-max isometric strengthening and gentle isotonic - ROM/Stretching - Low level balance activities - Light to Moderate aerobic conditioning - Light weight PRE’s (Progressive Resistance Exercises) - Stretching (active stretching initiated) - Moderate Balance activities initiate activities with head position changes Stage 3 - Moderately aggressive aerobic exercises Target Heart Rate: 60-80% of maximum exertion * (Max HR – Rest HR X .65) + Rest HR Recommendations: any environment ok for exercise (indoor, outdoor); integrate strength, conditioning, and balance/proprioception exercise; can incorporate concentration challenges (counting exercises, MRS equipment/visual games) - All forms of strength exercise (80% max) (stage 1&2 exercises included, as appropriate) Stage 4 (Sport Performance Training) Target Heart Rate: 80% of maximum exertion * (Max HR – Rest HR X .80) + Rest HR Recommendations: continue to avoid contact activity; but resume aggressive training in all environments - Active stretching exercise - Impact activities running, Plyometrics (no contact) - Challenging proprioceptive/dynamic balance (integrated with strength and conditioning); challenging positional changes - Non-contact physical training - Aggressive strength exercise - Impact activities/plyometrics - Sport Specific Performance training Stage 5 (Sport Performance Training) Target Heart Rate: Full exertion Recommendations: initiate contact activities as appropriate to sport activity; full exertion activities for sport activities. - Resume full physical training activities with contact - Continue aggressive strength/conditioning exercise Recommended Exercises - Stationary Bike; Seated Elliptical; UBE; Treadmill walking: (10-15 min) - Quad sets; Ham sets; (UE) light hand weights; resistive band rowing; (LE) SLR’s, resistive bands ankle strengthening - Cervical ROM exercises, Trap/LS stretching, Pec stretching, Hamstring stretching, Quad stretching, Calf stretching - Romberg exercises (feet together, tandem stance, eyes open-closed); single leg balance - Treadmill; Stationary Bike; Elliptical (upright/seated); UBE; (10-20 min) -Light weight strengthening exercises (Nautilus style equipment); resistive band exercises (UE/LE); wall squats, lunges, step up/downs - Any stage 1 stretching; active stretching as tolerated (lunge walks, side to side groin stretching, walking hamstring stretch) - Romberg exercises, VOR exercise (vestibular ocular reflex exercises: walking with eyes focused with head turns); Swiss ball exercises; single leg balance - Treadmill (jogging); Stationary Bike; Elliptical (upright/seated); UBE (25-30 min) - Passive weight training including free weights, MRS/Functional Squat; dynamic strength activities - Active stretching (lunge walks, side to side groin stretching, walking hamstring stretch) - Initiate agility drills (zig zag runs, side shuffle, etc…); jumping on tramp/blocks - Higher level balance activities: ball toss on plyo floor, balance disc, trampoline squats and lunges on BOSU ball - Program to be designed by Sports Performance Trainers - Graded treadmill testing - Interval training - Sport specific drills/training - Program to be designed by Sports Performance Trainers - Practice and game intensity training - Sport specific activities - Sport Specific Activities * Target Hear Rates calculated by Karvonen’s equation: Max HR (220 – Age) – Resting HR X Target Percentage + Resting HR Appendix C Recommendations for Traumatic Brain Injury Home Care Please read over the following recommendations to ensure proper management of your mild concussion/TBI. If possible, please have a roommate or friend in your household read over the following recommendations. Call EMS (911) and Consult with a Medical Professional Trained in Concussion Identification and Management Practices Immediately If: • • • • • • • • • Decreases in Neurological Function Decreases in Consciousness Decreased or Irregular Breathing Decreased or Irregular Pulse Changes in Pupils Seizure Nausea Vomiting Worsening Headaches or Any Other Symptoms What You Should Do: • • • • Take Acetaminophen/Tylenol for Headaches o No ibuprofen or other anti-inflammatories Eat Light Nutritious Meals Return to School Go To Sleep/Rest What You Shouldn’t Do: • Check Eyes With Flashlight • Wake During Sleeping • Test Reflexes • Stay in Bed Do Not: • Drink Alcohol • Eat Spicy Food • Participate in Strenuous Activities/Sports *All recommendations are based on those outlined in the NATA’s Position Statement on Management of Sport Related Concussion. Updated June 2015 Purdue University Athletics Department Purdue Sports Medicine Concussion Plan Updated: 4/2015 Concussion management of athletes is a rapidly evolving field. Purdue Sports Medicine is committed to providing the most up-to-date care for the student athlete who has suffered a concussion in order to allow a safe return to sport and to prevent any long-term adverse sequelae. Each student athlete is screened during the pre-participation physical examination for a history of concussions, symptom evaluation, and balance measurement and each athlete involved in a contact sport (including football, volleyball, wrestling, basketball, cheerleading, diving, soccer, pole vaulting, baseball, softball) undergoes a valid computerized baseline neurocognitive test (ImPACT). The baseline neurocognitive testing is repeated between the student athletes’ sophomore and junior years. A critical element of managing concussions is candid reporting by the student athlete of their symptoms following an injury. Accordingly, student athletes are encouraged to be candid with team medical staff and fully disclose any symptoms that may be associated with concussion. Student athletes, team physicians, PT/ATCs, coaches, and the athletic director along with sport administrators will undergo concussion education (Power Point presentation) and sign an acknowledgement of this educational program and a commitment to provide the medical staff with all symptoms that may be related to concussion. A student athlete who exhibits the signs or symptoms of a concussion will be removed from participation and undergo evaluation by the medical staff to include symptoms, physical examination (including cognitive function and balance), and assessment for catastrophic injury (c-spine trauma, skull injury, intracranial bleeding, etc.). The Emergency Action Plan will be activated for any concerning findings to include Glasgow coma scale<13, prolonged loss of consciousness, focal neurological deficit suggesting intracranial injury, spine injury, or persistent/worsening mental status or other neurological signs/symptoms. A student athlete who is diagnosed with a concussion shall not return to play or practice or academic activities on the same day as the injury. The student athlete will undergo serial monitoring and will be provided with written instructions at the time of discharge from the initial episode (preferably with a companion). After the initial diagnosis of concussion is made, the student athlete will undergo the following steps for a determination on a return to play: Step 1 The athlete is removed from all physical and significant cognitive activity. On a case by case basis, a student athlete may also be placed on academic restrictions. If this becomes necessary, it will be done in conjunction with Academics Support Services. The student athlete shall report to his/her athletic trainer each day in the Athletic training room and will remain out of all activity including noncontact activity until back to symptom baseline. Step 2 Once back to baseline, he or she will be allowed to return to competition in a stepwise fashion: • • • • Aerobic exercise/stress Progressive resistive exercises Non-contact sport specific maneuvers Non-contact practice If the student athlete has a recurrence of any symptoms with exercise, he or she will again be removed from that step and dropped back to the preceding step which did not cause issues. The student athlete may be retested by the team athletic trainer once daily until he or she can perform all steps without a recurrence of symptoms. If the student athlete remains at baseline, then he or she will undergo post-concussion neurocognitive testing (ImPACT), if a contact athlete, under the supervision of the team athletic trainer. Step 3 The student athlete will return for re-evaluation to the team physician (with the postconcussion computerized neurocognitive test results if a contact athlete). If the reevaluation is normal (symptom-free, normal examination, negative exercise stepwise testing, and ImPACT has returned to baseline or near baseline (contact athlete)), the student athlete may be released to return to play barring other complications (i.e. multiple concussion history). If the re-evaluation remains abnormal, then the student athlete will remain out of contact activity and will undergo serial repeat evaluations at the direction of the team physician. The final authority for return to play decisions rests with the team physician or his/her designee i.e. athletic trainer. More complicated concussion evaluations (e.g. persistent symptoms (>2 weeks) leading to alternative diagnoses, multiple concussions over a brief time period, history of several concussions over a career, concussion complicated by a learning disability or ADHD) may require further testing including CT or MRI scans, formal neuropsychological testing, and evaluation by the team neurosurgeon. The process from initial evaluation to the final return to play decision will be documented and entered in the student athlete’s medical record. Return to Learn Purdue University athletics has identified our Team Physicians and our Senior Associate Athletics Director for Student-Athlete Services as our point person(s) to navigate our Return-To-Learning management plan as part of our Concussion Protocol. In the event that an individual sustains a concussion that leads to a prolonged recovery, the team physician and/or Senior Associate AD will solicit input from a group of multi-disciplinary consultants consisting of, but not limited to: neuropsychologists, psychologists, athletic trainers, faculty athletic representatives, academic counselors, Dean of students, Vice provost for Teaching & Learning, college administrators, coaches and/or the Purdue office of disability services. Utilizing the services that Purdue has available on campus for individuals that need assistance, will assure that our actions are ADAAA compliant. In the event that a student-athlete sustains a concussion episode during competition/participation, she/he will not be permitted to attend classes or academic services on that same day. Instructions will be issued by the team physician or designee. Concussion instruction sheets have been created and will be given to the patient. The team physician will follow-up with respective professionals if concussion symptoms worsen and will arrange for a re-evaluation. The return to learn post-concussion plan will be individualized to the student athlete based on symptom response. The student-athlete may be required to remain out of class/classes based on the inability to tolerate the required cognitive activity. A graded return to class/classes may be implemented as needed. Modification of schedule/academic accommodations will be managed by the above mentioned point-person(s) for up to two weeks. The team physician will perform a re-evaluation in cases where the concussion symptoms last longer than two weeks. The team physician will also engage members of the multi-disciplinary group if necessary. Purdue University campus resources include: Learning Specialists, The Purdue Office of Disability Services and the ADAAA office. Reducing Exposure In regards to football, Purdue University follows the Adherence to Inter-Association Consensus: Year-round Football Practice Contact Guidelines in an attempt to reduce student-athlete practice exposure time. Also in regards to football, prior to the first full contact session, coaches provide education and instructional drills on proper tackling techniques stressing the "heads up" approach. In order to promote independent medical care for the student athlete, the team physicians are responsible for final determination for medical eligibility and return to play decisions. The team physicians have a direct reporting line to the athletic director in the event of any question regarding a student athlete’s medical clearance. The Director of Sports Medicine is also an Assistant Athletic Director with a direct line of reporting to the athletic director. This individual attends all Sport Administrator/Senior Staff meetings and provides a medical perspective to all sport decisions. Each individual sport athletic trainer has an open line of communication to their coaching staffs providing daily reports regarding a student athlete’s progression through the Purdue University Concussion Protocol and answers any specific questions regarding that athlete’s status. Rutgers Universitv Sports Medicine Concussion Management Program The foliowing document wiil serve as Rutgers University?s policy on concussion management. It is a living document and subiect to change as the medicai iiterature evolves. This document will be reviewed annually by the Athletic Director, all athletic trainers and team physicians managing Rutgers athletes. Confirmation of this will be done by the head athletic trainers and head team physician. This policy will also be reviewed annually with each head coach by their assigned athietic trainer. Administrative issues \r \7 Athletic healthcare providers (physician athletic trainer) shali have the unchallenged authority to determine management and return to play of an ill or injured student~ath ete, in ali manners, especially with concussions. Emergency Action Plan (EAP) for all venues including Concussion Plan for sports medicine. is on in the policy and procedures and reviewed annually with sports medicine staff and coaches. Coaching Education regarding EAP concussion plan: Done yearly by ATC, signed statement by ATC and coach, review of CPR requirement, educational information sent yeariy on concussion or more frequent if problems noted or areas of concern. Student Athlete concussion education is reviewed annually each pre?season by each team assigned athletic trainer. First year/transfer student athietes review and sign a concussion education form, review policy and procedures and watch the NCAA concussion education video. The team physician will sign off on a document acknowledging that each student athlete has been educated on the concussion material. The Athletic Director, Team Physician and Co-Head Athletic Trainers meet annually to review the concussion policy and updates. Each party provides a signed acknowledgement of having read and understood the concussion materiai. on site/available as determined by the head athletic trainer in consultation with the Director of Sports Medicine. A physician is on site/available for at risk home events. Documentation of baseline testing using various instruments C3 Logics, BioSway and other) for ail varsity athletic teams. Documentation of initial injury evaluation (SCAT3 other) as well as scoring every 18 days while Documentation (ATC team physician) of initial subsequent evaluations, change in status regarding activities and final clearance to return to play. Ali documentation should foilow standard medical charting and be kept in the athlete?s file. Head injuries in sports cannot be prevented entirely, but we are able to reduce the risk of head trauma from playing contact and collision sports. Some preventative measures include; coaching and student? athiete education regarding sate play and proper technique, enforcement of the concussion and return to play/learn policies, proper equipment and inspection, and neck strengthening for high risk sports. I In regards to football, the medical staff will work with the coaches to educate and follow the Adherence to Inter-Association Consensus: Year-Round Football Practice Contact Guidelines. I The medical staff will follow the Big Ten policy regarding head impact exposure monitoring having a ?spotter? above the playing fieid for football games) i The medical staff and coaches wili work together to reduce gratuitous contact during practice, and take a safety first approach to sport. Rutgers Sports Medicine Pro-Participation Exam: 151: year and follow?ups Education of student athletes regarding concussion at pre-participation exam, including signs and required NCAA video oniine. Concussion education is done annually during their pre? season to ali of our student athletes by the team athietic trainer. Academic support and the athietic healthcare providers annually review the Return to Learn Program (see appendix Pie-participation Physicai Examinations (PPE) performed for ail new NCAA athletes with focused history on concussion events. Returners flagged for potential foliowup by team physician or athletic trainer on a yearly basis. Yeariy signed Student Athlete (SA) agreement regarding reporting of all injuries illnesses, including signs and of concussion, to Rutgers sports medicine staff. PPE includes questions regarding modifiers: prior concussion history, learning disabilities requiring stimulant medications, migraines, seizure history. Baseline computerized (NP) testing and balance testing "immediate Post? Concussion Assessment and Cognitive Testing? C3 Logics and BioSwayj) are performed for ail NCAA athletes at the time of initiai starting in the program. High Risk sports may get further testing (FB, Soccer, Lacrosse, Field Hockey, Gymnastics, Basketball, Baseball, Softball, Wrestling, Volleyball) and other sports or athletes as determined by the team physician and athletic trainers in consultation with the administration including coaches. If an athlete has a significant history of prior concussion(s), or significant other modifiers, the team physician may request that testing include computerized testing C3 Logics) as weil as additional paper 8: pencil (P P) tests, and may request additional consuitation and/or testing. Follow?up preparticipation exam forms used to follow-up those with significant or muitipie concussions so as they get re-evaluated and as needed retested for a new baseiine. After a complete evaluation and review, the team physician wiil determine the final pre-participation clearance. Emergency Situations in the event an athiete sustains a serious or potentially life?threatening head injury, prolonged loss of consciousness (LOC), the Emergency Action Plan (EAP) should be followed for the particular venue where the injury has occurred. If an ATC is present, he she shail assume controi of the situation and manage all aspects of the EAP, also notifying the team physician ofthe injury. if an is not present, EMS should be notified immediately, followed by notification of the ATC for that particular sport, followed by notification of the team physician. On?Field Sideline Evaluation When an athlete has sustained a head injury and is displaying signs and of a concussion, he/she will be removed from play (practice or game) and not allowed to return until being examined by a healthcare professionai (ATC, physician). Any athlete diagnosed with a concussion NOT RETURN TO FOR THE REMAINDER OF THAT DAY. Any athlete that presents with concussion iike wili he examined by a team physician or designee and, the physician may elect to clear the athlete for participation if the diagnosis is NOT a concussion. If a concussion is suspected, the heaith care professional should err on the side of safety and assume one if the diagnosis of a concussion is unsure. Any athlete with a spinal injury, associated neck pain, a Glasgow Coma Scale less than 13, prolonged loss of consciousness, focal neuroiogical deficit suggesting intracraniai trauma, repetitive emesis or persistentiy diminished/worsening mental status or other neurological wili foliow the Emergency Action Plan spine board immobilization, hospitai transportation). \7 if an ATC is not present, and the athlete has minor (headache, mild dizziness), the ATC for the sport should be contacted to determine the next course of action. If an ATC is present, an evaluation wiil be performed to determine the seriousness ofthe situation, and to determine whether or not a physician consuit is necessary. if a concussion is assessed, the athlete should not be ailowed to return to play untii being further examined by a physician. ATC will use a standard evaluation, preferably SCAT 3 if a physician consult is needed, but a physician is not readily available, the athlete should be transported to a hospital. if at any point in time the athlete?s worsen dramatically (extreme headache, nausea, vomiting, extreme sleepiness, increased dizziness, seizures or convulsions), the athlete should be transported by EMS to a hospital. The team athletic trainer and physician wili arrange for continued evaluation and monitoring following Injury. Physician Evaluation Timing dependent upon assessment of ATC foliowing injury, but preferable within 24-72 hours. If physician evaluation not immediately necessary, the athlete should be educated on recognizing any worsening and notifying the ATC as soon as possible. In addition, a roommate/teammate/parent should be educated on the potential risks associated with a head injury. Next day physician evaluation should be performed at the eariiest convenience. The athlete should not return to play until being evaluated and cieared by a physician. The ATC wiil adhere to the physician?s advice as far as return to play, additionai testing, and any necessary modifications to the athlete?s academic obligations (class, exams, etc), and update the coach to the athiete?s condition. SCAT3 performed and logged. Detailed information sheet such as the Canadian Sports Medicine: ThinkFirst-SportSmart Concussion Education Awareness Program as needed/determined by the physician to the athlete. Summary sheet of restrictions and important telephone numbers, etc given to athlete as determined by physician. Summary form letter to academics with diagnosis, potential prognosis and school modifications as needed. Foliow-up Monitoring of via SCAT3 or similar form program, as determined by physician. Testing as recommended by physician, cognitive function and balance such as SCAT3, C3 Logics, and BioSway. Any referral to specialist as recommended by team physician. The athletic trainer, learning specialist and physician will determine the appropriate time tabie for additionai follow-up evaiuations. The sports medicine dept. and academic advisors wili follow in general the Return? To- Learn protocol (see appendix for the athlete?s return to activity and academics. This can be individualized based on the presentation and facts of the case. The physician follow up evaiuation will include post-concussion sieep dysfunction, migraine or other headache disorders, mood disorders Anxiety, depression), and ocular or vestibular dysfunction. Return to Learn Protocol After a concussion, the student athlete wiil begin a Return?To~Leorn Program (see appendix Each case is individual and at no point shonid the student? athlete work through that make their case worse. A designated learning specialist wili serve as the liaison to navigate Return?To~Learn procedures with the student-athlete (see appendix The learning specialist, team athletic trainer, team physician, academic counselor and coach wiil navigate the Return-T0~Learn protocol with the student-athiete. The team physician will reevaluate the student-athlete if worsen with academic challenges. For more complex cases with prolonged of more than 2 weeks, further accommodations will be required to further the welfare of the student?athlete. Additionai members such as a consultant, Faculty athletic representative, course instructor, college administrators and the Office of disability services representative will work together to set appropriate accommodations, and foilow as required. The team physician will re-evaluate the studentwathlete if his or her are prolonged for greater than 2 weeks. Return to Play Decision VV individualized decision; made by the team physician. Consultation from the athletic trainer, athlete, neurocognitive balance testing as well as additionai outside consultation as appropriate. I Time athlete heid out of activity, rate of progression, all individualized, with decision made by team physician. I Modifiers to consider; 0 Age in Prior history of concussion specifics of injurie(s), severity of injuries, recency) - Learning disabilities ADI-ED) Migraine History 0 Seizure history 0 Other emotional readiness, parental concern) Athlete must be free prior to returning to cardiovascular exertion An athlete with of concussion at rest or exertion should not continue to play Gradual progression in activity; step-wise with graduai increments in physical exertion and risk of contact: 0 Cardiovascular challenge (15 20 minutes) such as the Balke and Bruce test a Unlimited cardiovascular activity, sport-specific activities a Non~contact drills a Full-contact drills a Return to game play - Rate of progression is determined by the team physician 1* Neurocognitive tests and balance tests used as a supplemental tool a Final clearance is determined by the team physician If NP testing interpreted as abnormal, repeat N13 testing as appropriate, with probable 48 hours between repeat testing. Steps should be every 24 hours but may be modified by team physician on an individual basis. Clearance 8: Final Follow Up SA Education regarding importance of reporting all as well as increased risk for concussion, and deiay in recovery, with subsequent injury. Consider Repeat NP testing (computerized) prior to foliowing year to establish a new baseline. *The Athletic Director, Director of Sports Medicine and Co-Directors of Athletic Training Services will meet annually to review and implement the concussion policy. Athletic Director (Print) Date rill/Ir Awmrector (Sig/nature) Date Dir. of Sports Medicine (?rint) Date Dir. of Sports Medicine (Signature) Date Date: (Appendix CONCUSSION PROTOCOL STUDENT: SPORT: DATE or CONCUSSION: Probiems could arise over the first 24~48 hours after a suspected concussion. Contact their athletic trainer and/or go to the hOSpital if: Have a headache that gets worse - Behave unusually or seem confused; very irritabie Have repeated vomiting Have seizures Are very drowsy or can?t be awakened - Have weak or numb arms/legs - Can?t recognize people or places - Are unsteady on their feet; have slurred speech Other important points: Rest (physicaliy and mentaiiy) - No alcohol, No prescription or non?prescription drugs without medical supervision. Take Tyienol oniy. No aspirin or anti? inflammatory medication or sedating pain kiliers Advil) Avoid driving until cleared by a physician RETURN TO LEARN PROGRAM The clinician has determined the above student athlete has had a concussion and is most likely at the specific stage ofthe return to learn program as noted below. Each case is individual and at no point should the student perform work that makes concussive worse. Please set up an appointment as noted below to help you in your return to academic work. Dr. Brian Maher or Erica Beli or Scott Walker (732) 445?8109 (732) 672-6616 (732) 406-6946 ebeli@scarletknights.com swalker@scarletknights.com Step 1: Complete Cognitive rest. Avoid anything that aggravates Limit texting, computer games, reading, computer work, TV, loud areas. NO schoot or homework, NO practice/game attendance unless approved. Student?athiete remains at home/dorm if he/she cannot toterate light cognitive activity. Usually will be for 48-72 hours. Comments: Step 2: Starting short periods of cognitive activities for to 15 minutes, but only to the point of remaining These periods shouid be seif?paced with 20-30 minute breaks in between as needed. it is ok to add back some light computer work and reading. Comments: Step 3: Begin homework in longer increments (eg. 2030 min at a time) to increase cognitive stamina. Student can begin attending tutoring sessions as needed. After tolerating 1-2 cumulative hours of homework, the student should then begin a gradual reentry into school. Comments: Step 4: Gradual return to school; Accommodations may be needed during this time, such as preferential seating, note takers, tape recording of lectures, tutoring services and professor notes and/or outlines. Breaks may still be needed. Avoid non- essential work and makeup work. Work with Learning Specialist to develop an academic plan based on course load and schedute. Comments: Step 5: Full return should occur when the student can tolerate 3-4 hours of homework and or ciasses per day. Accommodations should decrease at the athiete continues to improve. No testing should be done until tolerating a full day of school, then consider possibly untimed tests till fully recovered. The learning specialist should determine accommodations with input as needed from the medical staff. Comments: Step 6: Full Return to learn when student has no remaining and is cleared by the medical staff. Comments: Foliow up with sports medicine at the following date: Athiete should not return to play until cleared by the medical staff and have completed return to learn play protocols. USC Head Injury Program and Concussion Management Plan July 2015 Overview The USC Athletics Head Injury Program & Concussion Management Plan was developed and updated as a result of careful discussions regarding relevant research, areas of prevention, recognizing emergent situations, selecting appropriate testing methods, identifying the optimal processes of following the athlete post-concussion, and determining when it is safe to return. The USC Athletics Head Injury Program & Concussion Management Plan is evaluated and discussed each year at the USC Athletic Medicine Meeting. It is a program that we continually assess and update. USC Athletic Medicine is overseen by a lead physician who jointly reports to the athletic director and a designee of the provost and senior vice president for academic affairs with appropriate medical expertise and authority. For many years, USC Athletic Medicine has employed a comprehensive, multidisciplinary approach to head injuries, including concussions. The Head Injury Program is overseen by the lead Athletic Department neurosurgeon, who maintains a contemporary global perspective regarding his discipline and expertise in brain and spinal injuries and other events involving neurological deficit, as well as historical knowledge of the sports teams, personnel, and student-athletes. USC Athletic Medicine operates with a team approach that is based on mutual respect among team physicians and staff athletic trainers and where excellent communication is expected to best serve the studentathlete. To this end, team physicians and staff athletic trainers receive continuing education related to concussions and other head injuries through the conferences, and they educate coaching staff on the identification and management of suspected concussions. Team physicians and staff athletic trainers also maintain open and direct communication with the university administration and team coaches. Awareness and Education Each year, all student-athletes must receive awareness education regarding the signs and symptoms of concussions. Student-athletes must acknowledge that they have received the information about the signs and symptoms of concussions, and that they have a responsibility to report such signs and symptoms and concussion-related injuries and illnesses to the USC Athletic Medicine Staff. Parents of student-athletes will also be provided with head injury awareness education upon request. Student-athletes are informed that basketball, football, lacrosse, soccer, volleyball, baseball, diving, pole vault, and water polo (the Contact Sports) have been identified as sports with an increased potential for head injury. Baseline data collections, injury evaluations, and return-to-play guidelines, as explained in further detail below, are now required for each student-athlete all sports. 1 Team physicians, staff athletic trainers, coaches and senior associate athletic directors are educated about concussions by policy review, an educational video about the signs and symptoms of concussion and are given NCAA Concussion Handouts. They must acknowledge they have received and reviewed the educational information and that they understand their role within the policy. The acknowledgements are documented and maintained within the athletic department. Prevention In the area of head injury prevention, equipment and style of play are factors that require special consideration. The USC Athletic Equipment Staff play a very important role in the fit and selection of football helmets. The team Neurosurgeon assists the athletic equipment staff in selecting and approving the model of helmets for football. Coaches also play a pivotal role in educating and training players to use proper techniques to reduce the risk of injuries, and are required to instruct players in techniques that reduce the risk of concussion when appropriate. In football, coaching staff teach proper tackling and blocking techniques and endeavor, to the extent practicable and reasonable, to conduct less hitting practices than currently allowed by the NCAA. In July of 2013, the PAC 12 Conference initiated a reduction in contact practices in football. USC adheres to these regulations. Pre-participation Physical Examination (PPE) Each student-athlete must undergo a pre-participation physical examination conducted by a team physician. In that examination, the physician will review the student-athlete’s previous history of concussion or head injury and evaluate for any signs or symptoms. The team physician will determine final clearance to participate. Staff athletic trainers are responsible for coordinating baseline data collection that includes symptoms, cognitive assessment and balance evaluation prior to the first contact practice. Baseline Data Collection Part of our comprehensive program involves collection of baseline data. Currently, USC collects data from the Standard Assessment of Concussion (SAC), Post Concussion Symptom Scale (PCSS), Balance Error Scoring System (BESS) and a computerized psychometric program called ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). The baseline SAC, PCSS, and BESS are stored and are accessible in a secure cloud. The baseline ImPACT is collected on a computer via a secure website and may be viewed and/or downloaded into a PDF file. The assigned staff athletic trainer is responsible for coordinating baseline data collection for their sport. Baseline data must be collected for each student-athlete prior to their first contact practice. 2 Evaluation of Head Injury Sideline Evaluation Immediately after a suspected head injury, a student-athlete will be removed from athletic activities and given a careful evaluation by a USC athletic medicine staff member with experience in the evaluation and management of concussions, which may include a staff athletic trainer, team physician, or neurosurgeon. Coaches shall defer to the USC athletic medicine staff member’s decision to remove a student-athlete from practice or competition. Coaches also have a responsibility to report any suspected head injuries to the appropriate USC athletic medicine staff for an immediate assessment. This assessment will be conducted by a neurosurgeon when present. A team neurosurgeon will be on the sideline at every football game, whether home or away. A general physical assessment will be conducted, including an evaluation of memory, concentration, motor-function (both general and specific), balance/coordination, and cranial nerve function. A thorough history will be taken that includes questions about common concussion symptoms as well as a previous history of concussion. The athletic medical staff will be furnished with IPads for each game, which will contain each student-athlete’s concussion history and baseline test data, as well as a sideline assessment tool. The IPad data shall be updated regularly as needed by the athletic training staff. The sideline assessment tool represents a standardized method of evaluating student-athletes for concussion. It is not a substitute for the clinical judgment of the team neurosurgeon, which remains a key element in diagnosing head injuries. Any student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion will be removed from athletic activities (e.g., competition, practice, conditioning sessions) and evaluated by a medical staff member (e.g., sports medicine staff, team physician) with experience in the evaluation and management of concussions. Student-athletes exhibiting signs, symptoms or behaviors consistent with a concussion may not return until authorized to do so by a physician with experience in the evaluation and management of concussions. Any student-athlete who is diagnosed with a concussion or sustains a loss of consciousness will not return to athletic activity or class that day. Oral and/or written instructions will be given to the student-athlete and/or responsible adult on the signs and symptoms to watch out for and the need to follow up the next day. These instructions will be documented into the student-athlete’s chart. Any student-athlete who has a progression of symptoms, signs or function will be hospitalized immediately for further evaluation with notification to the team neurosurgeon. In addition to evaluating for concussion, the physician/athletic will evaluate the student-athlete for skull fracture, intracranial bleed and possible cervical spine injury. If there is a suspected skull fracture, intracranial bleed or possible cervical spine injury, the student-athlete will be sent to the hospital for further evaluation. The 3 Emergency Action Plan will be followed depending on the circumstances but may include activation of Emergency Medical Services for transport, spine boarding with removal of football facemask, CPR, AED or First Aid as necessary. Follow-Up Evaluation The recovery and progress of any student-athlete diagnosed with a concussion or exhibiting signs, symptoms or behaviors consistent with a concussion will be followed by the staff athletic trainers. The student-athlete will be evaluated serially throughout the process, including through continued historical and physical assessment, and by conducting SAC, PCSS, and/or BESS tests. The results of these tests will be documented in the student-athlete’s chart and communicated to the team physician and/or neurosurgeon. Generally, once asymptomatic and the SAC, PCSS, and/or BESS tests are measured at baseline levels while at rest, the student-athlete will be exerted under the guidance and observation of a staff athletic trainer. Whenever possible, exertion will follow a progression from light aerobic exercise without resistance, to resistance training, to sport specific exercise without contact, unrestricted training and return to competition. Clinical judgement will be used to determine the exercise progression. If the student-athlete remains asymptomatic after exertion, ImPACT will be administered. Post-injury ImPACT test results are compared to baseline data and are evaluated by the neuropsychologist. The staff athletic trainer communicates all information to a team neurosurgeon. If a student-athlete has a prolonged recovery (>2 weeks), they will be referred to a team neurosurgeon for further evaluation. Careful consideration will be given for possible post-concussion syndrome, sleep dysfunction, migraine or headache disorders, mood disorders or ocular/vestibular dysfunction. The team neurosurgeon will determine the best management options. Return to Learn USC Athletics has a multidisciplinary approach to return to learn for student-athletes who sustain a concussion. This approach is ADAAA compliant. USC Athletics Academic Services has counselors, learning specialists and tutors to assist student-athletes with academics. They may facilitate communication with the academic instructors. USC Athletics also utilizes clinical psychologists and neuropsychologists who may assist as well with those student-athletes in need of those services. • • The Director of the Academic Services, or their designee, will follow the Progression of the concussed student-athlete with light cognitive activity until a there is a fully integrated return to learn. Once the student-athlete’s symptoms normalize, a gradual Return to attending classes and studying will be permitted, as long as this is tolerated well by the student-athlete. 4 • • There may be no classroom activity on the same day of a diagnosed concussion. The student-athlete will be continually evaluated by the athletic medicine staff, so if symptoms worsen, this will be communicated to the team neurosurgeon and the academic plan will be adjusted accordingly. Return to Play Clinical judgment remains a key element of making return to play decisions. The health and welfare of the student-athlete is the priority when determining when it is safe for the student-athlete to return to play. Return to play decisions are based on the body of evidence suggesting injury resolution, the truthfulness of the studentathlete and the clinical judgment of the physicians and staff athletic trainers. Involvement of knowledgeable neurological and neurosurgical specialists, who are integral to the program, its development and evolution, is an essential feature of the USC composite of care and evaluation of neurological injury. Return to play decisions for student-athletes, while within the clinical judgment of the medical professional, must nonetheless be consistent with the below: • • • • • Any student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion will be held out of athletic activities until authorized to return by a physician with experience in the evaluation and management of concussions. Any student-athlete who is diagnosed with a concussion or sustains a loss of consciousness will not attend class or return to athletic activity that day. Any student-athlete who is diagnosed with a concussion is not permitted to exercise while symptomatic. Any student-athlete who is diagnosed with a concussion may not return to athletic activity until authorized to return by a physician with experience in the evaluation and management of concussions after that physician determines that the student-athlete meets each of the below USC Return to Play Guidelines, which must be followed in all cases: o o o o Asymptomatic at rest and after exertion Return to baseline tests (SAC, PCSS, and/or BESS); ImPACT data reviewed by neuropsychologist for evaluation; and Final decision made with clinical judgment. 5 UNIVERSITY OF SOUTH CAROLINA DEPARTMENT OF ATHLETICS Concussion Management Policy 1. Definition of Concussion In accordance with the 3ml International Conference on Concussion in Sport (2008), a cerebral concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Common elements of concussions include: a) May be caused by a direct blow to the head or elsewhere on the body with an ?impulsive? force transmitted to the head. b) Typically result in a rapid onset of short?lived impairment of neurologic function that resolves spontaneously. c) May result in neuropathological changes, but acute clinical largely reflect a functional disturbance rather than structural injury. d) Result in a graded set of clinical that may or may not involve loss of consciousness. e) Resolution of the clinical and cognitive typically follows a sequential course, but post?concussive may be prolonged. f) No abnormality is evident on standard structural neuroimaging studies. 2. Pre-season Education a) Provide NCAA concussion fact sheets or other applicable material annually to Student Athletes, Coaches, Team Physicians, Athletic Trainers, and Directors of Athletics b) Each party provides a signed acknowledgement of having read and understood the concussion material 3. Pre~Participation Assessment Documentation per the Scat 3 evaluation that each varsity student athlete has received at least one pre-participation baseline concussion assessment, that addresses: a) Brain injury and concussion history b) evaluation Cognitive assessment Balance evaluation Team General Medical Physician will determine pre?participation clearance and/or the need for additional consultation or testing to determine status. New testing may be considered for any athlete with a documented concussion. (D 4. Signs and of Concussion Concussions may cause abnormalities in clinical physical signs, behavior, balance, cognition, and/or sleep. Signs and of concussions include, but are not limited to: Headache Inability to focus Loss of consciousness Delayed verbal or motor responses Visual disturbances Feeling like "in a fog? or dazed Confusion or disorientation Ringing in ears Amnesia Irritability Dizziness or balance problems Emotional lability Slurred or incoherent speech Fatigue or feeling slowed down Nausea or vomiting Excessive drowsiness Vacant stare Sleep disturbances 5. Evaluation: Any student athlete exhibiting signs and of a concussion will be immediately removed from practice or play and evaluated by a physician or certified athletic trainer with concussion evaluation experience. A complete physical and mental status examination will be performed by the athletics healthcare provider and any student- athlete diagnosed with a concussion shall not return to activity for the remainder of that day. The student athlete will undergo a assessment, physical and neurological examination, cognitive assessment and balance testing including but not limited to the SCAT 3. Concussed student athletes will also be subjected to clinical assessment for cervical spine injury, skull fracture and intracranial bleeding. The student?athlete will be serially monitored for deterioration and will be provided with written instructions if discharged home after suffering a concussion. Written instruction will also be provided to another responsible adult, a parent or roommate. Student?Athlete will be required to sign a document stating his/her 6. Referral to Emergency Department Appropriate activation of the on-site Emergency Action Plan will occur for any student- athlete exhibiting focal neurological deficits suggesting intracranial bleed, progressive or worsening signs and and/or signs and of associated injuries neck injury) per the Glasgow Coma scale <13, prolonged loss of consciousness or repetitive emesis. 7. Physician Referral Student?athletes who experience a concussion will be referred to a physician and will not be allowed to return to activity/play until cleared by the physician or a medically qualified physician designee. 8. Return to Activity Student-athletes suffering a concussion must be free at rest for a minimum of 24 hours before starting any exertional activity. Student?athletes will complete the following protocol under the direction of a healthcare provider with expertise in concussion in sequence before returning to full activity. The student?athlete must remain free for 24 hours following each step before progressing to the next step. If occur during a step, the student?athlete will revert back to the previous step for a minimum of 24 hours before attempting the progression again. Step 1: Light Aerobic Exercise/Agility Drills without resistance training. Step 3: Sport specific exercise without head impact Step 3: Non?Contact Drills with progressive training Step 4: Unrestricted training including Contact Drills Step 5: Game/Competition 9. Post-Concussion Testing Student?athletes involved in sports with an increased risk of concussion, or athletes with a personal history of multiple concussions football, diving, basketball, baseball, pole vaulting, and soccer) will undergo pre?participation baseline testing using the testing system. Post?concussion testing will be performed and compared to baseline values in these student?athletes to aid in clearance decisions. consultation will be obtained for appropriate student?athletes as determined by the physician. Post-concussion balance testing may also be utilized as needed to assist with clearance decisions. Student athletes with prolonged recovery will be considered for additional diagnosis, including but not limited to: post-concussion sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression and ocular or vestibular dysfunction and will be referred for best management options. 10. Return to Learn Plan A person within the academic enrichment center will be identified for each team to coordinate the return to learn plan for the student athlete. A multi-disciplinary team will be identified including but not limited to: Team physician, athletic trainer, faculty athletic representative, academic counselor, course instructor, college administrators, office of disability services and coaches. Compliance with must be met. No classroom activity on the same day as the concussion. Establish an individualized initial plan that includes remaining at home or dorm if the student athlete cannot tolerate light cognitive activity and a gradual return to classroom/studying as tolerated. Re-evaluation by team physician if concussion worsen with academic challenges. Modification of schedule and/or academic accommodations for up to two weeks, as indicated, with assistance from identified team point person. Concussion Ma nagementPoiicy5/1/2015 Re?evaluation by team physician and members of the multi-dlsciplinary team, as appropriate, for student athletes with greater than two weeks. For cases that cannot be managed through schedule modifications or academic accommodations campus resources, such as learning specialists, the office of disability services and will assist. 11. Multiple Concussions Any student?athlete suffering two or more concussions within the same calendar year will be evaluated on a case by case basis at the discretion of the team physician. Multiple concussions may lead to a termination of season or a disqualification from further athletic participation. 12. Exposure to Head Trauma: Reduction of head trauma exposure should be considered by all sports, limiting concussive practice drills especially repetitive hits where the head is the first point of contact. This may be accomplished by adhering to the Inter?Association Consensus: Year? round football practice contact guidelines, using independent medical care guidelines, reducing gratuitous contact during practice, by taking a ?safety first? approach to all sports, taking the head out of contact and by coaching and by continuing the student- athlete education regarding safe play and proper technique. Concussion ManagementPolicyS/l/ZOIS ACKNOWLEDGMENT OF RECEIPT OF INFORMATION AND RESPONSIBILITY TO REPORT INJURIES AND ILLNESSES NAME: PLEASE READ THE FOLLOWING CAREFULLY. IF YOU HAVE ANY QUESTIONS, HAVE THEM ANSWERED BEFORE SIGNING THIS DOCUMENT. I am a student?athlete participating in intercollegiate athletics activities at the University of South Carolina (USC) in the sport(s) of i acknowledge that i have received in formation about the signs and of concussions. also acknowledge and accept the responsibility to report ail injuries and illnesses to the Medical/Athletic Training staff, including signs and of concussions. I Speci?cally, understand and acknowledge the following (Please initial each statement): That signs and of a concussion may include, but are not limited to, the following: headache, loss of consciousness. visual disturbances, contusion or disorientation, amnesia, dizziness or balance problems, slurred or incoherent speech, nausea or vomiting, vacant stare. inability to focus. delayed verbal or motor responses, feeling like ?in a fog? or dazed, ringing in ears. irritability. emotional liability, fatigue or feeling slowed down, excessive drowsiness, sleep disturbances. That i have received information regarding the signs and of concussions. That I will seek prompt medical care when experiencing any signs and or any unusual physical distress That 1 will report any and all injuries and illnesses, including signs or of concussions, to the USC Medical/Athletic Training staffimmediately. I further acknowledge that my participation in intercollegiate athietics at the University of South Carolina is voluntary. In consideration ol? being allowed to participate in intercollegiate athletics activities at USC, I hereby agree that have a responsibility to notify the USC Medical/Athletic Training staff immediately of any and all signs and of a concussion, of any and all injuries and illnesses. of any and all physical distress I may experience, and of any and ail concerns I may have about my physical condition. I further understand that I must abide by the decisions of the team physician and athletic trainers with regard to my playing status and my medical care and treatment. I agree to attend all scheduied treatments, appointments and testing,'and that wili follow all prescribed treatment protocols. I understand and agree that this Acknowledgment and Responsibility Agreement shall be construed in accordance with the laws of the State of South Carolina. If any term or provision ofthis Agreement shail be held illegal, unenforceable, or in conflict with any law governing this Agreement, the validity ot?the remaining portions shall not be affected thereby. I HAVE CAREFULLY READ THIS ACKNOWLEDGMENT AND RESPONSIBILITY AGREEMENT AND UNDERSTAND IT TO REQUIRE ME TO BE ACTIVLY INVOLVED IN REPORTING ALL INJURIES AND ILLNESSES TO THE ilSC TRAINING STAFF. Student~Athlere Signature Date Parent or Guardian Signature?? student under age 18) Date ny 2 7. 30 I 2 Concussion  Education,  Management,  and  Return  to  Daily  Activity       Purpose:   The  purpose  of  these  guidelines  is  to  identify  a  standard  procedure  to  be  used  for  the  identification  and   management  of  sport  and  non-­‐sport  related  concussion  for  varsity  student-­‐athletes  at  Stanford  University.    This   includes  the  education  of  key  stakeholders,  as  well  as  educational  recommendations  to  be  considered  by  the   Stanford  Office  of  Accessible  Education  (OAE),  the  Department  of  Athletics,  Physical  Education  and  Recreation   (DAPER),  and  University  faculty.  These  guidelines  comply  with  the  2015  NCAA  Concussion  Safety  Protocol  Checklist   and  apply  the  best-­‐known  evidence-­‐based  methods  to  ensure  optimal  health  and  performance  of  Stanford  varsity   student-­‐athletes.             Understanding  Concussion   Concussion  is  an  undefined  condition,  however  recent  efforts  have  been  made  to  better  understand  concussion   diagnosis  and  treatment  by  agreeing  on  a  universal,  evidence-­‐based  definition.  In  2014,  concussion  was  described   and  adopted  by  the  NCAA  as  being  associated  with:   • A  change  in  brain  function   • following  a  force  to  the  head   • that  may  be  accompanied  by  temporary  loss  of  consciousness   • is  identified  in  awake  individuals,  and   • includes  measures  of  neurologic  and  cognitive  dysfunction     Concussion  Management  Plan   The  most  important  components  of  a  successful  Concussion  Management  Plan  are  those  designed  to  educate,   promote  early  reporting,  and  support  objective  detection.  Due  to  the  lack  of  evidence  base  supporting  diagnosis   and  ideal  management  strategies,  clinicians  have  been  largely  reliant  on  subjective  reporting.  However,  it  is  the   responsibility  of  the  Sports  Medicine  staff  to  use  objective  diagnostic  tools  to  properly  diagnose,  treat,  and   implement  recovery  methods.  This  management  plan  is  outlined  here:     Required  Concussion  Education   On  an  annual  basis,  the  following  steps  will  be  taken  to  promote  and  educate:   1. Student-­‐athletes  will  receive  NCAA  approved  education  materials  about  concussion  and  will  document   their  acceptance  of  responsibility  for  reporting  their  injuries  and  illness  to  the  Stanford  University  Sports   Medicine  staff,  including  signs  and  symptoms  of  concussion  (a.  CONCUSSION  –  A  FACT  SHEET  FOR   STUDENT  ATHLETES,  b.  Concussion  Education,  Management,  and  Return  to  Daily  Activity  (Concussion   Management  Plan),  c.  Acknowledgement  of  Receipt  of  Concussion  Fact  Sheet).       2. DAPER  Athletic  administrators,  coaches,  and  medical  personnel  at  Stanford  University  will  also  receive   NCAA  approved  educational  materials  about  concussion  and  will  document  their  understanding  of  this   plan  (d.  CONCUSSION  –  A  FACT  SHEET  FOR  COACHES,  e.  Concussion  Management  Plan,  f.   Acknowledgement  of  Receipt  of  Concussion  Fact  Sheet).   3. Football  coaches  understand  and  abide  by  the  Year-­‐Round  Football  Practice  Contact  Guidelines   established  by  the  Pac-­‐12  Conference.     Baseline  Concussion  Testing   All  student-­‐athletes  will  be  required  to  complete  baseline  testing,  which  will  most  often  occur  at  the  time  of  the   Pre-­‐Participation  Evaluation  (PPE).  During  this  time,  brain  injury  risk  and  concussion  history  will  be  reviewed  via   the  completed  Health  History  Questionnaire  (Form  A)  collected  as  part  of  the  ePPE.  Per  Sports  Medicine  policy,   only  a  Stanford  Team  Physician  is  authorized  to  grant  medical  clearance  as  part  of  the  PPE  process.  Currently,   Stanford  University  Sports  Medicine  employs  two  baseline-­‐testing  tools:     1. Integrated  Concussion  Evaluation  (ICE):  a  SCAT3  (Standardized  Concussion  Assessment  Tool)  compliant,   tablet-­‐based  software  application  created  by  X2  Biosystems  (Seattle,  WA).  All  concussion  baseline  testing,   post  injury  assessments,  and  return  to  sport  progressions  are  captured  using  this  secure,  cloud  based   system.  These  data  are  then  replicated  into  the  student-­‐athlete  Electronic  Medical  Record  (EMR).   2. EYE-­‐SYNC:  a  commercial  eye  tracking  device  that  objectively  measures  eye  performance,  created  by  Sync   Think,  Inc.  (Boston,  MA).  This  device  monitors  cognitive  impairments  through  use  of  the  predictive  timing     Concussion  Education,  Management,  and  Return  to  Daily  Activity       element  of  oculomotor  function.  All  baseline  testing  and  post  injury  assessments  will  be  captured  on  this   system,  and  will  also  be  employed  to  assess  recovery.       Concussive  Event   Student-­‐athletes  who  exhibit  signs  and/or  symptoms  of  a  concussion  will  be  removed  from  participation  in   practice  or  competition  and  evaluated  by  an  informed  member  of  the  Stanford  University  Sports  Medicine  staff.   Any  student-­‐athlete  suspected  of  sustaining  a  concussive  injury  WILL  NOT  return  to  play  on  the  same  day  of  injury   and  will  be  medically  assessed  and  monitored  for  deterioration.  The  student-­‐athlete  should  be  clinically  evaluated   by  a  team  physician  immediately  following  completion  of  post  injury  assessment  testing  or  within  24  hours,   whichever  is  soonest  and  feasibly  possible  given  the  circumstances  of  each  case.  In  cases  of  confirmed  concussion   diagnosis,  written  management  recommendations  will  be  provided  to  the  student-­‐athlete,  roommate,  and  others   as  necessary  for  at  home  care  (e.  Concussion  Management  for  Roommates/Parents).     In  some  cases,  signs  and  symptoms  may  warrant  a  prioritization  in  care.    Under  these  circumstances,  appropriate   medical  care  will  be  delivered  in  a  timely  manner,  and  the  student-­‐athlete’s  disposition  will  continue  to  be   followed  under  the  supervision  of  a  team  physician.    Should  any  of  the  following  be  identified  upon  examination  or   monitoring,  refer  to  the  specific  athletic  venue  Emergency  Action  Plan  for  immediate  transfer  to  the  Emergency   Department: • Glasgow  Coma  Scale  <13 • Prolonged  loss  of  consciousness  (>1  minute) • Focal  neurological  deficit  suggesting  intracranial  trauma • Repetitive  emesis • Persistently  diminished/worsening  mental  status  or  other  neurological  signs/symptoms • Spine  Injury     The  team  physician  may  also  choose  to  make  timely  referrals  for  immediate  treatment  and  further  evaluation.     After  the  initial  evaluation,  the  team  physician  may  consult  the  Stanford  Concussion  and  Brain  Performance  Center   for  further  testing,  evaluation,  and  management  recommendations.  Additionally,  in  cases  of  confirmed  vestibular   dysfunction,  the  team  physician  may  refer  student-­‐athletes  to  physical  therapy/athletic  training  to  begin   rehabilitation  immediately.  In  cases  where  recovery  is  slowed  (unresolved  deficits  greater  than  2  weeks),   additional  referrals  for  neuropsychological  testing,  neurological  evaluation,  and  brain  imaging  may  be  warranted.   However,  the  team  physician  remains  the  only  medical  professional  who  can  clear  the  student-­‐athlete  to  resume   prior  activity  levels.     Management  of  Concussion  in  the  Absence  of  an  Athletic  Trainer   In  the  event  that  a  team  is  off-­‐campus  without  an  athletic  trainer  and  a  student-­‐athlete  is  suspected  of  having   sustained  a  concussion,  the  student-­‐athlete  will  be  withheld  from  practice  and/or  competition  until  the  team   physician  has  evaluated  them.  This  procedure  will  also  be  utilized  when  student-­‐athletes  sustain  a  concussion  not   related  to  sports  participation.       Use  of  Neuromotor  Analytics  in  the  Return  to  Activities  of  Daily  Living     It  is  important  to  understand  that  concussion  is  not  just  a  sport  related  injury,  it  is  a  disruption  of  daily  life  for   many  student  athletes.  Simple  tasks  that  require  attention  focus  such  as  reading,  operating  a  computer,  riding  a   bicycle,  or  driving  a  car  may  be  impaired  after  a  concussive  event.  Additionally,  academic  routines  may  be   temporarily  compromised  until  the  treatment  plan  has  been  established  and  recovery  has  begun.  As  a  result,  those   providing  care  for  the  injured  student-­‐athlete  may  impose  specific  limitations  to  these  activities.  It  is  a  goal  of  the   medical  staff  to  develop  a  specific  plan  that  meets  the  needs  of  each  individual  student-­‐athlete.       With  regard  to  academic  considerations,  a  multi-­‐disciplinary  team  of  Sports  Medicine  staff  (consisting  of  team   physicians,  neurologists,  athletic  trainers  and/or  physical  therapists  as  appropriate),  the  AARC  staff  led  by  the   Assistant  Athletic  Director  for  Student-­‐Athlete  Advising  &  Development,  the  FAR  and  OAE  staff  will  communicate   their  recommendations  for  accommodations  to  the  University  faculty  and  student-­‐athlete.    This  academic  care     Concussion  Education,  Management,  and  Return  to  Daily  Activity       team  will  rely  on  the  recommendations  of  the  Sports  Medicine  staff,  on  a  case-­‐by-­‐case  basis.  Student-­‐athletes  who   have  an  inability  to  focus  after  a  concussion  are  at  risk  for  poor  academic  performance  and  will  need  individualized   academic  advice  to  make  the  transition  to  full  recovery.    In  compliance  with  the  Americans  with  Disabilities   Amendments  Act  (ADAAA),  and  in  order  to  limit  cognitive  stressors  and  support  recovery  during  this  period,   reasonable  accommodations  will  be  made  to  ensure  continued  academic  progress.     Stepwise  Progression     In  cases  of  suspected  concussion,  student-­‐athletes  will  be  withheld  from  classroom  activity  on  the  same  day  of   injury,  in  accordance  with  NCAA  guidelines.  If  objective  measures  demonstrate  clear  variance  from  prior  baseline   tests,  indicating  a  concussion,  student-­‐athletes  will  be  withheld  from  daily  activities  that  require  attention,  focus,   and  concentration  until  it  is  objectively  clear  that  recovery  has  occurred.  At  times,  this  may  occur  on  the  next  day.   In  cases  of  attention  focus  with  no  objective  variance  from  baseline,  contact  sport  student-­‐athletes  will  still  be   required  to  complete  a  stepwise  progression  of  physical  exertion.  However,  non-­‐contact  student-­‐athletes  may  be   cleared  to  return  to  sport  immediately  without  the  completion  of  a  stepwise  progression.  A  sample  progression  of   daily  and  physical  activities  may  involve  the  following:     Post  Injury   Daily  Activity   Physical  Exertion   Day  One   Cognitive  rest;  10-­‐15  minute  bouts  reading,  writing,  cell  phone     Moderate  Intensity  Exertion   Day  Two   Resume  limited  driving,  biking,  studying     Modified  Weight  Lifting   Day  Three   Increased  daily  activities,  resume  normal  classroom  attendance   On  Field/Court  Physical  Conditioning   Day  Four   Normal  daily  activities,  resume  homework/tests     Non  Contact  Practice   Day  Five   Resume  normal  academic  routine   Normal  Full  Practice     Continuation  of  Care   As  recovery  continues,  modifications  and/or  additional  steps  may  be  required  to  complete  the  progression,   depending  on  the  academic  and  sport  demands  of  the  student-­‐athlete.  It  is  the  responsibility  of  the  Sports   Medicine  staff  to  appreciate  these  nuances  and  adjust  progressions  accordingly  for  each  student-­‐athlete.  Ultimate   return  to  normal  academic  routines,  as  well  as  return  to  play  will  only  occur  after  completion  of  progression(s),   and  the  team  physician  has  granted  final  clearance.     References   1. Carney,  N.,  et  al.  Concussion  guidelines  step  1:  systematic  review  of  prevalent  indicators.  Neurology.  2014;  75(3):   S3-­‐S15.   2. Leddy,  J.L.,  et  al.  Brain  or  strain?  Symptoms  alone  do  not  distinguish  physiologic  concussion  from   cervical/vestibular  injury.  Clin  J  Sport  Med.  2014;0:  1-­‐6.   3.  Ventura,  R.,  et  al.  Diagnostic  tests  for  concussion:  Is  vision  part  of  the  puzzle?  J  Neur  Opthalmol.  2015;  35:  73-­‐ 81.   4.  Concussion  Guidelines:  Diagnosis  and  management  of  sport  related  concussion.  http://www.ncaa.org/health-­‐ and-­‐safety/concussion-­‐guidelines   5.  NCAA  Concussion  Safety  Protocol  Checklist.  http://www.ncaa.org/health-­‐and-­‐safety/concussion-­‐guidelines     th 6.  McCrory,  P.,  et  al.    (2013).  Consensus  Statement  on  Concussion  in  Sports:  the  4  International  Conference  on   Concussion  in  Sports  held  in  Zurich,  November  2012.    Br.  J.  Sports  Med.  47:  250-­‐258.   7.  Broglio  SP  et  al.    National  Athletic  Trainers’  Association  position  statement:  management  of  sport  concussion.    J   Athl  Train  2014;  49:245-­‐265.   8.  Centers  for  Disease  Control  and  Prevention:  Returning  to  school  after  a  concussion:  a  fact  sheet  for  school   professionals.    http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-­‐a.pdf.     9.  Halstead  ME  et  al:    Returning  to  learning  following  a  concussion.    Pediatrics  2013;  132:948-­‐957.           .           Concussion  Education,  Management,  and  Return  to  Daily  Activity         Suspected  Concussive  Event—   Student-­‐Athlete  is  removed  from  play         Physician(s)  On-­‐Site   No  Physician  On-­‐Site           AT  Performs  Evaluation:   1. ICE   2. EYE-­‐SYNC   AT  Performs  Evaluation:   1. ICE   2. EYE-­‐SYNC         Physician  and  AT  make  RTP  decision         RTP  –  No  Concussion   No  RTP  –  Concussion   is  confirmed         1. Athlete  is  monitored  for     signs  of  deterioration   2. Athlete  DOES  NOT  RTP   Athlete  is  monitored  for   signs  of  deterioration  and   provided  home  care   instructions   Athlete  is  referred  to  a  physician  within   24  hours  of  concussive  event  and   provided  home  care  instructions         Athlete  is  re-­‐evaluated  daily  by  AT   or  as  directed  by  physician.    Per   MD,  student-­‐athlete  begins   stepwise  progression             Upon  successful  completion  of   stepwise  progression,  athlete  is   re-­‐evaluated  by  physician  to   determine  readiness  for  RTP   Syracuse University Sports Medicine Department Concussion Policy The Syracuse University Sports Medicine Department has established a protocol for the prevention, assessment, care, return to learning and return-to-play progression of concussions for studentathletes. The sports medicine staff and physicians continue to review and evaluate evolving research on concussions. The approach in care for concussions has always been conservative by the staff and physicians. The physicians have the exclusive responsibility in returning student-athletes to participation following a concussion, and follow recommendations from the Prague Conference on Concussions, and the work of Dr. Robert Cantu. This protocol for managing concussions applies to all student-athletes regardless of sport. Pre-season Education:   Each Syracuse University student-athlete participates in a pre-season meeting where they are educated on the proper signs, symptoms and care of concussions. NCAA concussion awareness brochures are distributed to each attendee and each student-athlete signs off they have read and understand the material. The Athletic Director including the senior staff, sports medicine staff (including all team physicians and athletic trainers) and every coach sign a document to acknowledging they have read and understand the Syracuse University Concussion policy. Prevention (Reduction of Concussions)        The Syracuse University Equipment Staff are responsible for the reconditioning of presently used helmets, ordering of new helmets, and fitting of helmets for football, men’s lacrosse and women’s ice hockey. The equipment staff are members of the Equipment Managers’ Association, and go through an educational component for helmet fitting at their annual meetings. The equipment staff checks the air suspension of helmets in football. Any helmet low in air will be filled and any helmet requiring more air or repeated days of attention is re-evaluated and repaired or replaced by the staff. The football coaches review and teach proper blocking and tackling technique daily to minimize head and neck injuries to the student-athlete. Safety is their primary concern. The women’s ice hockey coaches employ daily drills raising awareness of the boards as well as any other situation involving collisions or whiplash injuries. The field hockey coaches employ drills to raise awareness to open field collisions and the best practices to avoid contact with a deflected ball or contact with a field hockey stick. The men’s and women’s lacrosse coaches employ drills raising awareness to open field collisions, whiplash injuries and avoiding contact to the head with errant sticks. The volleyball coaches employs drills to improve blocking skills and teach proper rolling and diving skills to drastically reduce collisions when diving on the floor.      The men’s and women’s soccer coaches utilize drills to teach proper technique for heading the balls and raise awareness to open field head to head contact. The softball coaches utilize drills for batting, catching fly balls at the fence and proper sliding techniques. The spirit squad coaches teach safety skills during vaulting mounting and dismounting maneuvers. The strength and conditioning staff provide exercises for all contact and collision athletes to strengthen the core and extrinsic and intrinsic cervical spine muscles to help decrease the amount of whiplash type injuries to the head and neck. The football athletic training room displays a poster on helmet contact foul and defenseless opponent foul, and the locker room also has a poster about proper and improper tackling techniques. Pre-participation Physical Examination    A student-athletes physical examination medical history is reviewed for any past history of concussions. If any are listed, records from home are required to complete their chart. These records are reviewed by the physician. Any restrictions in participation and raised awareness to a concussion history are noted and communicated to the coach and team athletic trainer. There have been incidents where the student-athlete neglected to inform the sports medicine staff and their coach during the recruiting process that they sustain one or more concussions in high school. Research has shown that the young brain is more vulnerable to concussions, and once concussed, is more vulnerable for repeated concussions. There have been incidences where a student-athlete is concussed while participating at Syracuse University, and did not inform the staff or coaches of their prior concussion history. This can lead to a protracted period of rest in order to provide the brain an opportunity to heal before returning to activity. Any student-athlete with two documented time-loss concussions of any length while at Syracuse University receives a letter from the Assistant Director of Athletics for Sports Medicine, outlining their concussion history and the recommendations from the physician that another concussion may disqualify the student-athlete from further participation in contact sports at Syracuse University. The head coach is also copied on this letter which is also acknowledged by the student-athlete with their signature. A baseline Sport Concussion Assessment Tool (SCAT3) neuropsychological test is administered to all student-athletes and the results are kept for future comparison in the event of a concussion. The Team physician will review the baseline testing and determine clearance prior to play. Additionally, those student-athletes with a significant concussion or concussion history also perform a computerized IMPACT test for future comparison if needed. Assessment and Evaluation Following a Concussion          The student-athlete is evaluated by the staff and physician for cognitive, physical, and behavioral signs and symptoms of a concussion, included but not limited to: headaches, amnesia, nausea, dizziness, balance and visual disturbances, poor SCAT3 scores versus the baseline, and light sensitivity. If these symptoms are present following the SCAT3 test, the student-athlete will be initially withheld from the calendar day of activity. Any suspected concussion will be evaluated by the team physician within 24 hours. The student-athlete is assessed for cervical spine trauma, skull fractures and inter-cranial bleeding. The Syracuse University Emergency Action Plan is enacted if any student-athlete shows signs of prolonged unconsciousness, spinal injury, repetitive emesis, focal neural deficit or a diminishing neurological status or Glasgow Coma Scale <13. A physician will evaluate the student-athlete at the hospital and the student-athlete will be hospitalized if their condition warrants. The student-athlete parents are notified of the concussion. If the physician permits the student-athlete to go home following a minor concussion, arrangements are made with a responsible individual to monitor the student-athlete. Written instructions with phone numbers are given prior to departure to the student-athlete and a responsible adult. Later that same day and night, an athletic trainer will call the studentathlete to check on their status and make any arrangements for further evaluation if necessary that same day. A student-athlete will not attend class on the day of the concussion. The student-athlete is assessed several times daily by the sports medicine staff to monitor status. The classification in severity of a concussion is now done retrospectively, not on the day of injury. The severity of the concussion, with or without loss of consciousness, is determined in the following day or days/weeks by evaluating any and all symptoms of Post Concussive Syndrome, and resolution of symptoms will be different for each individual based on prior history and present severity. Any CT Scans, MRIs, and/or referral to a local neuropsychologist for evaluation are determined by the physician based on signs and symptoms of the student-athlete’s concussion. Return to the Classroom (Return to Learn)  While maintaining compliance with all ADAAA laws, a gradual return to class program will be initiated. At times, student-athletes have difficulty in returning to the classroom. A multidisciplinary return to classroom team has been formed. This team consists of the team physician, athletic trainer, Assistant Provost, learning specialist, psychologist and the Office of Disability Services. This team will assess the needs of the student-athlete and monitor their return to the classroom. The team physician will serve as chair and will reassess the student-athlete if the rigors of academics are too much. The team will modify the class load as necessary to provide the ultimate return to the classroom.     If the student-athlete cannot tolerate light cognitive activity, then they may stay at their home/dorm. A written medical excuse from the team physician will be provided to the Assistant Provost for Student-Athlete Academic Development for dissemination to the appropriate schools/professors. If a student-athlete cannot attend class, they will not be allowed to attend any athletic activity even as a spectator. If a student-athlete’s symptoms increase from academic challenges, they will be re-evaluated by the team physician. A student-athlete will be re-evaluated if symptoms are unchanged for greater than five (5) days or if symptoms persist for greater than two weeks. Campus resources will be engaged when a student-athlete’s schedule cannot be managed through schedule modification/academic accommodations. This includes learning specialists and the office of disability services. Return-To-Play Protocol      Medical disqualification of a student-athlete from contact sports following any concussion is always possible. The Head Team Physician contemplates the total history of concussions, the most recent concussion in terms of severity and duration in resolution, and the sport involved. Disqualification is based on a vulnerability to further concussion as a result of exposure to contact sports, which would place the student-athlete at risk for long-term cognitive, physical, or behavioral disability. The Head Team physician or physician designee who are all experienced in concussion management will monitor and progress the student-athlete through the return to play protocol, and will have final determination of return–to-play status. Once the student-athlete is asymptomatic for a period of time (perhaps a day if it was a mild concussion, or days/weeks if more severe or they have a history of concussions) and will give the final determination of return-to-play, the progression is as follows: (1) Light aerobic exercise on a bike, if asymptomatic with light aerobic exercise then progress to (2)moderate aerobic exercise on elliptical or walking on an inclined treadmill, if asymptomatic with moderate exercise then progress to (3)strenuous exercise(running, biking) to see if any symptoms return; if asymptomatic, progress to (4) limited practice without contact; if asymptomatic with limited contact, then progress to (5) limited contact in terms of repetitions or level of contact; following limited contact if asymptomatic, (6) full return to participation and contact with extra observation by the athletic trainer and/or coach. Any return of symptoms over this return period is met with withholding the student-athlete from participation and re-evaluation by the physician. The helmet is re-checked and refitted by the equipment staff prior to returning to limited contact. The student-athlete’s concussion and resolution time frame is recorded for reference in the event of another concussion to the same student-athlete in the future. Syracuse University Sports Medicine Department Concussion Awareness Letter The Syracuse University Sports Medicine and Student Services/Academic Counseling Departments would like to inform you that ______________ sustained a concussion on ________________. A concussion or mild traumatic brain injury can cause a variety of physical, cognitive, and emotional symptoms. Concussions range in significance from minor to major, but they all share one common factor- they temporarily interfere with the way your brain works. We would like to inform you that during the next few weeks this student-athlete may experience one or more of these signs and symptoms: Headache Balance Problems Diplopia- Double Vision Photophobia- Light Sensitivity Misophonia- Noise Sensitivity Feeling Sluggish or Groggy Difficulty Concentrating Nausea Dizziness Confusion Difficulty Sleeping Blurred Vision Memory Problems As a department, we wanted to make you aware of this injury and the related symptoms that the student-athlete may experience. When the student athlete is permitted to return to class, please be aware that the side effects of the concussion may adversely impact her academic performance. Any consideration you may provide academically during this time would be greatly appreciated. We will continue to monitor the progress of this athlete and anticipate a full recovery. Should you have any questions or require further information, please do not hesitate to contact me. Thank you in advance for your time and understanding with this circumstance. _______________________________________ Athletic Trainer Syracuse University _______________________________________ Team Physician Syracuse University TCU CONCUSSION SAFETY PROTOCOL TABLE OF CONTENTS A. Concussion Management Plan i. ii. iii. iv. v. vi. vii. viii. Concussion Fact Sheet for Student-Athletes Concussion Education Statement – Student-Athletes Concussion Fact Sheet for Coaches/Staff Sample Return to Play Guidelines Concussion Education Statement – Coaches/Staff SCAT 3 Tool Student-Athlete Post-Concussion Instructions Notification Letter to Academics B. Concussion Protocol for Evaluation and Management C. Roles in Concussion Management D. Return to Learn Protocol E. Prevention of Concussion in Sport Appendix A Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Appendix B Inter-Association Consensus: Independent Medical Care for College Student-Athletes Guidelines Concussion Management Plan: This plan is based on the most current evidence on concussions available as well as the recommended best practices for concussion management distributed by the NCAA Committee on Competitive Safeguards in Sport. As such, modifications may follow as the science of concussion diagnosis, education, and treatment advances. All incoming student-athletes, including transfer students and anyone new to the program, will be subject to this plan. PRE-PRACTICE EDUCATION: 1) Student athletes will undergo a formal education program on concussion in sport. Topics covered will include mechanism of injury, recognition of signs and symptoms of concussion, and strategies to avoid injury/prevent further sequelae. The ‘Concussion Fact Sheet for Student-Athletes’ provided by the NCAA will also be distributed at this time. This will be completed before participating in the first official practice session and will be directed by a staff athletic trainer and/or team physician. 2) ALL coaches, athletic training staff, strength and conditioning staff, student support staff and other individuals associated and familiar with the student athlete on a regular basis shall undergo concussion education before the official start of the season. This will be conducted by a member of the TCU Sports Medicine staff (currently David Gable) and renewed annually. The Concussion Fact Sheet for Coaches supplied by the NCAA, as well as a synopsis of the return to play (RTP) guidelines as established by the 4th International Conference on Concussion in Sport, will be reviewed and all will sign a statement stating such. 3) Team physicians will be provided with the NCAA Concussion Fact Sheet and any other applicable documents. In addition to pre-practice education all athletes will sign a statement in which they accept responsibility for reporting all injuries, including signs and symptoms of a concussion, to the appropriate healthcare personnel. PRE-PRACTICE SCREENING: Athletes in at risk sports will undergo pre-participation baseline assessment before the first official practice session. Testing will be administered by certified staff or certified graduate assistant athletic trainers. 1) Student-Athletes will have a baseline assessment utilizing the Sport Concussion Assessment Tool 3 (SCAT 3) which includes a brain injury and concussion history section. 2) Student-athletes will submit a baseline computerized neurocognitive test utilizing the C 3 Logix program which includes a symptom evaluation, cognitive assessment and balance evaluation. SIGNS OR SYMPTOMS OF CONCUSSION PRESENT: • When a student-athlete exhibits any signs, symptoms or behaviors consistent with a concussion they will be removed from practice or competition by a member of the coaching staff, athletic training staff, team physician or his/her designee. They will be promptly evaluated by an athletics healthcare provider (certified athletic trainer, team physician or his/her designee). • Evaluation will follow procedures based on the Evaluation and Management protocol. • Without exception, a student-athlete diagnosed with a concussion shall be withheld from competition or practice and not return to activity for the remainder of the day. • The student-athlete will receive serial monitoring for deterioration until discharge. Should worsening of signs or symptoms occur, the student-athlete may be taken to the nearest hospital emergency department. • Upon discharge, the student-athlete will be provided a follow up time for the next day and will be released to a responsible party (roommate, significant other, family member, etc…) who will be provided a copy of the post-concussion discharge instructions. A copy of the discharge instructions will be retained by the healthcare provider and placed in the athlete’s permanent medical file. • If not already done, the athlete will be evaluated by the team physician or his/her designee as soon as able. • Academic services will be notified by the team physician or his/her designee when an athlete is diagnosed with a concussion and will be advised of the recommendation to avoid class, papers, projects, presentations, and exams until further notice. RETURN TO ACTIVITY • No athlete shall return to competition, practice, strength training, or conditioning without being evaluated and cleared for participation by the team physician or his/her designee. • All concussions, whether athletically related or not, will undergo a gradual return to activity as outlined in the 4th International Conference on Concussions in Sport, Zurich 2012 (Zurich Guidelines). • As outlined in the Zurich Guidelines, certain modifying factors may prolong or delay the return to activity including but not limited to: prolonged loss of consciousness, number and/or severity of symptoms, frequency and/or recency of concussions, co- and premorbidities, medication(s), behavior, and sport. • No one form of assessment will determine an athlete’s return to activity. In addition to the clinical exam, post-event SCAT 3 scores will be monitored as well as C 3 Logix neurocognitive exams. • Computerized neurocognitive examination will not occur until the patient is asymptomatic as determined by the team physician or his/her designee. • The ultimate decision for an athlete’s return to activity rests solely with the team physician or his/her designee. IMAGING • • • Routine imaging (X ray, CT, MRI/MRA, fMRI, PET) for concussions is not recommended. In the event an athlete deteriorates or requires transfer to an emergency department imaging will be at the sole discretion of the on call staff attending physician and this information will be communicated to a TCU team physician. At any point in the athletes recovery outpatient imaging may be ordered by the team physician or his/her designee if deemed necessary. POST CONCUSSIVE SYNDROME/PROLONGED SYMPTOMS • If an athlete remains symptomatic for a prolonged period of time, the athlete may be referred to sub-specialists at the team physicians discretion for consultation to include, but not limited to: Neurologist, Neuropsychologist, Sports Psychologist, Psychologist, Psychiatrist, Vision Specialist, Physical Therapist trained in vestibular and oculomotor therapy etc… • Imaging and/or formal neurocognitive testing may be pursued at the discretion of the team physician and/or neurological consultant. • At the discretion of the team physician or his/her designee, sub-specialty consultation may be sought at any time while an athlete has symptoms. Inclusions: - Concussion Fact Sheet for Student-Athletes and Concussion Education Statement - Concussion Fact Sheet for Coaches/Staff; Concussion Education Statement; sample return to play protocol - SCAT 3 Tool - Student Athlete Post-Concussion Instructions - Notification Letter to Academics Appendix A: Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Appendix B: Inter-Association Consensus: Independent Medical Care for College Student-Athletes Guidelines CONCUSSION A fact sheet for student-athletes What is a concussion? A concussion is a brain injury that: • Is caused by a blow to the head or body. – From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. • Can change the way your brain normally works. • Can range from mild to severe. • Presents itself differently for each athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness. How can I prevent a concussion? Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport. What are the symptoms of a concussion? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. What should I do if I think I have a concussion? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. It’s better to miss one game than the whole season. When in doubt, get checked out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. Concussion Education Statement Student Athletes A concussion is an injury sustained to the brain as a result of a bump, hit, blow or jolt that causes the brain substance to be moved or shifted within the head. These injuries, if not diagnosed and managed properly, can lead to serious complications and improper brain functioning. Even though most concussions are mild, all concussions are potentially serious and may result in complications including, but not limited to, brain damage and death if not recognized and managed properly by a trained health care professional. As a TCU Student- Athlete, I attest that I have received verbal education and the FACT SHEET FOR STUDENT-ATHLETES, developed by the NCAA, from the TCU Athletic Training / Sports Medicine staff, or its designees, regarding recognition and reporting of a concussion. Furthermore, I attest that I have been educated on the medical signs and symptoms of a concussion and I agree to report any clinical signs or symptoms of a suspected head injury to my/a Staff Athletic Trainer, Team Physician or designee immediately. I understand that as a TCU Student- Athlete it is my responsibility to report all injuries/illnesses, regardless of perceived severity, to my/a Staff Athletic Trainer immediately, to include concussions. I also hereby recognize and agree that my health and well being is a shared responsibility between myself, the Coaching Staff, the Staff Athletic Trainer, Team Physicians and Sports Medicine team at TCU. Student-Athletes Printed Name: __________________________________________________ Student-Athletes Signature: __________________________________________________ Student-Athletes I.D. Number: __________________________________________________ Date: ___________________________________________________ CONCUSSION A fact sheet for Coaches The Facts • A concussion is a brain injury. • All concussions are serious. • Concussions can occur without loss of consciousness or other obvious signs. • Concussions can occur from blows to the body as well as to the head. • Concussions can occur in any sport. • Recognition and proper response to concussions when they first occur can help prevent further injury or even death. • Athletes may not report their symptoms for fear of losing playing time. • Athletes can still get a concussion even if they are wearing a helmet. • Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries, depending on the sport. What is a concussion? A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Recognizing a possible concussion To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; -AND2. Any change in the student-athlete’s behavior, thinking or physical functioning (see signs and symptoms). Signs and Symptoms Signs Observed By Coaching Staff • Appears dazed or stunned. • Is confused about assignment or position. • Forgets plays. • Is unsure of game, score or opponent. • Moves clumsily. • Answers questions slowly. • Loses consciousness (even briefly). • Shows behavior or personality changes. • Can’t recall events before hit or fall. • Can’t recall events after hit or fall. Symptoms Reported By Student-Athlete • Headache or “pressure” in head. • Nausea or vomiting. • Balance problems or dizziness. • Double or blurry vision. • Sensitivity to light. • Sensitivity to noise. • Feeling sluggish, hazy, foggy or groggy. • Concentration or memory problems. • Confusion. • Does not “feel right.” PREVENTION AND PREPARATION As a coach, you play a key role in preventing concussions and responding to them properly when they occur. Here are some steps you can take to ensure the best outcome for your student-athletes: • Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to-play. – Review and practice your emergency action plan for your facility. – Know when you will have sideline medical care and when you will not, both at home and away. – Emphasize that protective equipment should fit properly, be well maintained, and be worn consistently and correctly. – Review the Concussion Fact Sheet for Student-Athletes with your team to help them recognize the signs of a concussion. – Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete. • Insist that safety comes first. – Teach student-athletes safe-play techniques and encourage them to follow the rules of play. – Encourage student-athletes to practice good sportsmanship at all times. – Encourage student-athletes to immediately report symptoms of concussion. • Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death. IF YOU THINK YOUR STUDENT-ATHLETE HAS SUSTAINED A CONCUSSION: IF A CONCUSSION IS SUSPECTED: Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion. 1. Remove the student-athlete from play. Look for the signs and symptoms of concussion if your student-athlete has experienced a blow to the head. Do not allow the student-athlete to just “shake it off.” Each individual athlete will respond to concussions differently. An athlete who exhibits signs, symptoms or behaviors consistent with a concussion, either at rest or during exertion, should be removed immediately from practice or competition and should not return to play until cleared by an appropriate health care professional. Sports have injury timeouts and player substitutions so that student-athletes can get checked out. 2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the studentathlete to the appropriate athletics medical staff, such as a certified athletic trainer, team physician or health care professional experienced in concussion evaluation and management. 3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return-to-play progression should occur in an individualized, step-wise fashion with gradual increments in physical exertion and risk of contact. 4. Develop a game plan. Student-athletes should not return to play until all symptoms have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact, as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change. It’s better they miss one game than the whole season. When in doubt, sit them out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. Sample Return to Play Guideline as Established by the International Conference on Concussion in Sport, Zurich, 2012 Concussion, or mild traumatic brain injury (mTBI), is defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” Signs and Symptoms: Loss of consciousness Confusion Disorientation Delayed verbal and motor responses Inability to focus Headache Nausea/vomiting Excessive drowsiness Antero grade amnesia Visual disturbances (blurry, double, photophobia) Disequilibrium (balance problems) Feeling in a “fog” or “zoned out” Vacant stare Irritability or emotional changes Dizziness Slurred or incoherent speech Hearing problems or ringing in the ears Retrograde amnesia Symptomatic – reporting or finding of symptoms relative to a concussion Asymptomatic – does not report any symptoms and no symptoms are found on clinical exam by physician or Athletic Trainer Below are the current guidelines for return to activity as established by the Conference on Concussion in Sport: • • An athlete diagnosed with a concussion will not be allowed to return to play that same day Return to play will be sport specific given the demands of that particular sport 1. No activity, complete physical and cognitive rest until they are asymptomatic. What this means: If an athlete reports any on-going symptoms or fails any of the clinical exams they are not asymptomatic. They must be asymptomatic for approximately 24 hours before they can proceed to the next step. NO resistance training 2. Light aerobic exercise such as walking, swimming or stationary cycling. NO resistance training. What this means: If they have had no symptoms and have a normal exam for 24 hours, they can walk, swim or stationary bike for 20-30 minutes. Following the exercise they will be re-evaluated for any changes. If any of the symptoms return they must return to step 1 and have no symptoms for 24 hours again before they can exercise. If, following the 20-30 minutes of exercise, they have no symptoms, they can proceed to the next step the following day. NO resistance training. 3. Sport specific exercise (eg, running, light agility drills, throwing/catching a ball, shooting a basketball etc…without body contact. What this means: They can perform drills or running specific to their sport under the supervision of their Athletic Trainer. If they continue to be symptom-free they can proceed to step 4 the following day. If symptoms reoccur they must again be asymptomatic for 24 hours before attempting this step again. 4. Practice and drills without body contact. May resume LIGHT progressive resistance training. What this means: They can return to practice and perform individual or team drills, but cannot have contact with other players such as blocking, hitting the sleds, getting knocked to the ground by another player. A player is allowed to be in the full uniform of the day at this time. If they continue to be symptom free they can proceed to step 5 the following day. If symptoms reoccur they must again be asymptomatic for 24 hours before attempting this step again. 5. Full practice with body contact. Continue progressive resistance training. What this means: The athlete can return to normal practice and perform all drills and team work provided that they remain symptom free. If symptoms reoccur they must again be asymptomatic for 24 hours before attempting this step again. (As a precaution it would be advised to avoid any unnecessary direct contact to the head). 6. Return to game play. What this means: The athlete can return to a normal game situation as long as they have remained symptom free throughout this progression. It is important to note that returning an athlete to play too soon may actually put them at risk for additional concussions and more lost time. With each documented concussion the return to play time will likely lengthen and ultimately put the athlete’s career in jeopardy. In cases of more complex concussions, the rehabilitation and return to play process may be more prolonged for the protection of the athlete. An athlete should never be advised to falsify answers to the clinical examiner, but rather encouraged to be honest regarding his/her symptoms so that their long-term health is never put at risk. If it is found the athlete has been advised to falsify the reporting of symptoms by any coach or staff member, that information will be documented and forwarded to the Athletic Director for review and appropriate disciplinary action. The team physician, or team physician’s designee, will report concussions to the academic office so the athletes professors can be apprised of the situation and the athlete will be allowed the opportunity to receive cognitive rest as well as physical rest. The team physician or the designee of the team physician will make all decisions or recommendations regarding the evaluation, progress and return to activity for an athlete who has been diagnosed with a concussion. I attest that I have undergone formal training and received written information specific to concussions, recognizing the signs and symptoms of a concussion, prevention of concussions and return to play guidelines as outlined by the International Conference on Concussions and TCU Athletic Training Sports Medicine and agree to abide by such guidelines. Print Name___________________________ Position Held/Sport_______________________ Signature____________________________ Date___________________________________ Concussion Education Statement Staff A concussion is an injury sustained to the brain as a result of a bump, hit, blow or jolt that causes the brain substance to be moved or shifted within the head. These injuries, if not diagnosed and managed properly, can lead to serious complications and improper brain functioning. Even though most concussions are mild, all concussions are potentially serious and may result in complications including, but not limited to, brain damage and death if not recognized and managed properly by a trained health care professional. As a TCU full time staff member, student support staff or other individual associated with or in direct contact with TCU student athletes I attest that I have received verbal education and the FACT SHEET FOR COACHES, developed by the NCAA, from the TCU Athletic Training / Sports Medicine staff, or its designees, regarding recognition and reporting of a concussion. Furthermore, I attest that I have been educated on the medical signs and symptoms of a concussion and I agree to report any clinical signs or symptoms of a suspected head injury to a Staff Athletic Trainer, Team Physician or designee immediately. I understand that as a TCU staff member, student support staff or individual directly associated with TCU student athletes, it is my responsibility to report all injuries/illnesses, regardless of perceived severity, to a Staff Athletic Trainer or physician immediately, to include concussions. I also hereby recognize and agree that the health and well-being of the student athlete is a shared responsibility between myself, Staff Athletic Trainers, Team Physicians and Sports Medicine team at TCU. Staff Member Printed Name: __________________________________________________ Staff Member Sport: __________________________________________________ Staff Member Signature: __________________________________________________ Date: ___________________________________________________ SCAT3 ™ Sport Concussion Assessment Tool – 3rd edition For use by medical professionals only name What is the SCAT3?1 the SCAt3 is a standardized tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older. it supersedes the original SCAt and the SCAt2 published in 2005 and 2009, respectively 2. For younger persons, ages 12 and under, please use the Child SCAt3. the SCAt3 is designed for  use  by  medical  professionals.  If  you  are  not  qualifi ed,  please  use  the  Sport  Concussion recognition tool1. preseason baseline testing with the SCAt3 can be helpful for interpreting post-injury test scores. Specifi c instructions for use of the SCAT3 are provided on page 3. If you are not  familiar with the SCAt3, please read through these instructions carefully. this tool may be freely copied in its current form for distribution to individuals, teams, groups and organizations. Any revision or any reproduction in a digital form requires approval by the Concussion in Sport Group. NOTE: the diagnosis of a concussion is a clinical judgment, ideally made by a medical professional. the SCAt3 should not be used solely to make, or exclude, the diagnosis of concussion in the absence of clinical judgement. An athlete may have a concussion even if their SCAt3 is “normal”. What is a concussion? A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specifi c signs and / or symptoms (some  examples listed below) and most often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following: - 1 glasgow coma scale (gCS) Best eye response (e) no eye opening 1 eye opening in response to pain 2 eye opening to speech 3 eyes opening spontaneously 4 Best verbal response (v) no verbal response 1 incomprehensible sounds 2 inappropriate words 3 Confused 4 oriented 5 Best motor response (m) no motor response 1 extension to pain 2 Abnormal fl exion to pain  3 Flexion / Withdrawal to pain  4 localizes to pain 5 obeys commands 6 glasgow Coma score (e + v + m) Symptoms (e.g., headache), or Physical signs (e.g., unsteadiness), or Impaired brain function (e.g. confusion) or Abnormal behaviour (e.g., change in personality).  of 15 GCS should be recorded for all athletes in case of subsequent deterioration. 2 maddocks Score3 Sideline ASSeSSmenT “I am going to ask you a few questions, please listen carefully and give your best effort.” Modifi ed Maddocks questions (1 point for each correct answer) indications for emergency management noTe: A hit to the head can sometimes be associated with a more serious brain injury. Any of the following warrants consideration of activating emergency procedures and urgent transportation to the nearest hospital: - examiner: Date / Time of Injury: Date of Assessment: Glasgow Coma score less than 15 Deteriorating mental status potential spinal injury progressive, worsening symptoms or new neurologic signs What venue are we at today?  0 1 Which half is it now? 0 1 Who scored last in this match? 0 1 What team did you play last week / game? 0 1 Did your team win the last game? 0 1 maddocks score of 5 Maddocks score is validated for sideline diagnosis of concussion only and is not used for serial testing. Potential signs of concussion? if any of the following signs are observed after a direct or indirect blow to the head, the athlete should stop participation, be evaluated by a medical professional and should not be permitted to return to sport the same day if a concussion is suspected. Y n Balance or motor incoordination (stumbles, slow / laboured movements, etc.)? Y n Disorientation or confusion (inability to respond appropriately to questions)? Y n loss of memory: Y n Blank or vacant look: Y n Visible facial injury in combination with any of the above: Y n Any loss of consciousness? notes: mechanism of injury (“tell me what happened”?): “if so, how long?“ “if so, how long?“ “Before or after the injury?" Any athlete with a suspected concussion should be removed From PlAy, medically assessed, monitored for deterioration (i.e., should not be left alone) and should not drive a motor vehicle until cleared to do so by a medical professional. no athlete diagnosed with concussion should be returned to sports participation on the day of injury. SCAT3 Sport ConCuSSion ASSeSment tool 3 PAge 1 © 2013 Concussion in Sport Group Background Cognitive & Physical Evaluation Name:  4 Cognitive assessment Date:  Examiner:  Standardized Assessment of Concussion (SAC) 4 Sport / team / school:  Date / time of injury: Age:  Years of education completed:   Gender: M F Orientation (1 point for each correct answer) What month is it? 0 1 What is the date today? 0 1 What is the day of the week? 0 1 When was the most recent concussion?  What year is it? 0 1 How long was your recovery from the most recent concussion?  What time is it right now? (within 1 hour) 0 1 Dominant hand: right  left    How many concussions do you think you have had in the past?  neither Have you ever been hospitalized or had medical imaging done for a head injury? Y N Orientation score Have you ever been diagnosed with headaches or migraines? Y N Immediate memory Do you have a learning disability, dyslexia, ADD / ADHD? Y N Have you ever been diagnosed with depression, anxiety or other psychiatric disorder? Y N Has anyone in your family ever been diagnosed with any of these problems? Y N Are you on any medications? If yes, please list: Y N List of 5 Trial 1 Trial 2 Trial 3 Alternative word list elbow 0 1 0 1 0 1 candle baby apple 0 1 0 1 0 1 paper monkey penny carpet 0 1 0 1 0 1 sugar perfume blanket saddle 0 1 0 1 0 1 sandwich sunset lemon bubble 0 1 0 1 0 1 wagon iron insect finger Total SCAT3 to be done in resting state. Best done 10 or more minutes post excercise. Symptom Evaluation Concentration: Digits Backward List 3 How do you feel? “You should score yourself on the following symptoms, based on how you feel now”. none mild of 15 Immediate memory score total moderate severe Headache 0 1 2 3 4 5 6 “Pressure in head” 0 1 2 3 4 5 6 Neck Pain 0 1 2 3 4 5 6 Nausea or vomiting 0 1 2 3 4 5 6 Dizziness 0 1 2 3 4 5 6 Blurred vision 0 1 2 3 4 5 6 Balance problems 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 Feeling slowed down 0 1 2 3 4 5 6 Feeling like “in a fog“ 0 1 2 3 4 5 6 “Don’t feel right” 0 1 2 3 4 5 6 Trial 1 Alternative digit list 4-9-3 0 1 6-2-9 5-2-6 4-1-5 3-8-1-4 0 1 3-2-7-9 1-7-9-5 4-9-6-8 6-2-9-7-1 0 1 1-5-2-8-6 3-8-5-2-7 6-1-8-4-3 7-1-8-4-6-2 0 1 5-3-9-1-4-8 8-3-1-9-6-4 7-2-4-8-5-6 Total of 4 Concentration: Month in Reverse Order (1 pt. for entire sequence correct) 0 Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan Concentration score of 5 5 Neck Examination: Range of motion Tenderness Upper and lower limb sensation & strength Findings:  Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6 Fatigue or low energy 0 1 2 3 4 5 6 Confusion 0 1 2 3 4 5 6 Drowsiness 0 1 2 3 4 5 6 Trouble falling asleep 0 1 2 3 4 5 6 Modified Balance Error Scoring System (BESS) testing5 More emotional 0 1 2 3 4 5 6 Which foot was tested (i.e. which is the non-dominant foot) Irritability 0 1 2 3 4 5 6 Testing surface (hard floor, field, etc.)  Sadness 0 1 2 3 4 5 6 Condition Nervous or Anxious 0 1 2 3 4 5 6 Double leg stance: 6 Balance examination Do one or both of the following tests. Footwear (shoes, barefoot, braces, tape, etc.)  Total number of symptoms (Maximum possible 22) Symptom severity score (Maximum possible 132) Y N Do the symptoms get worse with mental activity? Y N self rated self rated and clinician monitored clinician interview self rated with parent input Overall rating: If you know the athlete well prior to the injury, how different is the athlete acting compared to his / her usual self? Please circle one response: unsure Right Errors Single leg stance (non-dominant foot): Errors Tandem stance (non-dominant foot at back): Errors Tandem gait6,7 Time (best of 4 trials):    seconds 7 Coordination examination Upper limb coordination Left  Which arm was tested: very different Left  And / Or Do the symptoms get worse with physical activity? no different 1 N/A Scoring on the SCAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete’s readiness to return to competition after concussion. Since signs and symptoms may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion. Coordination score Right of 1 8 SAC Delayed Recall4 Delayed recall score SCAT3 Sport Concussion Assesment Tool 3 Page 2 of 5 © 2013 Concussion in Sport Group Instructions Balance testing – types of errors Words in Italics throughout the SCAT3 are the instructions given to the athlete by the tester. Symptom Scale “You should score yourself on the following symptoms, based on how you feel now”. To be completed by the athlete. In situations where the symptom scale is being completed after exercise, it should still be done in a resting state, at least 10 minutes post exercise. For total number of symptoms, maximum possible is 22. For Symptom severity score, add all scores in table, maximum possible is 22 x 6 = 132. SAC 4 Immediate Memory “I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order.” 1. Hands lifted off iliac crest 2. Opening eyes 3. Step, stumble, or fall 4. Moving hip into > 30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of test position > 5 sec Each of the 20-second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the athlete. The examiner will begin counting errors only after the individual has assumed the proper start position. The modified BESS is calculated by adding one error point for each error during the three 20-second tests. The maximum total number of errors for any single condition is 10. If a athlete commits multiple errors simultaneously, only one error is recorded but the athlete should quickly return to the testing position, and counting should resume once subject is set. Subjects that are unable to maintain the testing procedure for a minimum of five seconds at the start are assigned the highest possible score, ten, for that testing condition. Trials 2 & 3: OPTION: For further assessment, the same 3 stances can be performed on a surface of medium density foam (e.g., approximately 50 cm x 40 cm x 6 cm). “I am going to repeat the same list again. Repeat back as many words as you can remember in any order, even if you said the word before.“ Tandem Gait6,7 Complete all 3 trials regardless of score on trial 1 & 2. Read the words at a rate of one per second. Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the athlete that delayed recall will be tested. Concentration Digits backward “I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.” Participants are instructed to stand with their feet together behind a starting line (the test is best done with footwear removed). Then, they walk in a forward direction as quickly and as accurately as possible along a 38mm wide (sports tape), 3 meter line with an alternate foot heel-to-toe gait ensuring that they approximate their heel and toe on each step. Once they cross the end of the 3m line, they turn 180 degrees and return to the starting point using the same gait. A total of 4 trials are done and the best time is retained. Athletes should complete the test in 14 seconds. Athletes fail the test if they step off the line, have a separation between their heel and toe, or if they touch or grab the examiner or an object. In this case, the time is not recorded and the trial repeated, if appropriate. If correct, go to next string length. If incorrect, read trial 2. One point possible for each string length. Stop after incorrect on both trials. The digits should be read at the rate of one per second. Coordination Examination Months in reverse order Upper limb coordination Finger-to-nose (FTN) task: “Now tell me the months of the year in reverse order. Start with the last month and go backward. So you’ll say December, November … Go ahead” 1 pt. for entire sequence correct Delayed Recall The delayed recall should be performed after completion of the Balance and Coordination Examination. “Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order.“ Score 1 pt. for each correct response “I am going to test your coordination now. Please sit comfortably on the chair with your eyes open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow and fingers extended), pointing in front of you. When I give a start signal, I would like you to perform five successive finger to nose repetitions using your index finger to touch the tip of the nose, and then return to the starting position, as quickly and as accurately as possible.” Scoring: 5 correct repetitions in < 4 seconds = 1 Note for testers: Athletes fail the test if they do not touch their nose, do not fully extend their elbow or do not perform five repetitions. Failure should be scored as 0. References & Footnotes Balance Examination Modified Balance Error Scoring System (BESS) testing 5 This balance testing is based on a modified version of the Balance Error Scoring System (BESS)5. A stopwatch or watch with a second hand is required for this testing. “I am now going to test your balance. Please take your shoes off, roll up your pant legs above ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of three twenty second tests with different stances.“ (a) Double leg stance: “The first stance is standing with your feet together with your hands on your hips and with your eyes closed. You should try to maintain stability in that position for 20 seconds. I will be counting the number of times you move out of this position. I will start timing when you are set and have closed your eyes.“ (b) Single leg stance: “If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now stand on your non-dominant foot. The dominant leg should be held in approximately 30 degrees of hip flexion and 45 degrees of knee flexion. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.“ (c) Tandem stance: “Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly distributed across both feet. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.” 1. This tool has been developed by a group of international experts at the 4th International Consensus meeting on Concussion in Sport held in Zurich, Switzerland in November 2012. The full details of the conference outcomes and the authors of the tool are published in The BJSM Injury Prevention and Health Protection, 2013, Volume 47, Issue 5. The outcome paper will also be simultaneously co-published in other leading biomedical journals with the copyright held by the Concussion in Sport Group, to allow unrestricted distribution, providing no alterations are made. 2. McCrory P et al., Consensus Statement on Concussion in Sport – the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. British Journal of Sports Medicine 2009; 43: i76-89. 3. Maddocks, DL; Dicker, GD; Saling, MM. The assessment of orientation following concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5(1): 32 – 3. 4. McCrea M. Standardized mental status testing of acute concussion. Clinical Journal of Sport Medicine. 2001; 11: 176 – 181. 5. Guskiewicz KM. Assessment of postural stability following sport-related concussion. Current Sports Medicine Reports. 2003; 2: 24 – 30. 6. Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond-Tooke, G. & McCrory, P. Normative values for 16-37 year old subjects for three clinical measures of motor performance used in the assessment of sports concussions. Journal of Science and Medicine in Sport. 2010; 13(2): 196 – 201. 7. Schneiders, A.G., Sullivan, S.J., Kvarnstrom. J.K., Olsson, M., Yden. T. & Marshall, S.W. The effect of footwear and sports-surface on dynamic neurological screening in sport-related concussion. Journal of Science and Medicine in Sport. 2010; 13(4): 382 – 386 SCAT3 Sport Concussion Assesment Tool 3 Page 3 © 2013 Concussion in Sport Group Athlete Information Scoring Summary: Any athlete suspected of having a concussion should be removed from play, and then seek medical evaluation. Signs to watch for Test Domain Score Date:  Date:  Date:  Number of Symptoms of 22 Problems could arise over the first 24 – 48 hours. The athlete should not be left alone and must go to a hospital at once if they: -- Have a headache that gets worse -- Are very drowsy or can’t be awakened -- Can’t recognize people or places -- Have repeated vomiting -- Behave unusually or seem confused; are very irritable -- Have seizures (arms and legs jerk uncontrollably) -- Have weak or numb arms or legs -- Are unsteady on their feet; have slurred speech Symptom Severity Score of 132 Orientation of 5 Immediate Memory of 15 Concentration of 5 Delayed Recall of 5 SAC Total BESS (total errors) Tandem Gait (seconds) Coordination of 1 Remember, it is better to be safe. Consult your doctor after a suspected concussion. Return to play Athletes should not be returned to play the same day of injury. When returning athletes to play, they should be medically cleared and then follow a stepwise supervised program, with stages of progression. Notes: For example: Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage No activity Physical and cognitive rest Recovery Light aerobic exercise Walking, swimming or stationary cycling keeping intensity, 70 % maximum predicted heart rate. No resistance training Increase heart rate Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities Add movement Non-contact training drills Progression to more complex training drills, eg passing drills in football and ice hockey. May start progressive resistance training Exercise, coordination, and cognitive load Full contact practice Following medical clearance participate in normal training activities Restore confidence and assess functional skills by coaching staff Return to play Normal game play There should be at least 24 hours (or longer) for each stage and if symptoms recur the athlete should rest until they resolve once again and then resume the program at the previous asymptomatic stage. Resistance training should only be added in the later stages. If the athlete is symptomatic for more than 10 days, then consultation by a medical practitioner who is expert in the management of concussion, is recommended. Medical clearance should be given before return to play. Concussion injury advice Patient’s name   (To be given to the person monitoring the concussed athlete) This patient has received an injury to the head. A careful medical examination has been carried out and no sign of any serious complications has been found. Recovery time is variable across individuals and the patient will need monitoring for a further period by a responsible adult. Your treating physician will provide guidance as to this timeframe. Date / time of injury   Date / time of medical review   Treating physician  If you notice any change in behaviour, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please contact your doctor or the nearest hospital emergency department immediately. Other important points: -- Rest (physically and mentally), including training or playing sports until symptoms resolve and you are medically cleared -- No alcohol -- No prescription or non-prescription drugs without medical supervision. Specifically: ·· No sleeping tablets ·· Do not use aspirin, anti-inflammatory medication or sedating pain killers -- Do not drive until medically cleared -- Do not train or play sport until medically cleared Clinic phone number SCAT3 Sport Concussion Assesment Tool 3 Page 4 Contact details or stamp © 2013 Concussion in Sport Group TCU Sports Medicine Mild Traumatic Brain Injury/Post-Concussion Instructions Name: _______________________________ Date: _________________ Time: ____________ By sustaining a mild traumatic brain injury (concussion), you need to be cautious with your activities and monitor your symptoms. There are various signs and symptoms which can show-up immediately or several hours after the initial injury: o o o o o o o o Loss of consciousness Headache Confusion Delayed verbal or motor responses Neck pain Nausea and/or Vomiting Loss of appetite Dizziness or loss of balance o o o o o o o o Excessive drowsiness/fatigue Inability to focus Visual disturbance Feeling in a “fog” or “zoned out” Unusual irritability/emotional changes Slurred or incoherent speech Hearing problems or ringing in the ears Memory problems pre or post injury Please be aware of your symptoms and report them to the Athletic Training/Sports Medicine Staff In addition, please follow these instructions: It is OK to: • Use the medicine given to you by the sports medicine staff • Use ice (15 minutes) for neck pain • Go to sleep at a decent hour • Stay hydrated and eat foods that sound appetizing • Rest – quiet, comfortable, dim room • Call if symptoms worsen It is NOT OK to: • Take sleeping pills • Drink alcohol or caffeine • Do any physical/strenuous activity • Drive a vehicle • Stay up late • Watch TV/play video games, sit at your computer or listen to loud music • Be exposed to bright light Please remember to report back to the TCU Sports Medicine Staff tomorrow at ____________ for a follow-up evaluation. If your symptoms worsen, or if additional symptoms appear, report to the emergency room immediately and call the Athletic Trainer once the athlete is under appropriate medical care. Emergency Phone Numbers: On campus emergency- (817) 257-7777 Off campus emergency- 911 Harris ER Downtown- (817) 882-3333 Athletic Trainer- ________________________ Phone number- ______________________________ Physician - ________________________________Phone number - ________________________________ ______________________ has been released to _________________Ph. #_______________with instructions on mTBI/Concussion care and when to report back to the sports medicine staff. Released to signature_____________________________________ Date: _______________________ Athletic Trainer __________________________________ Date: _______________________ Athletic Academics Campus Life Professors To Whom It May Concern: A concussion is in fact a mild traumatic brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, stick or ball. Concussions can occur without loss of consciousness or other obvious signs or symptoms. All concussions should be taken seriously. Data taken from a recent NCAA Injury Surveillance System suggests that concussions represent between 5 to 18 percent of all reported injuries, depending on the sport. Unfortunately, like most universities around the country, TCU athletes suffer from concussions related to sport within the range above. What is important to know is that our athletes are immediately evaluated by our well-qualified Athletic Training staff and then again by our team physicians. Recommendations are made based on the severity of the immediate symptoms, but in most cases the immediate recommendation is for complete physical and cognitive rest. Our athletes are instructed to avoid TV, video games, computers, listening to music, bright light, alcohol, caffeine, driving a vehicle or staying up late as well as any physical or strenuous activity. In most cases this will mean the athlete will not be in class for several days following diagnosis with a concussion. Recommendations also include eating a well-balanced diet, staying hydrated and getting plenty of sleep. Student athletes are reevaluated daily by our team physicians. Current science, although evolving regularly with the more knowledge we gain about concussions, tells us that complete physical and cognitive rest gives a person the best chance to recover more quickly from on-going symptoms. Unfortunately no two concussions or athletes are the same and there is no way to determine how long an athlete will be affected by concussion symptoms. We understand this sometimes puts a burden on the student in the classroom. However, we believe that exacerbating their symptoms by returning them to the classroom or sport to soon will only make it more difficult for them to recover physically and academically in the long run. Once they are cleared by a physician to resume limited activity they follow a strict return-to-play/return to class protocol recommended and followed closely by our Sports Medicine staff. Please know that we do our very best to keep academics notified of any and all injuries we are aware of in a timely manner. We truly appreciate your patience and understanding as we deal with these sometime very difficult situations. We take all injuries and illnesses very seriously, particularly concussions, and in the end we all only want what is in the best interest of our student athlete. If you ever have any questions or concerns, please do not hesitate to contact our Sports Medicine Department through our Athletic Academic Office. Again, thank you for your understanding. Respectfully: David Gable, MS, ATC, LAT Associate Director – Sports Medicine Head Athletic Trainer - Football Michele Kirk, MD Head Team Physician - TCU TCU Concussion Protocol for Evaluation and Management A. Preseason Evaluation a. Baseline SCAT 3 all sports i. To be performed by appropriately trained ATC, GA, or physician ii. To include balance testing portion of SCAT 3 1. All athletes to be balance tested using modified BESS, barefoot b. Baseline C 3 Logix for the following sports i. Basketball, football, baseball, equestrian, diving, volleyball, soccer, pole vaulting ii. Athletes in other sports with significant history of concussion c. Team physician will determine final clearance on all athletes following preparticipation evaluation B. In-Season Evaluation a. If concern for signs, symptoms or behaviors consistent with concussion an athlete may be removed from practice or play by a: i. Coach, ATC staff or student, GA, physician, athlete himself or herself b. Initial evaluation will include examination for cervical spine injury, skull fracture, potential brain bleed or any other serious bodily injury. If any of these are suspected the appropriate emergency action plan (EAP) for that venue will be initiated c. Evaluation by the athletic training staff and/or physician will follow removal from activity i. Evaluation to include SCAT 3 (to be compared to baseline), neurologic exam (serial), other exam deemed appropriate by injury and medical staff ii. Athletes diagnosed with a concussion will NOT be returned to play the same day iii. Serial monitoring by the athletic training staff, team physician or team physician designee will be employed to monitor for deterioration of symptoms 1. Should deterioration of symptoms or concerning symptoms present to include, but not limited to, prolonged loss of consciousness, focal neurological deficit, or spine injury, and it is deemed necessary by the medical staff, the athlete may be transported to the nearest emergency department (ED) per EAP for that venue iv. If it has not already occurred, evaluation by the team physician will happen as soon as available, but within a maximum of 24 hours, unless the injury happens while traveling. Then the injury will be discussed via phone with the team physician(s) and team ATC. d. Athlete(s) Discharged i. Will be discharged with written instructions to include, but not limited to what activities to avoid, what meds can and can’t be taken, and when to follow-up 1. A copy of the above will be kept in the athlete’s medical file ii. Will be discharged to a responsible party, to include: 1. Roommate, family member, friend, or significant other iii. Academic services will be notified by the team physician(s) concerning the athlete’s diagnosis and physician’s recommendations as to academic activity every 1-2 days until full clearance C. Return to Activity a. Athletes will be seen every 1-2 days by the team physician(s) until symptom free b. Once the athlete is symptom free, the SCAT 3 will be re-administered (minimum of symptoms of modified BESS) and compared to baseline c. If symptom free and the SCAT 3 is similar to baseline (to be interpreted by physician), the C 3 Logix neurocognitive test will be administered and compared to baseline d. If the C 3 Logix is within acceptable parameters of baseline (to be interpreted by physician), then the athlete will be cleared to start the return to play (RTP) protocol under the guidance of the team ATC and physician(s) i. RTP protocol used is established by the 4th International Conference on Concussions in Sport, Zurich 2012 (Zurich Guidelines) D. Referrals/testing a. Imaging i. At the discretion of the treating physician b. Specialty Referrals, i.e. Neurologist, Neuropsychologist, Sports Psychologist, Psychologist, Psychiatrist, Vision specialist, Physical Therapist trained in vestibular and oculomotor therapy, etc… i. At the discretion of the treating physician Roles In Concussion Management A. ATCs may perform the following roles in concussion management: a. Evaluation i. Remove any athlete exhibiting signs, symptoms, or behaviors consistent with a concussion from practice/play ii. Perform an exam on athlete suspected of having a concussion 1. Exam to include, but not limited to: SCAT 3, neurological exam, further exam pertaining to injury or deemed necessary by ATC iii. Diagnose athlete(s) with concussion and remove from play for the remainder of the day iv. Monitor (serial monitoring) athlete for deterioration of symptoms v. Determine whether further treatment is needed at an emergency facility b. Management i. Notify team physician(s) of athlete(s) with concussions as soon as able ii. Direct athlete to see team physician when team physician available iii. Provide athlete with written instructions for concussion management iv. Discharge athlete to responsible party with follow-up care scheduled c. Return to Activity i. Work with team physician(s) to monitor athlete for symptoms (number and severity) daily ii. Create/direct return to play (RTP) protocol once athlete is cleared iii. Notify team physician(s) if any symptoms develop/return during RTP protocol B. Team Physician(s) may perform the following roles in concussion management: a. Evaluation i. Remove any athlete exhibiting signs, symptoms, or behaviors consistent with a concussion from practice/play ii. Perform an exam on athlete suspected of having a concussion 1. Exam to include, but not limited to: SCAT 3, neurological exam, further exam pertaining to injury or as deemed necessary by physician iii. Diagnose athlete(s) with concussion and remove from play for the remainder of the day iv. Monitor (serial monitoring) athlete for deterioration of symptoms v. Determine whether further treatment is needed at an emergency facility b. Management i. Evaluate athlete within 24 hours of injury, unless athlete is traveling. Then the physician(s) will coordinate care with the team ATC via phone until the athlete returns to campus to be evaluated. ii. Provide athlete with written instructions for concussion management when appropriate iii. Discharge athlete(s) to a responsible party with follow-up care scheduled iv. Notify Academic Services of athlete’s diagnosis and activity/academic restrictions every 1-2 days v. Prescribe appropriate medications as needed vi. Refer to appropriate outside services as necessary and at any time, such as: 1. Imaging-CT, MRI, etc. 2. Neuropsychological Testing (formal) with licensed neuropsychologist 3. Neurologist c. Return to Activity i. Monitor athlete for symptoms (number and severity) in conjunction with the team ATC ii. Perform appropriate testing when athlete is symptom free to determine clearance to start RTP protocol 1. Testing may include, but is not limited to: SCAT 3, AXON Sport neurocognitive test, neurological exam, etc iii. Follow/create RTP protocol in conjunction with ATC to monitor for return of concussive symptoms C. Neurologist a. None on TCU Staff or Campus b. Outside Referral c. To be involved when referral is deemed necessary by TCU team physician d. Role: To act in normal capacity as a consultant D. Neuropsychologist (one with experience in sport concussion is preferable) a. None on TCU Staff or Campus b. Outside Referral c. To be involved when referral is deemed necessary by TCU team physician d. Role: To act in normal capacity as a consultant E. Health and Wellness Committee a. This committee meets once a month (or more if needed) to discuss potential issues facing TCU student athletes b. Athletes with ongoing concussion symptoms lasting longer than 2 weeks and/or causing any academic or other stress will be discussed to insure everyone is educated on the situation c. This committee will be comprised of staff members representing: Athletic Department Administration Sports Medicine (Athletic Trainer and Team Physician) Athletic Academics Nutrition Compliance Strength and Conditioning d. Information will be disseminated to Campus Life, Professors, Coaches and any other TCU staff member who plays a role in insuring the overall health, wellbeing and success of the student athlete as indicated during the meeting Return to Learn Protocol A. B. C. D. E. F. G. H. Physical Rest a. Athletes are placed on both physical and cognitive rest upon diagnosis of a concussion. Cognitive Rest a. Athletes are placed on both physical and cognitive rest upon diagnosis of a concussion. b. Cognitive rest can include any or all of the following: i. No attendance of classes ii. No studying iii. No electronics (TV, phone, computer, video games) Athletes are seen by team physicians on a daily to every other day schedule and the following are evaluated and discussed: a. Number of symptoms b. Severity of symptoms c. Physical exam Return to Learn decisions are based on the following: a. INDIVIDUALIZED to each athlete b. Number and severity of symptoms c. Physical exam and general health Return to learn options may include any or all of the following and are always INDIVIDUALIZED: a. Partial return to classes (example: 4 classes in one day but athlete only attends 2) i. May modify classes as needed such as: no computer work, no watching of videos, use of sunglasses and/or earplugs, etc… ii. Athlete is instructed to leave class upon increase of symptoms or return of symptoms b. Full return to classes i. May modify classes as needed such as: no computer work, no watching of videos, use of sunglasses and/or earplugs, etc… ii. Athlete is instructed to leave class upon increase of symptoms or return of symptoms c. Studying in small increments with frequent breaks (example: 20-30 minutes of studying followed by a 10-15 min break), i. Studying may continue as long as symptoms do not return or worsen Progression of return to learn a. INDIVIDUALIZED to each athlete b. Dependent upon same criteria as D c. May include any of the options listed in E d. Athlete will be re-evaluated by the team physician if symptoms worsen or return with academic challenges Academics a. Academic advisor (for each sport) to be point person for return to learn b. Notified of all athletes with a concussion c. Updated on a daily to every other day basis on their status of return to learn Prolonged Return to Learn a. INDIVIDUALIZED plan for each athlete b. Multidisciplinary approach with referrals to specialists as needed i. Specialists may include but are not limited to neurologist, neuropsychologist, psychiatrist, visual specialist, PT/OT with training in vestibular and oculomotor therapies c. Health and Wellness Committee involvement i. Meets once a month (more if needed) ii. Athletes with symptoms lasting longer than 2 weeks or experiencing significant academic issues would be discussed for possible accommodations and to update all necessary departments iii. Committee will be comprised of staff members representing: 1. Athletic Department Administration 2. Sports Medicine (Athletic Trainer and Team Physician) 3. Athletic Academics (including Learning Specialist) 4. Nutrition 5. Compliance 6. Strength and Conditioning iv. Information would be disseminated to Campus Life, professors, coaches, and any other departments deemed crucial to academic support and overall health and well-being of the athlete d. Return to learn and prolonged return to learn will comply with ADAAA and all other campus policies and resources to include our academic learning specialists and the Office of Disability Services Prevention of Concussion in Sport A. Education of athletes a. Athletes receive education yearly (see Pre-Practice Education in TCU Sports Medicine Concussion Management Plan) b. Education is provided to each sport by their respective athletic trainer c. Education includes, but is not limited to, how to recognize signs and symptoms of concussions, importance of reporting symptoms or suspected concussion to appropriate staff on themselves or a teammate, who they can report symptoms to, and procedures in place to help prevent concussions and treat athletes with concussions d. Athletes are required to sign a Concussion Education Form to document their concussion education e. Athletes are provided with a fact sheet on concussions from the CDC and NCAA to retain for their review B. Education of Coaching Staff a. All head coaches, assistant coaches, strength and conditioning staff, and other staff members involved with student athletes receive yearly education b. Education is provided by David Gable, Associate Director of Sports Medicine and Head Football Athletic Trainer c. Education includes, but is not limited to, how to recognize signs and symptoms of concussions, importance of reporting athletes with suspected concussions to the medical staff, and procedures in place to help prevent concussions and treat athletes with concussions d. All staff listed above must sign a sheet indicating they have been educated on and understand the importance of concussion safety protocols C. Baseline Testing a. See TCU Concussion Protocol for Evaluation and Management D. Equipment a. Properly fitting and appropriately maintained equipment is provided to all student athletes i. Primarily important for football athletes in the prevention of concussion ii. Well-fitting helmets may reduce the risk of concussion E. Practice Guidelines a. Best practice guidelines are followed as issued by the Big 12 Conference, effective 2014 F. Concussion Action Plan a. See TCU Concussion Protocol for Evaluation and Management b. See Roles in Concussion Management G. Injury Management System a. All injuries, including concussions, are tracked using an EMR (electronic medical records) Gable, David, ATC, LAT; Kirk, Michele, MD 2014 APPENDIX Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement Editor’s choice Scan to access more free content ▸ Additional material is published online only. To view these files please visit the journal online (http://dx.doi. org/10.1136/bjsports-2013092313). For numbered affiliations see end of article. Correspondence to: Dr Paul McCrory, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3084, Australia; paulmccr@bigpond.net.au Received 8 February 2013 Accepted 8 February 2013 To cite: McCrory P, Meeuwisse WH, Aubry M, et al. Br J Sports Med 2013;47:250–258. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Paul McCrory,1 Willem H Meeuwisse,2,3 Mark Aubry,4,5,6 Bob Cantu,7,8 Jiří Dvořák,9,10,11 Ruben J Echemendia,12,13 Lars Engebretsen,14,15,16 Karen Johnston,17,18 Jeffrey S Kutcher,19 Martin Raftery,20 Allen Sills,21 Brian W Benson,22,23,24 Gavin A Davis,25 Richard G Ellenbogen,26,27 Kevin Guskiewicz,28 Stanley A Herring,29,30 Grant L Iverson,31 Barry D Jordan,32,33,34 James Kissick,6,35,36,37 Michael McCrea,38 Andrew S McIntosh,39,40,41 David Maddocks,42 Michael Makdissi,43,44 Laura Purcell,45,46 Margot Putukian,47,48 Kathryn Schneider,49 Charles H Tator,50,51,52,53 Michael Turner54 PREAMBLE This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3 The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or converted to a digital format. The authors request that the document and/or the accompanying tools be distributed in their full and complete format. This consensus paper is broken into a number of sections 1. A summary of concussion and its management, with updates from the previous meetings; 2. Background information about the consensus meeting process; 3. A summary of the specific consensus questions discussed at this meeting; 4. The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT (designed for lay use). McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 SECTION 1: SPORT CONCUSSION AND ITS MANAGEMENT The Zurich 2012 document examines the sport concussion and management issues raised in the previous Vienna 2001, Prague 2004 and Zurich 2008 documents and applies the consensus questions from section 3 to these areas.1–3 Definition of concussion A panel discussion regarding the definition of concussion and its separation from mild traumatic brain injury (mTBI) was held. There was acknowledgement by the Concussion in Sport Group (CISG) that although the terms mTBI and concussion are often used interchangeably in the sporting context and particularly in the US literature, others use the term to refer to different injury constructs. Concussion is the historical term representing lowvelocity injuries that cause brain ‘shaking’ resulting in clinical symptoms and that are not necessarily related to a pathological injury. Concussion is a subset of TBI and will be the term used in this document. It was also noted that the term commotio cerebri is often used in European and other countries. Minor revisions were made to the definition of concussion, which is defined as follows: Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’ force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms 1 of 12 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged. Recovery of concussion The majority (80–90%) of concussions resolve in a short (7– 10 day) period, although the recovery time frame may be longer in children and adolescents.2 Symptoms and signs of acute concussion The diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, cognitive impairment, neurobehavioural features and sleep disturbance. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a preparticipation examination. The detailed clinical assessment of concussion is outlined in the SCAT3 and Child SCAT3 forms, which are given in the appendix to this document. The suspected diagnosis of concussion can include one or more of the following clinical domains: 1. Symptoms—somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability); 2. Physical signs (eg, loss of consciousness (LOC), amnesia); 3. Behavioural changes (eg, irritability); 4. Cognitive impairment (eg, slowed reaction times); 5. Sleep disturbance (eg, insomnia). If any one or more of these components are present, a concussion should be suspected and the appropriate management strategy instituted. On-field or sideline evaluation of acute concussion When a player shows ANY features of a concussion: A. The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury. B. The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged. C. Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools. D. The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury. E. A player with diagnosed concussion should not be allowed to RTP on the day of injury. Sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. In some sports, this may require rule change to allow an appropriate off-field medical assessment to occur without affecting the flow of the game or unduly penalising the injured player’s team. The final determination regarding concussion diagnosis and/or fitness to play is a medical decision based on clinical judgement. 2 of 12 Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the SCAT3, which incorporates the Maddocks’ questions4 5 and the Standardized Assessment of Concussion (SAC).6–8 It is worth noting that standard orientation questions (eg, time, place and person) have been shown to be unreliable in the sporting situation when compared with memory assessment.5 9 It is recognised, however, that abbreviated testing paradigms are designed for rapid concussion screening on the sidelines and are not meant to replace comprehensive neuropsychological testing which should ideally be performed by trained neuropsychologists who are sensitive to subtle deficits that may exist beyond the acute episode; nor should they be used as a stand-alone tool for the ongoing management of sports concussions. It should also be recognised that the appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode and that concussion should be seen as an evolving injury in the acute stage. Evaluation in the emergency room or office by medical personnel An athlete with concussion may be evaluated in the emergency room or doctor’s office as a point of first contact following injury or may have been referred from another care provider. In addition to the points outlined above, the key features of this examination should encompass: A. A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning, gait and balance. B. A determination of the clinical status of the patient, including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitnesses to the injury. C. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality. In large part, these points above are included in the SCAT3 assessment. Concussion investigations A range of additional investigations may be utilised to assist in the diagnosis and/or exclusion of injury. Conventional structural neuroimaging is typically normal in concussive injury. Given that caveat, the following suggestions are made: Brain CT (or where available an MR brain scan) contributes little to concussion evaluation but should be employed whenever suspicion of an intracerebral or structural lesion (eg, skull fracture) exists. Examples of such situations may include prolonged disturbance of the conscious state, focal neurological deficit or worsening symptoms. Other imaging modalities such as fMRI demonstrate activation patterns that correlate with symptom severity and recovery in concussion.10–14 Although not part of routine assessment at the present time, they nevertheless provide additional insight to pathophysiological mechanisms. Alternative imaging technologies (eg, positron emission tomography, diffusion tensor imaging, magnetic resonance spectroscopy, functional connectivity), while demonstrating some compelling findings, are still at early stages of development and cannot be recommended other than in a research setting. McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement Published studies, using both sophisticated force plate technology, as well as those using less sophisticated clinical balance tests (eg, Balance Error Scoring System (BESS)), have identified acute postural stability deficits lasting approximately 72 h following sports-related concussion. It appears that postural stability testing provides a useful tool for objectively assessing the motor domain of neurological functioning, and should be considered as a reliable and valid addition to the assessment of athletes suffering from concussion, particularly where the symptoms or signs indicate a balance component.15–21 The significance of Apolipoprotein (Apo) E4, ApoE promoter gene, Tau polymerase and other genetic markers in the management of sports concussion risk or injury outcome is unclear at this time.22 23 Evidence from human and animal studies in more severe traumatic brain injury demonstrates induction of a variety of genetic and cytokine factors such as: insulin-like growth factor 1 (IGF-1), IGF binding protein 2, Fibroblast growth factor, Cu-Zn superoxide dismutase, superoxide dismutase 1 (SOD-1), nerve growth factor, glial fibrillar acidic protein (GFAP) and S-100. How such factors are affected in sporting concussion is not known at this stage.24–31 In addition, biochemical serum and cerebral spinal fluid biomarkers of brain injury (including S-100, neuron-specific enolase (NSE), myelin basic protein (MBP), GFAP, tau, etc) have been proposed as a means by which cellular damage may be detected if present.32–38 There is currently insufficient evidence, however, to justify the routine use of these biomarkers clinically. Different electrophysiological recording techniques (eg, evoked response potential (ERP), cortical magnetic stimulation and electroencephalography) have demonstrated reproducible abnormalities in the postconcussive state; however, not all studies reliably differentiated concussed athletes from controls.39–45 The clinical significance of these changes remains to be established. Neuropsychological assessment The application of neuropsychological (NP) testing in concussion has been shown to be of clinical value and contributes significant information in concussion evaluation.46–51 Although cognitive recovery largely overlaps with the time course of symptom recovery in most cases, it has been demonstrated that cognitive recovery may occasionally precede or more commonly follow clinical symptom resolution, suggesting that the assessment of cognitive function should be an important component in the overall assessment of concussion and, in particular, any RTP protocol.52 53 It must be emphasised, however, that NP assessment should not be the sole basis of management decisions. Rather, it should be seen as an aid to the clinical decisionmaking process in conjunction with a range of assessments of different clinical domains and investigational results. It is recommended that all athletes should have a clinical neurological assessment (including assessment of their cognitive function) as part of their overall management. This will normally be performed by the treating physician often in conjunction with computerised neuropsychological screening tools. Formal NP testing is not required for all athletes; however, when this is considered necessary, it should ideally be performed by a trained neuropsychologist. Although neuropsychologists are in the best position to interpret NP tests by virtue of their background and training, the ultimate RTP decision should remain a medical one in which a multidisciplinary approach, when possible, has been taken. In the absence of NP and other (eg, formal balance assessment) testing, a more conservative RTP approach may be appropriate. McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 NP testing may be used to assist RTP decisions and is typically performed when an athlete is clinically asymptomatic; however, NP assessment may add important information in the early stages following injury.54 55 There may be particular situations where testing is performed early to assist in determining aspects of management, for example, return to school in a paediatric athlete. This will normally be best determined in consultation with a trained neuropsychologist.56 57 Baseline NP testing was considered by the panel and was not felt to be required as a mandatory aspect of every assessment; however, it may be helpful to add useful information to the overall interpretation of these tests. It also provides an additional educative opportunity for the physician to discuss the significance of this injury with the athlete. At present, there is insufficient evidence to recommend the widespread routine use of baseline neuropsychological testing. Concussion management The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded programme of exertion prior to medical clearance and RTP. The current published evidence evaluating the effect of rest following a sports-related concussion is sparse. An initial period of rest in the acute symptomatic period following injury (24–48 h) may be of benefit. Further research to evaluate the long-term outcome of rest, and the optimal amount and type of rest, is needed. In the absence of evidence-based recommendations, a sensible approach involves the gradual return to school and social activities ( prior to contact sports) in a manner that does not result in a significant exacerbation of symptoms. Low-level exercise for those who are slow to recover may be of benefit, although the optimal timing following injury for initiation of this treatment is currently unknown. As described above, the majority of injuries will recover spontaneously over several days. In these situations, it is expected that an athlete will proceed progressively through a stepwise RTP strategy.58 Graduated RTP protocol RTP protocol following a concussion follows a stepwise process as outlined in table 1. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 h so that an athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any postconcussion symptoms occur while in the stepwise programme, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24 h period of rest has passed. Same day RTP It was unanimously agreed that no RTP on the day of concussive injury should occur. There are data demonstrating that at the collegiate and high school levels, athletes allowed to RTP on the same day may demonstrate NP deficits postinjury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms.59–65 ‘Difficult’ or persistently symptomatic concussion patient Persistent symptoms (>10 days) are generally reported in 10–15% of concussions. In general, symptoms are not specific to concussion and it is important to consider other pathologies. 3 of 12 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement Table 1 Graduated return to play protocol Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage 1. No activity Symptom limited physical and cognitive rest Walking, swimming or stationary cycling keeping intensity <70% maximum permitted heart rate No resistance training Skating drills in ice hockey, running drills in soccer. No head impact activities Progression to more complex training drills, eg, passing drills in football and ice hockey May start progressive resistance training Following medical clearance participate in normal training activities Normal game play Recovery 2. Light aerobic exercise 3. Sport-specific exercise 4. Non-contact training drills 5. Full-contact practice 6. Return to play Increase HR Add movement Exercise, coordination and cognitive load Restore confidence and assess functional skills by coaching staff Cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion. just the perceived number of past concussions. It is also worth noting that dependence on the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable.69 The clinical history should also include information about all previous head, face or cervical spine injuries as these may also have clinical relevance. It is worth emphasising that in the setting of maxillofacial and cervical spine injuries, coexistent concussive injuries may be missed unless specifically assessed. Questions pertaining to disproportionate impact versus symptom severity matching may alert the clinician to a progressively increasing vulnerability to injury. As part of the clinical history, it is advised that details regarding protective equipment employed at the time of injury be sought, both for recent and remote injuries. There is an additional and often unrecognised benefit of the preparticipation physical examination insofar as the evaluation allows for an educative opportunity with the player concerned as well as consideration of modification of playing behaviour if required. Modifying factors in concussion management A range of ‘modifying’ factors may influence the investigation and management of concussion and, in some cases, may predict the potential for prolonged or persistent symptoms. However, in some cases, the evidence for their efficacy is limited. These modifiers would be important to consider in a detailed concussion history and are outlined in table 2. Female gender Psychological approaches may have potential application in this injury, particularly with the modifiers listed below.66 67 Physicians are also encouraged to evaluate the concussed athlete for affective symptoms such as depression and anxiety as these symptoms are common in all forms of traumatic brain injury.58 The role of female gender as a possible modifier in the management of concussion was discussed at length by the panel. There was no unanimous agreement that the current published research evidence is conclusive enough for this to be included as a modifying factor, although it was accepted that gender may be a risk factor for injury and/or influence injury severity.73–75 Role of pharmacological therapy Significance of LOC Psychological management and mental health issues Pharmacological therapy in sports concussion may be applied in two distinct situations. The first of these situations is the management of specific and/or prolonged symptoms (eg, sleep disturbance, anxiety, etc). The second situation is where drug therapy is used to modify the underlying pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms.68 In broad terms, this approach to management should be only considered by clinicians experienced in concussion management. An important consideration in RTP is that concussed athletes should not only be symptom-free, but also they should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion. Where antidepressant therapy may be commenced during the management of a concussion, the decision to RTP while still on such medication must be considered carefully by the treating clinician. In the overall management of moderate-to-severe traumatic brain injury, duration of LOC is an acknowledged predictor of Table 2 Concussion modifiers Factors Modifier Symptoms Number Duration (>10 days) Severity Prolonged loss of consciousness (LOC) (>1 min), Amnesia Concussive convulsions Frequency—repeated concussions over time Timing—injuries close together in time ‘Recency’—recent concussion or traumatic brain injury (TBI) Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Child and adolescent (<18 years old) Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Psychoactive drugs, anticoagulants Dangerous style of play High-risk activity, contact and collision sport, high sporting level Signs Sequelae Temporal Threshold Role of preparticipation concussion evaluation Recognising the importance of a concussion history, and appreciating the fact that many athletes will not recognise all the concussions they may have suffered in the past, a detailed concussion history is of value.69–72 Such a history may preidentify athletes who fit into a high-risk category and provides an opportunity for the healthcare provider to educate the athlete in regard to the significance of concussive injury. A structured concussion history should include specific questions as to previous symptoms of a concussion and length of recovery; not 4 of 12 Age Comorbidities and premorbidities Medication Behaviour Sport McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement outcome.76 Although published findings in concussion describe LOC associated with specific, early cognitive deficits, it has not been noted as a measure of injury severity.77 78 Consensus discussion determined that prolonged (>1 min duration) LOC would be considered as a factor that may modify management. There is renewed interest in the role of post-traumatic amnesia and its role as a surrogate measure of injury severity.64 79 80 Published evidence suggests that the nature, burden and duration of the clinical postconcussive symptoms may be more important than the presence or duration of amnesia alone.77 81 82 Further, it must be noted that retrograde amnesia varies with the time of measurement postinjury and hence is poorly reflective of injury severity.83 84 symptoms. School attendance and activities may also need to be modified to avoid provocation of symptoms. Children should not be returned to sport until clinically completely symptom-free, which may require a longer time frame than for adults. Because of the different physiological response and longer recovery after concussion and specific risks (eg, diffuse cerebral swelling) related to head impact during childhood and adolescence, a more conservative RTP approach is recommended. It is appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents. It is not appropriate for a child or adolescent athlete with concussion to RTP on the same day as the injury, regardless of the level of athletic performance. Concussion modifiers apply even more to this population than adults and may mandate more cautious RTP advice. Motor and convulsive phenomena Elite versus non-elite athletes A variety of immediate motor phenomena (eg, tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.85 86 All athletes, regardless of the level of participation, should be managed using the same treatment and RTP paradigm. The available resources and expertise in concussion evaluation are of more importance in determining management than a separation between elite and non-elite athlete management. Although formal NP testing may be beyond the resources of many sports or individuals, it is recommended that, in all organised high-risk sports, consideration be given to having this cognitive evaluation, regardless of the age or level of performance. Significance of amnesia and other symptoms Depression Mental health issues (such as depression) have been reported as a consequence of all levels of traumatic brain injury including sports-related concussion. Neuroimaging studies using fMRI suggest that a depressed mood following concussion may reflect an underlying pathophysiological abnormality consistent with a limbic-frontal model of depression.34 87–97 Although such mental health issues may be multifactorial in nature, it is recommended that the treating physician consider these issues in the management of concussed patients. SPECIAL POPULATIONS Child and adolescent athlete The evaluation and management recommendations contained herein can be applied to children and adolescents down to the age of 13 years. Below that age, children report concussion symptoms different from adults and would require age-appropriate symptom checklists as a component of assessment. An additional consideration in assessing the child or adolescent athlete with a concussion is that the clinical evaluation by the healthcare professional may need to include both patient and parent input, and possibly teacher and school input when appropriate.98–104 A child SCAT3 has been developed to assess concussion (see appendix) for individuals aged 5–12 years. The decision to use NP testing is broadly the same as the adult assessment paradigm, although there are some differences. The timing of testing may differ in order to assist planning in school and home management. If cognitive testing is performed, then it must be developmentally sensitive until late teen years due to the ongoing cognitive maturation that occurs during this period, which in turn limits the utility of comparison to either the person’s own baseline performance or to population norms.20 In this age group, it is more important to consider the use of trained paediatric neuropsychologists to interpret assessment data, particularly in children with learning disorders and/or ADHD who may need more sophisticated assessment strategies.56 57 98 It was agreed by the panel that no return to sport or activity should occur before the child/adolescent athlete has managed to return to school successfully. In addition, the concept of ‘cognitive rest’ was highlighted with special reference to a child’s need to limit exertion with activities of daily living that may exacerbate McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 Chronic traumatic encephalopathy Clinicians need to be mindful of the potential for long-term problems in the management of all athletes. However, it was agreed that chronic traumatic encephalopathy (CTE) represents a distinct tauopathy with an unknown incidence in athletic populations. It was further agreed that a cause and effect relationship has not as yet been demonstrated between CTE and concussions or exposure to contact sports.105–114 At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also recognised that it is important to address the fears of parents/athletes from media pressure related to the possibility of CTE. INJURY PREVENTION Protective equipment—mouthguards and helmets There is no good clinical evidence that currently available protective equipment will prevent concussion, although mouthguards have a definite role in preventing dental and orofacial injury. Biomechanical studies have shown a reduction in impact forces to the brain with the use of head gear and helmets, but these findings have not been translated to show a reduction in concussion incidence. For skiing and snowboarding, there are a number of studies to suggest that helmets provide protection against head and facial injury and hence should be recommended for participants in alpine sports.115–118 In specific sports such as cycling, motor and equestrian sports, protective helmets may prevent other forms of head injury (eg, skull fracture) that are related to falling on hard surfaces and may be an important injury prevention issue for those sports.118–130 Rule change Consideration of rule changes to reduce the head injury incidence or severity may be appropriate where a clear-cut mechanism is implicated in a particular sport. An example of this is in football (soccer) where research studies demonstrated that upper limb to head contact in heading contests accounted for approximately 50% of concussions.131 As noted earlier, rule changes 5 of 12 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement may also be needed in some sports to allow an effective off-field medical assessment to occur without compromising the athlete’s welfare, affecting the flow of the game or unduly penalising the player’s team. It is important to note that rule enforcement may be a critical aspect of modifying injury risk in these settings, and referees play an important role in this regard. Risk compensation An important consideration in the use of protective equipment is the concept of risk compensation.132 This is where the use of protective equipment results in behavioural change such as the adoption of more dangerous playing techniques, which can result in a paradoxical increase in injury rates. The degree to which this phenomenon occurs is discussed in more detail in the review published in this supplement of the journal. This may be a matter of particular concern in child and adolescent athletes where the head injury rates are often higher than in adult athletes.133–135 Aggression versus violence in sport The competitive/aggressive nature of sport that makes it fun to play and watch should not be discouraged. However, sporting organisations should be encouraged to address violence that may increase concussion risk.136 137 Fair play and respect should be supported as key elements of sport. Knowledge transfer As the ability to treat or reduce the effects of concussive injury after the event is minimal, education of athletes, colleagues and the general public is a mainstay of progress in this field. Athletes, referees, administrators, parents, coaches and healthcare providers must be educated regarding the detection of concussion, its clinical features, assessment techniques and principles of safe RTP. Methods to improve education including web-based resources, educational videos and international outreach programmes are important in delivering the message. In addition, concussion working groups, plus the support and endorsement of enlightened sport groups such as Fédération Internationale de Football Association (FIFA), International Olympic Commission (IOC), International Rugby Board (IRB) and International Ice Hockey Federation (IIHF), who initiated this endeavour, have enormous value and must be pursued vigorously. Fair play and respect for opponents are ethical values that should be encouraged in all sports and sporting associations. Similarly, coaches, parents and managers play an important part in ensuring that these values are implemented on the field of play.58 138–150 SECTION 2: STATEMENT ON BACKGROUND TO THE CONSENSUS PROCESS In November 2001, the 1st International Conference on Concussion in Sport was held in Vienna, Austria. This meeting was organised by the IIHF in partnership with FIFA and the Medical Commission of the IOC. As part of the resulting mandate for the future, the need for leadership and future updates was identified. The 2nd International Conference on Concussion in Sport was organised by the same group with the additional involvement of the IRB and was held in Prague, the Czech Republic, in November 2004. The original aims of the symposia were to provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in ice hockey, rugby, football (soccer) as well as other sports. To this end, a range of experts were invited to both meetings to address specific issues of epidemiology, basic and 6 of 12 clinical science, injury grading systems, cognitive assessment, new research methods, protective equipment, management, prevention and long-term outcome.1 2 The 3rd International Conference on Concussion in Sport was held in Zurich, Switzerland on 29/30 October 2008 and was designed as a formal consensus meeting following the organisational guidelines set forth by the US National Institutes of Health. (Details of the consensus methodology can be obtained at: http://consensus.nih.gov/ABOUTCDP.htm.) The basic principles governing the conduct of a consensus development conference are summarised below: 1. A broad-based non-government, non-advocacy panel was assembled to give balanced, objective and knowledgeable attention to the topic. Panel members excluded anyone with scientific or commercial conflicts of interest and included researchers in clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training and sports science. 2. These experts presented data in a public session, followed by inquiry and discussion. The panel then met in an executive session to prepare the consensus statement. 3. A number of specific questions were prepared and posed in advance to define the scope and guide the direction of the conference. The principal task of the panel was to elucidate responses to these questions. These questions are outlined below. 4. A systematic literature review was prepared and circulated in advance for use by the panel in addressing the conference questions. 5. The consensus statement is intended to serve as the scientific record of the conference. 6. The consensus statement will be widely disseminated to achieve maximum impact on both current healthcare practice and future medical research. The panel chairperson (WM) did not identify with any advocacy position. The chairperson was responsible for directing the consensus session and guiding the panel’s deliberations. Panellists were drawn from clinical practice, academics and research in the field of sports-related concussion. They do not represent organisations per se, but were selected for their expertise, experience and understanding of this field. The 4th International Conference on Concussion in Sport was held in Zurich, Switzerland on 1–3 November 2012 and followed the same outline as for the third meeting. All speakers, consensus panel members and abstract authors were required to sign an ICMJE Form for Disclosure of Potential Conflicts of Interest. Detailed information related to each author’s affiliations and conflicts of interests will be made publicly available on the CISG website and published with the BJSM supplement. Medical legal considerations This consensus document reflects the current state of knowledge and will need to be modified according to the development of new knowledge. It provides an overview of issues that may be of importance to healthcare providers involved in the management of sports-related concussion. It is not intended as a standard of care, and should not be interpreted as such. This document is only a guide, and is of a general nature, consistent with the reasonable practice of a healthcare professional. Individual treatment will depend on the facts and circumstances specific to each individual case. It is intended that this document will be formally reviewed and updated prior to 1 December 2016. McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement SECTION 3: ZURICH 2012 CONSENSUS QUESTIONS How can the SCAT2 be improved? Note that each question is the subject of a separate systematic review that is published in the BJSM (2013:47:5). As such, all citations and details of each topic will be covered in those reviews. It was agreed that a variety of measures should be employed as part of the assessment of concussion to provide a more complete clinical profile for the concussed athlete. Important clinical information can be ascertained in a streamlined manner through the use of a multimodal instrument such as the Sport Concussion Assessment Tool (SCAT). A baseline assessment is advised wherever possible. However, it is acknowledged that further validity studies need to be performed to answer this specific issue. A future SCAT test battery (ie, SCAT3) should include an initial assessment of injury severity using the Glasgow Coma Scale (GCS), immediately followed by observing and documenting concussion signs. Once this is complete, symptom endorsement and symptom severity, as well as neurocognitive and balance functions, should be assessed in any athlete suspected of sustaining a concussion. It is recommended that these latter steps be conducted following a minimum 15 min rest period on the sideline to avoid the influence of exertion or fatigue on the athlete’s performance. Although it is noted that this time frame is an arbitrary one, the expert panel agreed nevertheless that a period of rest was important prior to assessment. Future research should consider the efficacy for inclusion of vision tests such as the King Devick Test and clinical reaction time tests.155 156 Recent studies suggest that these may be useful additions to the sideline assessment of concussion. However, the need for additional equipment may make them impractical for sideline use. It was further agreed that the SCAT3 would be suitable for adults and youths aged 13 and over and that a new tool (Child SCAT3) be developed for younger children. When you assess an athlete acutely and they do not have a concussion, what is it? Is a cognitive injury the key component of concussion in making a diagnosis? The consensus panel agreed that concussion is an evolving injury in the acute phase with rapidly changing clinical signs and symptoms, which may reflect the underlying physiological injury in the brain. Concussion is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage. A majority of concussions in sport occur without LOC or frank neurological signs. At present, there is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of concussion in the sporting environment. Because of this evolving process, it is not possible to rule out concussion when an injury event occurs associated with a transient neurological symptom. All such cases should be removed from the playing field and assessed for concussion by the treating physician or healthcare provider as discussed below. It was recognised that a cognitive deficit is not necessary for acute diagnosis as it either may not be present or detected on examination. Are the existing tools/examination sensitive and reliable enough on the day of injury to make or exclude a diagnosis of concussion? Concussion is a clinical diagnosis based largely on the observed injury mechanism, signs and symptoms. The vast majority of sports-related concussions (hereafter, referred to as concussion) occur without LOC or frank neurological signs.151–154 In milder forms of concussion, the athlete might be slightly confused, without clearly identifiable amnesia. In addition, most concussions cannot be identified or diagnosed by neuroimaging techniques (eg, CT or MRI). Several well-validated neuropsychological tests are appropriate for use in the assessment of acute concussion in the competitive sporting environment. These tests provide important data on symptoms and functional impairments that clinicians can incorporate into their diagnostic formulation, but should not solely be used to diagnose concussion. What is the best practice for evaluating an adult athlete with concussion on the ‘field of play’ in 2012? Recognising and evaluating concussion in the adult athlete on the field is a challenging responsibility for the healthcare provider. Performing this task is often a rapid assessment in the midst of competition with a time constraint and the athlete eager to play. A standardised objective assessment of injury, which includes excluding more serious injury, is critical in determining disposition decisions for the athlete. The on-field evaluation of sports-related concussion is often a challenge given the elusiveness and variability of presentation, difficulty in making a timely diagnosis, specificity and sensitivity of sideline assessment tools, and the reliance on symptoms. Despite these challenges, the sideline evaluation is based on recognition of injury, assessment of symptoms, cognitive and cranial nerve function, and balance. Serial assessments are often necessary. Concussion is often an evolving injury, and signs and symptoms may be delayed. Therefore, erring on the side of caution (keeping an athlete out of participation when there is any suspicion for injury) is important. An SAC is useful in the assessment of the athlete with suspected concussion but should not take the place of the clinician’s judgement. McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 Advances in neuropsychology: are computerised tests sufficient for concussion diagnosis? Sports-related concussions are frequently associated with one or more symptoms, impaired balance and/or cognitive deficits. These problems can be measured using symptom scales, balance testing and neurocognitive testing. All three modalities can identify significant changes in the first few days following injury, generally with normalisation over 1–3 weeks. The presentation of symptoms and the rate of recovery can be variable, which reinforces the value of assessing all three areas as part of a comprehensive sport concussion programme. Neuropsychological assessment has been described by the CISG as a ‘cornerstone’ of concussion management. Neuropsychologists are uniquely qualified to interpret neuropsychological tests and can play an important role within the context of a multifaceted-multimodal and multidisciplinary approach to managing sports-related concussion. Concussion management programmes that use neuropsychological assessment to assist in clinical decision-making have been instituted in professional sports, colleges and high schools. Brief computerised cognitive evaluation tools are the mainstay of these assessments worldwide, given the logistical limitation in accessing trained neuropsychologists; however, it should be noted that these are not substitutes for formal neuropsychological assessment. At present, there is insufficient evidence to recommend the widespread routine use of baseline neuropsychological testing. What evidence exists for new strategies/technologies in the diagnosis of concussion and assessment of recovery? A number of novel technological platforms exist to assess concussion including (but not limited to) iPhone/smart phone apps, quantitative electroencephalography, robotics—sensory motor 7 of 12 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement assessment, telemedicine, eye-tracking technology, functional imaging/advanced neuroimaging and head impact sensors. At this stage, only limited evidence exists for their role in this setting and none have been validated as diagnostic. It will be important to reconsider the role of these technologies once evidence is developed. Advances in the management of sport concussion: what is evidence for concussion therapies The current evidence evaluating the effect of rest and treatment following a sports-related concussion is sparse. An initial period of rest may be of benefit. However, further research to evaluate the long-term outcome of rest, and the optimal amount and type of rest, is needed. Low-level exercise for those who are slow to recover may be of benefit, although the optimal timing following injury for initiation of this treatment is currently unknown. Multimodal physiotherapy treatment for individuals with clinical evidence of cervical spine and/or vestibular dysfunction may be of benefit. There is a strong need for high-level studies evaluating the effects of a resting period, pharmacological interventions, rehabilitative techniques and exercise for individuals who have sustained a sports-related concussion. The difficult concussion patient—What is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms? Persistent symptoms (>10 days) are generally reported in 10–15% of concussions. This may be higher in certain sports (eg, elite ice hockey) and populations (eg, children). In general, symptoms are not specific to concussion and it is important to consider and manage co-existent pathologies. Investigations may include formal neuropsychological testing and conventional neuroimaging to exclude structural pathology. Currently, there is insufficient evidence to recommend routine clinical use of advanced neuroimaging techniques or other investigative strategies. Cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion. Important components of management after the initial period of physical and cognitive rest include associated therapies such as cognitive, vestibular, physical and psychological therapy, consideration of assessment of other causes of prolonged symptoms and consideration of commencement of a graded exercise programme at a level that does not exacerbate symptoms. Revisiting concussion modifiers: how should the evaluation and management of acute concussion differ in specific groups? The literature demonstrates that the number and severity of symptoms and previous concussions are associated with prolonged recovery and/or increased risk of complications. Brief LOC, duration of post-traumatic amnesia and/or impact seizures do not reliably predict outcome following concussion, although a cautious approach should be taken in an athlete with prolonged LOC (ie, >1 min). Children generally take longer to recover from concussions and assessment batteries have yet to be validated in the younger age group. Currently, there are insufficient data on the influence of genetics and gender on outcome following concussion. Several modifiers are associated with prolonged recovery or increased risk of complications following concussion and have important implications for management. Children with concussion should be managed conservatively, with the emphasis on return to learn before return to sport. In cases of concussion 8 of 12 managed with limited resources (eg, non-elite players), a conservative approach should also be taken such that the athlete does not return to sport until fully recovered. What are the most effective risk reduction strategies in sport concussion?—from protective equipment to policy? No new valid evidence was provided to suggest that the use of current standard headgear in rugby, or of mouthguards in American football, can significantly reduce players’ risk of concussion. No evidence was provided to suggest an association between neck strength increases and concussion risk reduction. There was evidence to suggest that eliminating body checking from Pee Wee ice hockey (ages 11–12 years) and fair-play rules in ice hockey were effective injury prevention strategies. Helmets need to be able to protect from impacts resulting in a head change in velocity of up to 10 m/s in professional American football, and up to 7 m/s in professional Australian football. It also appears that helmets must be capable of reducing head-resultant linear acceleration to below 50 g and angular acceleration components to below 1500 rad/s2 to optimise their effectiveness. Given that a multifactorial approach is needed for concussion prevention, well-designed and sport-specific prospective analytical studies of sufficient power are warranted for mouthguards, headgear/helmets, facial protection and neck strength. Measuring the effect of rule changes should also be addressed by future studies, not only assessing new rule changes or legislation, but also alteration or reinforcement to existing rules. What is the evidence for chronic concussion-related changes?—behavioural, pathological and clinical outcomes It was agreed that CTE represents a distinct tauopathy with an unknown incidence in athletic populations. It was further agreed that CTE was not related to concussions alone or simply exposure to contact sports. At present, there are no published epidemiological, cohort or prospective studies relating to modern CTE. Owing to the nature of the case reports and pathological case series that have been published, it is not possible to determine the causality or risk factors with any certainty. As such, the speculation that repeated concussion or subconcussive impacts cause CTE remains unproven. The extent to which age-related changes, psychiatric or mental health illness, alcohol/ drug use or co-existing medical or dementing illnesses contribute to this process is largely unaccounted for in the published literature. At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also recognised that it is important to address the fears of parents/ athletes from media pressure related to the possibility of CTE. From consensus to action—how do we optimise knowledge transfer, education and ability to influence policy? The value of knowledge transfer (KT) as part of concussion education is increasingly becoming recognised. Target audiences benefit from specific learning strategies. Concussion tools exist, but their effectiveness and impact require further evaluation. The media is valuable in drawing attention to concussion, but efforts need to ensure that the public is aware of the right information. Social media as a concussion education tool is becoming more prominent. Implementation of KT models is one approach organisations can use to assess knowledge gaps; identify, develop and evaluate education strategies; and use the outcomes to facilitate decision-making. Implementing KT strategies requires a defined plan. Identifying the needs, learning styles and preferred learning strategies of target audiences, coupled with evaluation, should be McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement a piece of the overall concussion education puzzle to have an impact on enhancing knowledge and awareness. Author affiliations 1 The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia 2 Faculty of Kinesiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada 3 Faculty of Medicine, Sport Injury Prevention Research Centre, Calgary, Alberta, Canada 4 International Ice Hockey Federation, Switzerland 5 IOC Medical Commission Games Group, Ottawa, Ontario, Canada 6 Ottawa Sport Medicine Centre, Ottawa, Ontario, Canada 7 Department of Neurosurgery, Boston University Medical Center, Boston, Massachusetts, USA 8 Center for the Study of Traumatic Encephalopathy, Boston University Medical Center, Boston, Massachusetts, USA 9 Department of Neurology, University of Zurich, Zurich, Switzerland 10 Schulthess Clinic Zurich, Zurich, Switzerland 11 F-MARC (FIFA Medical Assessment and Research Center), Zurich, Switzerland 12 Psychological and Neurobehavioral Associates, Inc., State College, Pennsylvania, USA 13 University of Missouri–Kansas City, Kansas City, Missouri, USA 14 Department of Orthopaedic Surgery, Oslo University Hospital and Faculty of Medicine, University of Oslo, Norway 15 Oslo Sports Trauma Research Center, Norway 16 International Olympic Committee (IOC), Lausanne, Switzerland 17 Division of Neurosurgery, University of Toronto, Toronto, Canada 18 Concussion Management Program Athletic Edge Sports Medicine, Toronto, Canada 19 Michigan NeuroSport, Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA 20 International Rugby Board, Dublin, Ireland 21 Department of Neurosurgery, Orthopaedic Surgery and Rehabilitation, Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA 22 Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada 23 Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada 24 Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada 25 Department of Neurosurgery, Austin and Cabrini Hospitals & The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia 26 Theodore S. Roberts Endowed Chair Department of Neurological Surgery University of Washington Seattle, WA, USA 27 NFL Head, Neck and Spine Medical Committee 28 Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina, USA 29 Clinical Professor Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, USA 30 Seattle Sports Concussion Program, Team Physician Seattle Seahawks and Seattle Mariners, Seattle, Washington, USA 31 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada 32 Weill Medical College of Cornell University, New York, New York, USA 33 Burke Rehabilitation Hospital, White Plains, New York, USA 34 New York State Athletic Commission. New York, New York, USA 35 Department of Family Medicine, University of Ottawa, Ottawa, Canada 36 Canadian National Men’s Sledge Hockey Team, Canada 37 National Football League Players Association (NFLPA) Mackey-White Traumatic Brain Injury Committee 38 Brain Injury Research, Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Wisconsin, USA 39 Australian Centre for Research into Injury in Sports and its Prevention, Monash Injury Research Institute, Monash University, Australia 40 Transport and Road Safety Research, Faculty of Science, the University of New South Wales, Australia 41 McIntosh Consultancy and Research Pty Ltd. Sydney, Australia 42 Perry Maddocks Trollope Lawyers, Melbourne, Australia 43 The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Austin Campus, Melbourne, Australia 44 Centre For Health Exercise and Sports Medicine, Melbourne Physiotherapy Department, University of Melbourne, Melbourne, Australia 45 Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada 46 David Braley Sport Medicine and Rehabilitation Centre, McMaster University, Hamilton, Ontario, Canada 47 Princeton University, New Jersey, USA 48 Robert Wood Johnson, University of Medicine and Dentistry of New Jersey (UMDNJ), USA 49 Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, McCrory P, et al. 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Clin J Sp Med 2004;14:193–6. Finch C, Mcintosh AS, McCrory P, et al. A pilot study of the attitudes of Australian Rules footballers towards protective headgear. J Sci Med Sport 2003;6:505–11. Finch CF, McIntosh AS, McCrory P. What do under 15-year-old schoolboy rugby union players think about protective headgear? BrJ Sports Med 2001;35:89–94. Finch C, Mcintosh AS, McCrory P. What is the evidence base for the use of protective headgear and mouthguards in Australian football. Sport Health 2000;18:35–8. Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med 2000;154:11–15. Shaw NH. Bodychecking in hockey. CMAJ 2004;170:15–16; author reply 6, 8. Denke NJ. Brain injury in sports. J Emerg Nurs 2008;34:363–4. Gianotti S, Hume PA. Concussion sideline management intervention for rugby union leads to reduced concussion claims. NeuroRehabilitation 2007;22:181–9. Guilmette TJ, Malia LA, McQuiggan MD. Concussion understanding and management among New England high school football coaches. Brain Inj 2007;21:1039–47. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 2007;42:311–19 Valovich McLeod TC, Schwartz C, Bay RC. Sport-related concussion misunderstandings among youth coaches. Clin J Sport Med 2007;17:140–2. Sye G, Sullivan SJ, McCrory P. High school rugby players’ understanding of concussion and return to play guidelines. Br J Sports Med 2006;40:1003–5. Theye F, Mueller KA. “Heads up”: concussions in high school sports. Clin Med Res 2004;2:165–71. Kashluba S, Paniak C, Blake T, et al. A longitudinal, controlled study of patient complaints following treated mild traumatic brain injury. Arch Clin Neuropsychol 2004;19:805–16. Gabbe B, Finch CF, Wajswelner H, et al. Does community-level Australian football support injury prevention research? J Sci Med Sport 2003;6:231–6. Kaut KP, DePompei R, Kerr J, et al. Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention. Clin J Sport Med 2003;13:213–21. Davidhizar R, Cramer C. The best thing about the hospitalization was that the nurses kept me well informed” issues and strategies of client education. Accid Emerg Nurs 2002;10:149–54. McCrory P. What advice should we give to athletes postconcussion? Br J Sports Med 2002;36:316–18. Bazarian JJ, Veenema T, Brayer AF, et al. Knowledge of concussion guidelines among practitioners caring for children. Clin Pediatr (Phila) 2001;40:207–12. Guskiewicz KM, Weaver NL, Padua DA Jr, et al. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med 2000;28:643–50. McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290:2556–63. Macciocchi SN, Barth JT, Alves W, et al. Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery 1996;39:510–14. 11 of 12 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement 154 Meehan WP III, d’Hemecourt P, Comstock RD. High school concussions in the 2008–2009 academic year: mechanism, symptoms, and management. Am J Sports Med 2010;38:2405–9. 155 156 12 of 12 Eckner JT, Kutcher JS, Richardson JK. Between-seasons test-retest reliability of clinically measured reaction time in National Collegiate Athletic Association Division I athletes. J Athl Train 2011;46:409–14. Eckner JT, Richardson JK, Kim H, et al. A novel clinical test of recognition reaction time in healthy adults. Psychol Assess 2012;24:249–54. McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313 Downloaded from bjsm.bmj.com on March 13, 2013 - Published by group.bmj.com Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Paul McCrory, Willem H Meeuwisse, Mark Aubry, et al. Br J Sports Med 2013 47: 250-258 doi: 10.1136/bjsports-2013-092313 Updated information and services can be found at: http://bjsm.bmj.com/content/47/5/250.full.html These include: Data Supplement "Supplementary Data" http://bjsm.bmj.com/content/suppl/2013/03/11/47.5.250.DC1.html References This article cites 153 articles, 34 of which can be accessed free at: http://bjsm.bmj.com/content/47/5/250.full.html#ref-list-1 Email alerting service Topic Collections Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. Articles on similar topics can be found in the following collections Editor's choice (147 articles) Notes To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/ APPENDIX Inter-Association Consensus: Independent Medical Care for College Student-Athletes Guidelines Purpose: The Safety in College Football Summit (see appendix) resulted in inter-association consensus guidelines for three paramount safety issues in collegiate athletics: 1. Independent medical care in the collegiate setting; 2. Concussion diagnosis and management; and 3. Football practice contact. This document addresses independent medical care for college student-athletes in all sports. Background: Diagnosis, management, and return to play determinations for the college student-athlete are the responsibility of the institution’s athletic trainer (working under the supervision of a physician) and the team physician. Even though some have cited a potential tension between health and safety in athletics,1,2 collegiate athletics endeavor to conduct programs in a manner designed to address the physical well-being of college student-athletes (i.e., to balance health and performance).3,4 In the interest of the health and welfare of collegiate student-athletes, a studentathlete’s health care providers must have clear authority for student-athlete care. The foundational approach for independent medical care is to assume an “athlete-centered care” approach, which is similar to the more general “patient-centered care,” which refers to the delivery of health care services that are focused only on the individual patient’s needs and concerns.5 The following 10 guiding principles, listed in the Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges,5 are paraphrased below to provide an example of policies that can be adopted that help to assure independent, objective medical care for college student-athletes: 1. The physical and psychosocial welfare of the individual student-athlete should always be the highest priority of the athletic trainer and the team physician. 2. Any program that delivers athletic training services to student-athletes should always have a designated medical director. 3. Sports medicine physicians and athletic trainers should always practice in a manner that integrates the best current research evidence within the preferences and values of each student-athlete. 4. The clinical responsibilities of an athletic trainer should always be performed in a manner that is consistent with the written or verbal instructions of a physician or standing orders and clinical management protocols that have been approved by a program’s designated medical director. 5. Decisions that affect the current or future health status of a student-athlete who has an injury or illness should only be made by a properly credentialed health professional (e.g., a physician or an athletic trainer who has a physician’s authorization to make the decision). 6. In every case that a physician has granted an athletic trainer the discretion to make decisions relating to an individual student-athlete’s injury management or sports participation status, all aspects of the care process and changes in the student-athlete’s disposition should be thoroughly documented. 7. Coaches must not be allowed to impose demands that are inconsistent with guidelines and recommendations established by sports medicine and athletic training professional organizations. 8. An athletic trainer’s role delineation and employment status should be determined through a formal administrative role for a physician who provides medical direction. 9. An athletic trainer’s professional qualifications and performance evaluations must not be primarily judged by administrative personnel who lack health care expertise, particularly in the context of hiring, promotion, and termination decisions. 10. Member institutions should adopt an administrative structure for delivery of integrated sports medicine and athletic training services to minimize the potential for any conflicts of interest that could adversely affect the health and well-being of student-athletes. Team physician authority becomes the linchpin for independent medical care of student-athletes. Six preeminent sports physicians associations agree with respect to “… athletic trainers and other members of the athletic care network report to the team physician on medical issues.”6 Consensus aside, a medical-legal authority is a matter of law in 48 states that require athletic trainers to report to a physician in their medical practice. The NCAA Sports Medicine Handbook’s Guideline 1B opens with a charge to athletics and institutional leadership to “create an administrative system where athletics health care professionals – team physicians and athletic trainers – are able to make medical decisions with only the best interests of student-athletes at the forefront.”7 Multiple models exist for collegiate sports medicine. Athletic health care professionals commonly work for the athletics department, student health services, private medical practice, or a combination thereof. Irrespective of model, the answer for the college student-athlete is established independence for appointed athletics health care providers.8 Guidelines: Institutional medical line of authority should be established independently of a coach, and in the sole interest of student-athlete health and welfare. Medical line of authority should be transparent and evident in athletics departments, and organizational structure should establish collaborative interactions with the medical director and primary athletics health care providers (defined as all institutional team physicians and athletic trainers) so that the safety, excellence and wellness of student-athletes are evident in all aspects of athletics and are student-athlete centered. Institutions should, at a minimum, designate a licensed physician (M.D. or D.O.) to serve as medical director, and that medical director should oversee the medical tasks of all primary athletics health care providers. Institutions should consider a board certified physician, if available. The medical director may also serve as team physician. All athletic trainers should be directed and supervised for medical tasks by a team physician and/or the medical director. The medical director and primary athletics health care providers should be empowered with unchallengeable autonomous authority to determine medical management and return-to-play decisions of student-athletes. References: 1. Matheson GO. Maintaining professionalism in the athletic environment. Phys Sportsmed. 2001 Feb;29(2) 2. Wolverton B. (2013, September 2) Coach makes the call. The Chronicle of Higher Education. [Available online] http://chronicle.com/article/Trainers-Butt-Heads-With/141333/ 3. NCAA Bylaw 3.2.4.17 (Div. I and Div. II; 3.2.4.16 (Div. III). 4. National Collegiate Athletic Association. (2013). 2013-14 NCAA Division I Manual. Indianapolis, IN: NCAA. 5. Courson R et al. Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges. J Athletic Training 2014; 49:128-137. 6. Herring SA, Kibler WB, Putukian M. Team Physician Consensus Statement: 2013 update. Med Sci Sports Exerc. 2013 Aug;45(8):1618-22. 7. National Collegiate Athletic Association. (2013). 2013-14 NCAA Sports Medicine Handbook. Indianapolis, IN: NCAA. 8. Delany J, Goodson P, Makeoff R, Perko A, Rawlings H [Chair]. Rawlings panel on intercollegiate athletics at the University of North Carolina at Chapel Hill. Aug 29 ‘13. [Available online] http://rawlingspanel.web.unc.edu/files/2013/09/RawlingsPanel_Intercollegiate-Athletics-at-UNC-Chapel-Hill.pdf This Consensus Best Practice, Independent Medical Care for College Student-Athletes, has been endorsed by: American Academy of Neurology American College of Sports Medicine American Association of Neurological Surgeons American Medical Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Osteopathic Academy for Sports Medicine College Athletic Trainers’ Society Congress of Neurological Surgeons National Athletic Trainers’ Association NCAA Concussion Task Force Sports Neuropsychological Society UT Athletics Policy Number 14.8.3 – Concussion Management Plan Revised/Effective Date: Revised April 29, 2015; effective July 1, 2015 Purpose: To outline general guidelines for education, identification, evaluation, treatment, and return to play following a concussion for all University of Tennessee student-athletes. Policy A Concussion is a relatively common injury sustained by athletes, especially in contact sports. Although sports currently have rules in place to promote safety, athletics staff should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced. Proper management of most concussions allow for return to sport in a relatively short time frame. However, some concussions require a more prolonged recovery time. Returning to play too early after a concussion can result in worsening of symptoms and potentially devastating consequences. The purpose of this policy is to outline general guidelines for education, identification, evaluation, treatment, and return to play following a concussion for all University of Tennessee student-athletes. The University of Tennessee Department of Sports Medicine (UTSM) Concussion Policy will have the following objectives: • • • • • Educate student-athletes, coaches, administration, and support staff to proper management of concussions. Identify those student-athletes with signs and/or symptoms of concussion in a timely manner. Evaluate affected student-athlete at the time of injury and periodically thereafter until concussion has resolved utilizing physical examination, balance testing, neurocognitive testing, and imaging studies when appropriate. Determine general guidelines for return to play following a concussion. Initiate treatment for concussions including referrals to specialist when needed. THE TEAM PHYSICIAN WILL WORK CLOSELY WITH THE TEAM ATHLETIC TRAINER(S) IN EVALUATING STUDENT-ATHLETES WITH SUSPECTED CONCUSSIONS. RETURN TO PLAY DECISIONS WILL BE GUIDED BY THE EVALUATIONS DESCRIBED BELOW. UNIQUE CIRCUMSTANCES SPECIFIC TO AN INDIVIDUAL STUDENT-ATHLETE MAY NECESSITATE MINOR CHANGES TO GUIDELINES AND WILL BE DETERMINED BY THE TEAM PHYSICIAN. Procedures I. Education: All student-athletes will be given a copy of the NCAA Fact Sheet on Concussions for Student-Athletes annually. Also, all student-athletes will be required to read and sign the Athletic Risk Warning statement annually and indicate their receipt and understanding of the information contained in the NCAA Fact Sheet on Concussions for Student-Athletes. All coaches, athletic trainers, team physicians, and the athletic director will be given a copy of the NCAA Fact Sheet on Concussions for Coaches annually. They will also meet to review this policy and sign an acknowledgement that they understand the concussion management plan, their role within the plan, and that they have received education about concussions. In addition, the UTSM staff will review the Concussion Management Plan annually with the Team Physician to discuss proper identification, evaluation, and treatment of a student-athlete with a concussion. II. Pre-participation Assessment: Prior history of concussion(s) or traumatic brain injury(ies) will be obtained and documented for all new student-athletes by the team physician. The team physician will determine pre-participation clearance and need for medical referrals and additional testing. In addition, returning student-athletes who sustained a concussion in the prior year will meet with the team physician in order to determine the need for any additional testing or medical referral necessary to continue participation. All student-athletes will be required to have a baseline ImPACT test, and a baseline SCAT 3 test completed as part of their initial pre-participation exam. These baseline tests will be performed prior to participation, and then every two (2) years for athletes that do not sustain a concussion. If a player sustains a concussion, their baseline tests will be repeated prior to the next season of competition. ImPACT testing, SCAT3 testing and symptom scores via a Post-Concussion Symptom Scale (PCSS) should be used as tools to assist in making return-to-play decisions. They require reasonable interpretation by a qualified sports medicine professional and should NOT be used individually as a sole determinant for making return-toplay decisions. III. Recognition and Diagnosis of Concussion: Any student-athlete suspected of having sustained a concussion, based on signs, symptoms, or behaviors, will be removed from participation and evaluated by a team athletic trainer, or team physician, with concussion experience. The team athletic trainers and team physicians are empowered with unchallengeable autonomous authority to determine medical management and return-to-play decisions of student-athletes. When a student-athlete is suspected of having sustained a concussion, the following areas will be assessed on the field by the team athletic trainer, or team physician, in order to assist in diagnosis. A SCAT 3 test may be performed if determined to be necessary by the evaluating team athletic trainer or team physician to assist in diagnosis. This test will be performed in a quiet environment away from distractions when possible. • Symptoms: Common signs/symptoms of concussion include, but not limited to: •Headache •Nausea •Vomiting •Dizziness •Imbalance •Fatigue •Trouble sleeping •Sleeping too much •Drowsiness •Sensitive to light •Sensitive to noise •Sadness •Nervousness •Numbness/tingling •Feeling slow •Feel “in a fog” •Difficulty concentrating •Difficulty remembering • • • • Physical and Neurological exam Cognitive assessment Balance evaluation Cervical spine or skull injury evaluation If a student-athlete is determined to have sustained a concussion, they will be removed from participation in all athletic activities for the remainder of the day at a minimum, and referred to the Team Physician for further evaluation and planning, or transported to the nearest emergency medical facility for evaluation and treatment if necessary. No Return to Play (RTP) IF: Loss of consciousness OR Amnesia OR Persistent symptoms consistent with concussion Return to Play IF: No loss of consciousness or amnesia reported AND No motor or sensory signs/symptoms AND Resolution of symptoms AND Normal physical and neurocognitive evaluations AND No recurrence of signs/symptoms with exertion. IV. Post-Concussion Management Phase I: Initial Management Phase After a student-athlete has been determined to have sustained a concussion and has been removed from participation, he/she will be monitored/evaluated by a member of the sports medicine department or team physician for a period of time to be determined by the team physician. A SCAT 3 exam will be performed if not already completed during the on the field evaluation. The following conditions warrant the need for activation of the emergency action plan and timely transportation to the nearest emergency medical facility: - Glasgow Coma score < 13 - Prolonged loss of consciousness - Focal neurological deficit suggesting intracranial trauma - Repetitive emesis - Persistently diminished/worsening mental status or other neurological signs/symptoms - Suspected spinal injury or skull fracture The team physician or his/her designee will be charged with the responsibility to determine if transport to an emergency medical facility is warranted. Transportation will be arranged either with a sports medicine personnel or via ambulance as deemed appropriate by the team physician or his/her designee. Specific information pertaining to activation of Emergency Action Plans (EAPs) at each venue at the University of Tennessee can be obtained under the Emergency Action Plan section of the Policy and Procedures Manual. Phase II: Symptomatic Phase The student-athlete’s symptoms will be re-evaluated using a PCSS and physical exam. If still symptomatic, or has an abnormal physical exam, then the student-athlete will not be permitted to advance to Phase III. If asymptomatic, or equal to their baseline PCSS, proceed to Phase III. Phase II will be repeated until the student-athlete is asymptomatic, or equal to baseline, and a SCAT 3 test is deemed normal. Phase III: Exertional Testing Exertional Testing will be performed under direction of the Team Physician and under supervision of a Team ATC once the student-athlete is asymptomatic, or equal to baseline, at rest. (See Appendix for Exertional Testing Log) • Exertional testing will progress in a stepwise manner through each Phase. • If signs or symptoms return with Exertional Testing (e.g., headache, dizziness, etc.) the Exertional Testing should be discontinued. • If signs or symptoms do not return, the student-athlete can proceed with non-contact sport-specific drills. Proceed to Phase IV Phase IV: Neurocognitive testing (ImPACT) Once a student-athlete has completed Phases I-III, neurocognitive evaluation utilizing ImPACT will be performed. If a student-athlete successfully completes Phases I-III and ImPACT test results are interpreted by Team Physician (and if needed, in consultation with Neuropsychologist) as reflecting a return to baseline status, then student-athlete can progress to full contact participation. Final clearance for full participation will be determined by the team physician after Phases I-IV are complete. Treatment Following a concussion, the student-athlete will be provided with instructions verbally and, either written or electronically with emergency contact information should his/her symptoms worsen. (See Appendix for copy of written instructions form) It is desirable that the student-athlete should not be left alone for extended periods of time following the concussion. Therefore, written or electronic instructions and emergency contact information will also be provided to the student-athlete’s roommate or other responsible adult who will be in direct contact with the athlete, when available. Documentation of instructions will be kept by UTSM. Pharmaceutical treatment will generally consist of acetaminophen (Tylenol) in the first 48 hours and then OTC analgesics in consultation with the Team Physician and/or Team ATC thereafter. The need for diagnostic imaging studies including CT scans and/or MRI will be determined by the Team Physician. For a student-athlete with prolonged recovery, the Team physician will re-evalute his/her signs/symptoms in order to rule out additional diagnoses such as post-concussion syndrome, sleep dysfunction, Migraines or other headache disorders, mood disorders such as anxiety or depression, or ocular/vestibular dysfunction. Referrals to a specialist such as a Neurologist, Neuropsychologist, Neurosurgeon, or Physical Therapist also will be determined by the Team Physician. V. Return to Learn: (Adapted from NCAA Sport-Related Concussion) Return-to-Learn (RTL) guidelines assume that both physical and cognitive activities require brain energy utilization, and that after a sport-related concussion, brain energy may not be available for physical and cognitive exertion because of a brain energy crisis. The student-athlete may appear physically normal but may be unable to perform as expected due to concussive symptomatology. Not all student-athletes will require time away from academics, and the Team Physician, in collaboration with the Team Athletic Trainer, and the student-athlete’s academic advisor, will serve as the point person for determining when and if a concussed student-athlete will require academic accommodations. Generally, student-athletes will not be expected to return to class on the same day as a concussion. As with return-to-play, the first step of return-to-learn is relative physical and cognitive rest. The period of time needed to withhold the student-athlete from classes or class work will be individualized based on their symptoms. A gradual return to academics will be based on the absence of concussion symptoms following cognitive exposure. If these symptoms worsen, or return, with exposure to academic work, the student-athlete will be reassessed by the Team Physician to determine when to begin the stepwise progression again. The majority of student-athletes who are concussed will not need a detailed return-to-learn program because full recovery typically occurs within two weeks. For the student-athlete whose academic schedule requires some minor schedule/academic modifications in the first two weeks following a sport-related concussion, adjustments can often be made without requiring meaningful curriculum or testing alterations. These shortterm adjustments will be coordinated by the academic counselor, in consultation with the team physician. The University Of Tennessee Office Of Disability Services (ODS) offers academic accommodations to students that suffer academic impacting events. A concussion may qualify as such an event, and therefore may make a student-athlete eligible for such accommodations. When a student-athlete experiences concussion symptoms that 1) impact their academic ability, and 2) extend, or are predicted by the Team Physician to extend beyond a short duration such as two weeks, the Team Physician will re-evaluate the student-athlete in possible consultation with a multi-disciplinary team of professionals, including but not limited to the Team Athletic Trainer, academic support staff, or learning specialist, to determine the need for further diagnostic testing or treatment. The team physician will also write a letter to the ODS requesting academic accommodations for the student-athlete for a period of time to be determined by the Team Physician. The ODS will determine the exact accommodations that each student-athlete will be offered in accordance with current ADAAA guidelines. VI. Reduction of Exposure to Head Trauma In an effort to reduce unnecessary exposure to head trauma by a student-athletes, the University of Tennessee Athletic Department will adhere to the Inter-Association Consensus on Year-Round Football Practice Contact Guidelines, as well as the Independent Medical Care Guidelines. Further, all sports will take a “safety first” approach and make every effort to reduce gratuitous contact during practices, as well as provide coaching to avoid the use of their head during contact in sports, and to have safe and proper sport technique. Addendum Sports Camp Concussion Management Plan – 2014 Addendum to UT Policy 14.5 – Concussion Management Plan Youth sport camps present a unique population when dealing with suspected or confirmed concussion management. Most sport camp participants are minors, and a parent or legal guardian may or may not be present during evaluation and subsequent follow up discussions. The following guidelines will be used as a guide by all UTSM medical personnel when assessing or treating a sports camp participant for a suspected or confirmed concussion. Education Each youth sport camp participant will be advised of the inherent risks of concussions, as well as common signs and symptoms, and instructions on appropriate reporting of a suspected concussion, as part of the registration process for camp. This will be done either electronically, if registering online, or in writing, if registering in person. A parent or legal guardian, or temporary custodian [or adult chaperone] to which authority has been assigned as it pertains to camp attendance, will be required to acknowledge in writing the receipt and understanding of this educational material prior to being able to complete and submit a registration form for a UT sports camp. Youth sport camp coaches will also be educated about common signs and symptoms of concussions, as well as the appropriate steps to take to refer a camp participant to the appropriate medical staff member for evaluation if a concussion is suspected. Evaluation Sports medicine professionals (athletic trainers, and possibly physicians) educated in appropriate concussion management will be present at collision and/or contact sports camps, and on-call for minimal or non-contact sports camp. For camps utilizing multiple venues, attempts will be made to have a sports medicine professional or a representative of the sports medicine department (such as an undergraduate student assistant) present at each venue to increase communication when possible. When unable to have someone present at each venue, the athletic trainer in charge of covering the camps will utilize either a cell phone or 2way radio in order to communicate to coaches or other staff members at multiple venues at once. Any suspected concussion should be immediately referred to the nearest sports medicine professional for evaluation and management. If a UTSM Team Physician is present at the camp, the athletic trainer will provide an initial assessment of the camp participant and then refer them to the physician for follow up treatment and/or recommendations. Return to Play Any sport camp participant diagnosed with a concussion by the sports medicine professional shall not return to participate in athletic activity for the remainder of the day. If a camp participant is attending a multiple day camp, they will not be allowed to return to participation on following days of camp unless they have been evaluated by a physician or qualified health care professional, and given written permission to return to participation. If a physician or qualified health care professional is not available, the camp participant will not be allowed to return to participation for the remainder of the camp. Discharge Instructions In the event a camp participant is diagnosed with a concussion, and he/she is scheduled to leave campus at the end of the day or the end of the camp, the medical professional managing their care will give the parent or legal guardian the UTSM Take Home Instruction Form – Sport Camp Participant. The camp participant, as well as the adult present, will be informed that prior to the participant returning to athletic activity, they should be evaluated and cleared by a physician of their choosing. If a parent or legal guardian is not present to receive the written or verbal discharge instructions, they will be given to the adult chaperone (i.e. coach, parent of a friend or teammate) that is responsible for transporting the participant home, and phone calls will be made to inform the emergency contact(s) listed on the camp registration forms of details regarding the participants injury and recommendations. 15.13.7 06?02?2015 GUIDELINES FOR DIAGNOSIS AND MANAGEMENT OF SPORT-RELATED CONCUSSION PURPOSE: Provide guidelines for diagnosis and management of sport?related concussion. BACKGROUND: Concussion is: POLICY: a change in brain function following a force to the head, which may be accompanied by temporary loss of consciousness, but is identified in awake individuals, with measures of neurological and cognitive dysfunction. Pursuant to the NCAA Concussion Policy and Legislation mandate, UT Athletics implements the following: . An annual process that ensures student?athletes, coaches, team physicians, athletic trainers, and directors of athletics will be educated about the signs and of concussion. . A process that ensures a student-athlete who exhibits the signs, or behaviors consistent with concussion shall be removed from athletics activities and evaluated by a medical staff member with experience in the evaluation and management of concussion. Initial evaluation includes assessment, physical and neurological examination, cognitive assessment, balance examination, as well as clinical assessment for cervical spine trauma, skull fracture, and intracranial bleeding. A policy that precludes a student?athlete who is suspected concussion from returning to athletic activities for at least the remainder of that calendar day. A policy that requires medical clearance for a student?athiete diagnosed with a concussion to return to athletics activities as determined by a physician or physician?s designee. A policy that adheres to the Inter?Association Consensus: Year?Round Football Practice Contact Guidelines, emphasizing education regarding safe play and proper technique and reducing gratuitous contact during practice. A policy in which our athletics healthcare providers are empowered to have the unchallengeable authorityto determine management and return?to?play of any ill or injured student-athlete, as he or she deems appropriate. Sports Medicine, Policy and Procedural Manual The University of Texas at Austin 15.13.7 06-02-2015 CONCUSSION MANAGEMENT PLAN: The following concussion management plan will be utilized for UT student?athletes at risk for or suspected of sustaining a concussion: 1. Student?athletes, coaches, and other pertinent team personnel, including team physicians, athletic trainers, and directors of athletics will be provided the "Concussion Education Fact Sheet? (see 15.13.7b) and educated on concussions annually. Student?athletes, coaches, team physicians, athletictrainers, and directors of athletics will be required to provide signed acknowledgment and understanding of the concussion education materials. Further, student? athletes will be required annually to sign a statement in which they acknowledge their duty to report their injuries and illnesses to the sports medicine staff, including signs and of concussions. 2. A one?time, pre?participation baseline assessment will be conducted for each student?athlete in all sports. This assessment consists of 1) a brain injury/concussion history, 2) evaluation, 3) cognitive assessment, and 4) balance assessment. The subjective history will be captured in our institution?s online prewparticipation health history questionnaire and during the pre?participation physical exam with the team physician. The C3 Logix Integrated Concussion Management System will be utilized for the objective and quantitative analysis. The team physician will determine pre?participation clearance and/or the need for additional consultation or testing. 3. A sideline assessment tool for evaluating and managing a mild head injury sustained in practice or competition will be made available to all Sports Medicine staff members. Sideline assessment will be performed at the time the injury. The components ofthe sideline evaluation include assessment of cognition, oculomotorfunction, and balance. (see 15.13.7d). 4. A venue?specific emergency action plan will be activated and followed that includes further evaluation for a student-athlete with a Glascow Coma Scale score greater than 13, prolonged loss of consciousness, focal neurological deficit, repetitive emesis, deteriorating mental status, or spinal injury. The emergency action plan is an organized and coordinated plan that provides directive to team physicians, athletic trainers, and EMS personnel to manage the aforementioned circumstances. 5. Student?athlete showing any signs, or behaviors consistent with a concussion will be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. 6. A student?athlete diagnosed with a concussion will be withheld from competition or practice and will not be permitted to return to athletics activities for the remainder of that day. 7. Academic accommodations, if necessary, will be requested and coordinated by a designated member ofthe Student Services staff (see 15.13] Return to [earn guidelines). 8. The post?concussion management is directed by the team physician. The need for initial physical and cognitive rest will be determined based on individual serial assessments, concussion history, modifying factors, and specific needs of the student~athlete. Initial Sports Medicine, Policy and Procedural Manual The University of Texas at Austin 15.13.7 06-02?2015 assessment will be performed within 72 hours of report of injury and serial follow up will be repeated at least every seven days, or at the discretion ofthe team physician. Once serial evaluations and monitoring confirm the student-athlete has returned to a level consistent with his/her baseline, return to play will follow a medically supervised stepwise progression. Gradual increase in physical activity that includes both an incremental increase in physical demands and contact risk will be implemented. 9. Final authority for "Return?to?Play? resides with the team physician. 10. The incident, evaluation, continued management, and clearance of the student-athlete with a concussion will be documented and maintained in his/her medical file. Documentation will include oral and/or written instruction provide to the student?athlete and/or other responsible adult. REFERENCES: McCrory et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br. Sports Med 2013; 47:250-258. Inter-Association Consensus: Diagnosis and Management of Sport?Related Concussion Guidelines. 2014. Inter?Association Consensus: Independent Medical Care Guidelines. 2014. InternAssociation Consensus: Year?Round Football Practice Contact Guidelines. 2014. Sports Medicine, Poiicy and Procedural Manual The University of Texas at Austin 15.13.? 2/26/2015 SPORTS-RELATED CONCUSSEON: RETURN-TO-LEARN GUIDELINES PURPOSE: Provide guidelines for initiating cognitive rest following sports-related concussion and establishing a process to guide the transition back into the academic classroom. BACKGROUND: Return?to-learn is a parallel concept to return?to?play. The foundation of return?to-learn includes: Return?to?learn should be managed in a stepwise program that fits the needs of the individual. Return?to?learn guidelines assume that both physical and cognitive activities require brain energy utilization, and that such brain energy is not available for physical and cognitive exertion because of the concussion?induced brain energy crisis. The hallmark of return?to-learn is cognitive rest immediately following concussion, just as the hallmark of return?to-play is physical rest. Cognitive rest refers to avoiding potential cognitive stressors such as school work, video games, reading, texting and watching television, as well as team meetings and instruction. Current evidence suggests that providing both physical and cognitive rest allows the brain to heal more quickly as well as having a beneficial effect of cognitive rest on concussion recovery. 0 Return?to-Iearn recommendations are based on consensus statements, with a paucity of evidence?based data to correlate with such consensus recommendations. Return?to-learn recommendations should be made within the context of a multi- disciplinary team that includes Sports Medicine and Student Services personnel. Like return?to?play, it is not always easy to provide prescriptive recommendations for return-to-iearn because the student?athlete may appear physically normal but is unable to perform at his/her expected baseline due to concussive POLICY: Pursuant to the NCAA Sports?Related Concussion Policy and Concussion Safety Protocol, UT Athletics implements the following: A policy that ensures that a student-athlete diagnosed with concussion will be prescribed an initial period of physical and cognitive rest. A process that ensures the gradual return to cognitive activity is based on the absence of concussion following cognitive exposure. Sports Medicine, Policy and Procedural Manual The University of Texas at Austin 15.13.7 2/26/2015 MANAGEMENT PLAN: The multidisciplinary team involved in the Return-to?Learn process will be directed by the Executive Senior Associate Athletics Director for Student Services. The following tenets of cognitive recovery will be addressed: Cognitive Rest: Cognitive rest following concussion involves avoiding the classroom for at least 24 hours. lfthe student?athlete cannot tolerate the amount oftime required to participate in a class requiring light cognitive activity, he or she should remain at home or in the residence hall. For example, once the student?athlete can tolerate 30?45 minutes of cognitive activity without return of he/she should return to the classroom in a step?wise manner. Such return should include no more than 3045 minutes of cognitive activity at one time, followed by at least 15 minutes of rest. The levels of adjustment needed should be decided by a multi?disciplinary team that includes Sports Medicine and Students Services personnel, including but not limited to the Team Physician, athletic trainer, and academic counselor, and otherfaculty or individual teachers as appropriate. The level of multi-disciplinary involvement should be made on a case?by?case basis. Academic Procedures: Academic adjustment - a student-athlete?s academic schedule requires some modification in the first one to two weeks following concussion. in this case, full recovery is anticipated, and the student-athlete will not require any meaningful curriculum or testing alterations. Academic accommodation the student?athlete has persistent for more than two weeks following concussion. Because the student?athlete has not recovered in the anticipated period of time, he or she may require a change in the class schedule and special arrangements may be required for tests, term papers and projects. Although there is no fixed timeline for academic accommodation, this generally applies to student?athletes who have more prolonged concussion or who may be suffering with post?concussion It is important to verify, as best as possible, the diagnosis instead of assuming that the student?athlete has prolonged concussion Academic modification a more difficult scenario in which the student?athlete suffers with prolonged cognitive difficulties, which thereby requires a more specialized educational plan. Services for Students with Disabilities (SSD) In certain medical situations, including those involving sports-related concussion, SSD may need to be contacted to determine eligibility and approval for reasonable classroom and/or testing accommodations. mitigating measures to lessen the impairment of the condition will be implemented as appropriate. Sports Medicine, Policy and Procedural Manual The University of Texas at Austin 15.13.7 2/26/2015 Bsisienses McCrory et al: Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br] Sports Med 2013; 47:250?258. Harmon KG et al: American Medical Society for Sports Medicine position statement: concussion in sport. Sports Med 2013: 47:15?26. Schneider KJ et aI: The effects of rest and treatment following sport?related concussion: a systematic review of the literature. Sports med 2013; 47:304~307. Sports Medicine, Policy and Procedural Manual The University of Texas at Austin 15.13.7b 07?28v2010 CONCUSSION EDUCATION FACT SHEET The University of Texas at Austin WHAT IS A A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an ?impulsive? force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat or ball. SIGNS You may You may experience - 0 Appear dazed or stunned. - Headache or ?pressure? in head. 0 Be confused about assignment or position. 0 Nausea or vomiting. 0 Forget plays. 0 Balance problems or dizziness. 0 Be unsure of game, score or opponent. 0 Double or blurry vision. 0 Move clumsily. - Sensitivity to noise. 0 Lose consciousness (even briefly). 0 Sensitivity to light. 0 Answer questions slowly or inaccurately. 0 Feeling sluggish, hazy, foggy or groggy. 0 Show behavior or personality changes. 0 Concentration or memory problems. ?0 Can?t recall events before hit or fall. - Confusion. - Can?t recall events after hit or fall. 0 Sleep disturbances. 0 Not "feeling right.? THE FACTS A conCussion is a brain injury. 0 All concussions are serious. 0 Concussions can occur without loss of consciousness or other obvious signs. 0 Concussions can occurfrom blows to the body as well as to the head. 0 Concussions can occur in any sport. 0 Recognition and proper response to concussions when they first occur can help prevent further injury or even death. 0 Long term problems (including permanent brain damage or death) can possibly result from a concussion especially if practice or competition is resumed too early. 0 Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries, depending on the sport. REPORTING A CONCUSSION The sports medicine staff expects you 0 To immediately report any blow to the head or body and any of a concussion. Note that you may notice some immediately. However, others may show up hours or days after the initial injury. It is your responsibility to report any delayed as soon as possible. 0 To report if you suspect that one of your teammates sustained a head injurylor concussion or you have information that a teammate might have a concussion. Modified from A FACT SHEET FOR STUDENT-ATH NCAA 15,13,70 2/26/2015 DIAGNOSIS AND MANAGEMENT OF SPORTS-RELATED CONCUSSION ALGORITHM STUDENT-ATHLETE (SA) SUSTAINS MILD HEAD INJURY OR EXHIBITS OF CONCUSSION Athletic Trainer performs initial assessment SIDELINE SCREENING POSITIVE FINDINGS FOR CONCUSSION Withhold from practice/competition for the remainder of the day (minimum) Refer for comprehensive physical POSITIVE FINDINGS VALIDATED Initiate management per UT Athletic guidelines Impose cognitive and physical rest as directed by Team Physician Initiate ?Return-to?Learn? process per UT Athletics policy; assess need for academic adjustment, accommodation, TESTING 1L or modi?cation RESOLUTION OF SA returns to baseline levels of and cognitive function using objective and subjective criteria Cleared by UT Team Physician to resume graduated physical activity progression ATTENDING UT PHYSICIAN 0 Comprehensive physical exam concussion assessment diagnosis of concussion NEGATIVE FINDINGS FOR 0 Monitor 0 Consider return to play (RTP) ATHLETIC TRAINER Repeat serial assessment at direction of Physician I I I SPECIALTY REFERRALS (As needed) Computerized oculomotor, balance, and and head coordination assessment consult 0 Other specialty consults RESUMPTION OF PHYSICAL ACTIVITY Light aerobic exercise walking or stationary cycling) Sport speci?c training running drills, ball handling skills) Non-contact training drills Full contact training Timing of the progression through the stages of exertion for each SA will be determined by the Team Physician. If the SA becomes at any stage of eXercise progression, the SA will move back to the prior stage for a period of time determined by the Team Physician. drills Competition Sports Medicine, Policy and Procedural Manual The University of Texas at Austin Sideline Assessment Tool 15.13.7d con (21.159th5 assessme?l Checklist Changes in Vision Dizziness Unsteadiness Foggy Headed Headache Nausea Ringing in Ears Sensitivity to Light Sensitivity to Noise Any Weakness Orientation {to time, placefsitua?rion, person, self) Ask the athlete in thefol'lowfng sequence: What city is this? What day of the week is it? What month is it? Who is the opposing team? What year is this? Autemgmde Am nesia Ask the athlete to: Repeat 3 simple words, girl, dog, green (recalls items in correct sequence within 10 sec) Re b?ograd 9. Am iiesia. Ask the athlete: What happened in the prior quarter/period? What do you remember just prior to the hit? What was the score of the game prior to the hit? Ceneentmtimt Ask the. athlete to: Repeat the days of the week backwards Repeat these numbers backwards: 63 (36), 419 (914) Weird List Memory After 5-7 minutes, ask the athlete ta: Repeat the three words from earlier (girl, dog, green) Dcuiomoiorffmictionai Testing Normal Conjugate Gaze? ?gamma; - I i warm?! 1, (H \n . a "Hap-J- Ask the athlete to: Follow the examiner?s finger left and right at a SLOW constant speed (2 feet away at level and 30? to each side) for 3 repetitions back and forth. Romberg Sway Analysis (20 sec; EC) Tandem Rom berg (heel to toe/ND leg behind; (20 sec,- (10 sec; EC) 20 yard jog in a straight line or 20 sec. jog in place Follow?11p Evaluation Withhold from participation, retest every 15 minutes for status changes and consult with attending physician. DIVISION OF SPORTS MEDICINE INTERCOLLEGIATE ATHLETICS 0 THE UNIVERSITY OF TEXAS AT AUSTIN Post Of?ce Box 7399 Austin, Texas 78 713- 7399 (512) 471-4916 DUTY TO REPORT INJURY CONCUSSION ACKNOWLEDGEMENT FORM I, acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the Sports Medicine Staff at The University of Texas at Austin team physician, athletic training staff). I understand that I must provide an accurate medical hist01y and a full disclosure of any complaints, prior injuries and/or disabilities I have experienced for the Sp01ts Medicine Staff to understand my true physical condition. I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the Sports Medicine Staff at The University. I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. I have been educated on head injuu'es and concussions and understand I must immediately rep01t of a head injuly/concussion to the Sports Medicine Staff. By signing below, I acknowledge that the University?s Sports Medicine Staff has provided me with specific educational materials on what a concussion is, what the are, and have given me an opportunity to ask questions about anything that is not clear to me on this issue. I, have read the above, agree that the statements are accurate, and agree to disclose any to The University. Student?Athlete?s Signature Sport Date Signed Parent/ Guardian Signature (if student is under 18 years of age) Parent/Guardian Printed Name Date Signed Witness Signature Date Signed Apvd. by UT Austin Legal, G, 07/28/2010 Sports Medicine, Policy and Procedural Manual The University of Texas at Austin 15.13.7f 2/26/2015 DIVISION OF SPORTS MEDICINE INTERCOLLEGIATE ATHLETICS 9 THE UNIVERSITY OF TEXAS AT AUSTIN Post Office Box 7399 0 Austin, Texas 78713~7399 (512) 471-4916 CONCUSSION AWARENESS LETTER On behalf of UT Athletics Sports Medicine and Student Services Departments, I am notifying you that the following student-athlete sustained a concussion on the noted date: Student?Athlete: Date of Injury: A concussion or mild traumatic brain injury can cause a variety of physical, cognitive, and emotional Concussions range in severity, but they all share one common factor they temporarily interfere with brain function. This student-athlete may experience one or more of these signs and Headache Nausea Balance Problems Dizziness Double or Blurred Vision Confusion Light Sensitivity Difficulty Sleeping Difficulty Concentrating Noise Sensitivity Feeling Sluggish or Groggy Memory Problems I wanted to make you aware of this injury and the the student-athlete may experience. Although the student-athlete is attending class, please be aware that the side effects of the concussion may adversely impact his/her academic performance. He/she is currently engaged in our departmental "Sports?Related Concussion: Return-to-Learn Guidelines.? I will continue to monitor his/her progress and anticipate a full recovery. Should you have any questions Or require further information, please do not hesitate to contact me. Thank you in advance for your time and understanding with this circumstance. Sincerely, James Bray, MD Jessica Zarndt, DO Head Team Physician Associate Team Physician Texas A&M Sports Medicine Concussion Policy 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. All Texas A&M student-athletes must read the NCAA Concussion Fact Sheet and sign the attached student athlete statement acknowledging that: a. They have read and understand the NCAA Concussion Fact Sheet. b. They accept the responsibility for reporting their injuries and illnesses to the Sports Medicine staff, including the signs and symptoms of concussions. The Associate Athletics Director for Athletic Training will provide a copy of the Concussion Policy and Concussion Management Protocol to all student-athletes and their parents/legal guardians as well as to all Texas A&M athletics coaches, athletics administrators, and medical staff. The Texas A&M Athletics Department Concussion Policy and Concussion Management Protocol can be found in the Sports Medicine section on 12thman.com. After receiving and reviewing the NCAA Concussion Fact Sheet, ALL Texas A&M coaches (Head Coaches and Assistant Coaches) must read and sign the attached coaches statement acknowledging that they: a. Have read and understand the NCAA Concussion Fact Sheet. b. Will encourage their athletes to report any suspected injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions; and that they accept the responsibility for referring any athlete to the medical staff suspected of sustaining a concussion. c. Have read and understand the Texas A&M Concussion Management Protocol. After receiving and reviewing the NCAA Concussion Fact Sheet, All Texas A&M Team Physicians, Staff Athletic Trainers, Graduate Assistant Athletic Trainers, and Athletic Training Students, must read and sign the attached medical provider statement acknowledging that they: a. Will provide student-athletes with the NCAA Concussion Fact Sheet and encourage their athletes to report any suspected injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. b. Have read, understand, and will follow the Texas A&M Concussion Management Protocol. c. Have read and understand the NCAA Concussion Fact Sheet. After receiving and reviewing the NCAA Concussion Fact Sheet, ALL Texas A&M Athletics Administrators must read and sign the attached athletics administrator concussion statement acknowledging that they: a. Have read and understand the Texas A&M Athletics Department Concussion Management Protocol. b. Have read and understand the NCAA Concussion Fact Sheet. The Associate Athletics Director for Athletic Training will coordinate the distribution, educational session, signing, and collection of the necessary documents. The signed documents will be kept in each student-athlete’s medical file. The Associate Athletics Director for Athletic Training and the Director of Sports Medicine will coordinate the signing of the aforementioned documents on an annual basis for the medical personnel and coaches. The Associate Athletics Director for Athletic Training will keep the signed documents on file. A copy of the Texas A&M Concussion Policy will also be distributed through the Policies and Procedures manuals for each of the Athletic Training facilities and coaches’ manual. The Associate Athletics Director for Athletic Training will coordinate an annual meeting each May to review and update the Concussion Policy. Texas A&M Sports Medicine will have on file an annually updated Emergency Action Plan for each Athletics venue to respond to catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress, and sickle cell collapses. All athletics healthcare providers shall review and practice the plan annually. The Texas A&M Sports Medicine staff members shall be empowered to determine management and return-to-play of any ill or injured student-athlete as he or she deems appropriate. Conflicts or concerns will be forwarded to the Associate Athletics Director for Athletics Training or the Director of Sports Medicine for remediation. The Texas A&M Sports Medicine staff will have on file a written physician-directed concussion management plan that specifically outlines the roles of the Athletics healthcare staff. The Texas A&M Sports Medicine staff members and other Athletics healthcare providers will practice within the standards as established for their professional practice. The Texas A&M Sports Medicine staff will document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion. Athletics staff, student-athletes and officials will continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted. Revised: 06/16/2015 PLH Texas A&M Sports Medicine Concussion Management Protocol A concussion is a brain injury that is caused by a direct or indirect blow to the head. As a result, transient impairment of mental functions such as memory, balance/equilibrium, and vision may occur. It is important to recognize that many sportrelated concussions do not result in loss of consciousness and, therefore, all suspected head injuries should be taken seriously. Concussions and other brain injuries can be serious and potentially life threatening injuries in sports. Research indicates that these injuries can also have serious consequences later in life if not managed properly. In an effort to combat this injury the following concussion management protocol will be used for Texas A&M University Student-Athletes. 1. Every new (first year or transfer) student-athlete at Texas A&M must complete a detailed Medical History. Previous head injuries, brain injuries, and/or concussions must be documented in the Medical History. The Medical History will be reviewed by a Staff Athletic Trainer and Team Physician at Texas A&M. 2. The Team Physician at Texas A&M will determine the participation status for every new (first year or transfer) studentathlete at Texas A&M. Medical clearance for participation, or Medical non-clearance for participation, will be documented in writing on the student-athletes Pre- Participation Physical Exam by the Team Physician. 3. Texas A&M University Sports Medicine will record a baseline assessment for every new (first year or transfer) studentathlete. The same baseline assessment tools should be used post-injury at appropriate time intervals. The baseline assessment should consist of the use of: 1) C3 Logix (C3), and 2) ImPACT computerized neurocognitive assessment (CNT). a. The respective team’s Athletic Trainers will conduct the following assessments for all new athletes: C3, and CNT. b. The respective team’s Athletic Trainers will keep a copy of C3 Logix scores on file so they can have easy access for away contests, bowl games, and tournaments. 4. When a student-athlete shows any signs, symptoms, or behaviors consistent with a concussion, the athlete will be removed from practice or competition, by either a member of the coaching staff or Sports Medicine staff. If removed by a coaching staff member, the coach will refer the student-athlete for evaluation by a member of the Sports Medicine staff. Visiting sport team members evaluated by the Texas A&M Sports Medicine staff will be managed in the same manner as Texas A&M student-athletes. 5. A student-athlete suspected of sustaining a concussion will be evaluated by the team’s Athletic Trainer ASAP. Should the Team Physician not be present, the Athletic Trainer will notify the Team Physician ASAP in order to develop an evaluation and treatment plan. Ideally, an assessment of symptoms will be performed at the time of the injury and then serially thereafter (i.e. 2-3 hours post-injury, 24 hours, 48 hours, etc.). The presence or absence of symptoms will dictate the inclusion of additional neurocognitive and balance testing. 6. A student-athlete suspected of sustaining a concussion will be evaluated for a Cervical Spine injury during the initial evaluation. Any signs and symptoms of a Cervical Spine injury will warrant an immediate activation of the Texas A&M Athletics Department Emergency Action Plan. 7. The Texas A&M Athletics Department Emergency Action Plan will be initiated for a student-athlete who suffers a concussion and presents with any of the following: Glasgow Coma Scale < 13; prolonged loss of consciousness; focal neurological deficit suggesting intracranial trauma, repetitive emesis, persistently diminished/worsening mental staus or other neurological signs/symptoms; spine injury. (See attached: Concussion Management Physician Referral Checklist) 8. A student-athlete diagnosed with a concussion will be withheld from the competition or practice and not return to activity for the remainder of that day. Student-athletes that sustain a concussion outside of their sport will be managed in the same manner as those sustained during sport activity. Revised: 06/16/2015 PLH 9. The student-athlete will receive serial monitoring for deterioration. In the event that the student-athletes condition deteriorates, the Staff Athletic Trainer will contact the Team Physician and refer according to the Physician Referral Checklist. 10. Student-athletes will be provided with a copy of the Post-Concussion take home instructions; preferably with a roommate, guardian, or someone that can follow the instructions. The Medical Provider will include a copy of the signed Post-Concussion take home instructions in the student-athletes personal medical file. 11. The Medical Provider will document the injury, immediate care, follow-up care, & physician referrals in the studentathletes personal medical file. 12. The student-athlete will be monitored for recurrence of symptoms both from physical exertion and also mental exertion, such as reading, phone texting, computer games, watching film, athletic meetings, working on a computer, classroom work, or taking a test. Academic advisors will be notified of the student-athlete’s concussion, with permission for release of information from the student-athlete. 13. The Team Physician will be notified if there is a recurrence of symptoms from physical and/or mental exertion or if the student-athletes recovery is prolonged. The Team Physician will determine the course of care for the student-athlete. 14. The student-athlete will be evaluated by a Team Physician as outlined within the concussion management physician referral checklist and the concussion management follow-up assessment protocol. 15. Once asymptomatic and post-exertion assessments are within normal baseline limits, return to play shall follow a medically supervised stepwise process. 16. Final authority for return-to-play shall be the decision of the team physician. 17. The following assessment and return to play plan will be used for ALL concussions: Concussion Assessment: NO ATHLETE SUSPECTED OF HAVING A CONCUSSION IS PERMITTED TO RETURN TO PLAY THE SAME DAY. NO ATHLETE IS PERMITTED TO RETURN TO PLAY WHILE SYMPTOMATIC FOLLOWING A CONCUSSION. - Baseline Testing: to be completed upon entering as a freshman or transfer student-athlete. Time of Injury: clinical evaluation and symptom checklist to be completed. 1-3 hours post-injury: symptom checklist to be completed; referral if necessary. Next Day: follow-up clinical evaluation and symptom checklist to be completed. Daily: follow-up evaluations to track symptom recovery. Weekly: clinical evaluation by a Team Physician until asymptomatic and the 5-step graduated exertional return to play protocol has been completed successfully. Once Athlete Becomes Asymptomatic: 1. Determine where athlete is relative to baseline on the following measures: a. C3 Logix b. ImPACT Neurocognitive Assessment 2. Revised: 06/16/2015 If the measures listed above are at least 90% of baseline scores and the athlete remains asymptomatic for one additional day following these tests, the Team Physician can instruct the Athletic Trainer to begin a 5-step graduated exertional return to play (RTP) protocol (see below) with the athlete to assess for increasing signs and symptoms. Symptoms should be reassessed immediately following exertional activities. PLH 3. If the athlete remains asymptomatic on the day following the first step(s) of the graduated exertional RTP protocol, the athlete will be reassessed, and continue with the next step(s) on the graduated exertional RTP protocol. 4. All scores on the assessments and/or exertional activities will be documented in the student-athlete’s medical file by the Staff Athletic Trainer. 5. The Staff Athletic Trainer will share the scores on the assessments and/or exertional activities with the Team Physician. IF THE STUDENT-ATHLETE BECOMES SYMPTOMATIC AT ANY POINT DURING THIS PROCESS, THEY SHOULD BE RE-ASSESSED DAILY UNTIL ASYMPTOMATIC. ONCE ASYMPTOMATIC, THE ATHLETE SHOULD THEN FOLLOW STEPS 1-4 ABOVE. 5-Step Graduated Exertional Return to Play Protocol This exertional protocol allows a gradual increase in volume and intensity during the return to play process. The athlete is monitored for any concussion-like signs or symptoms during and after each exertional activity. The following steps are not ALL to be performed on the same day. In some cases, steps 1, 2, and 3 may be completed on the same day, but typically will occur over multiple days. Steps 4 and 5 will each be performed on separate and subsequent days. Exertion Step 1: 20 minute stationary bike ride (10-14 mph). Exertion Step 2: Interval bike ride: 30 second sprint (18-20 mph) followed by 30 second recovery (10-14 mph) x 10; and bodyweight circuit: Squats/Push-Ups/Sit-ups x 20 seconds x 3. Exertion Step 3: 60 yard shuttle run x 5 (40 second rest); and plyometric workout: 10 yard bounding/10 medicine ball throws/10 vertical jumps x 3; and non-contact, sports-specific drills for approximately 15 minutes. Exertion Step 4: Limited, controlled return to full-contact practice and monitoring for symptoms. Exertion Step 5: Full sport participation. No athlete can return to full activity or competitions until they are asymptomatic in limited, controlled, and full-contact activities, AND cleared by the Team Physician. Approved By: _______________________________, Director of Sports Medicine J.P. Bramhall, MD Revised: 06/16/2015 Date: ______________________ PLH Reference Documents 1. 2. 3. 4. 5. 6. 7. 8. NCAA & CDC Educational Material on Concussion in Sport. Available online at www.ncaa.org/health-safety. NCAA Sports Medicine Handbook. 2013-2014. NCAA Sport Science Institute Newsletter. Vol 1, Issue 2, 2013. National Athletic Trainers’ Association Position Statement: Management of Sport Concussion. Journal of Athletic Training, 2014;49(2). Consensus Statement on Concussion in Sport; the 4th International Conference on Concussion in Sport Held in Zurich, November, 2012. British Journal of Sports Medicine, 2013; 47: 250-258. North Carolina State University Concussion Management Policy and Procedure. 2013. The University of North Carolina Sport Concussion Policy. Matthew Gfeller Sport Related Traumatic Brain Injury Research Center and Division of Sports Medicine. 2010. The University of Georgia Athletic Association’s Concussion Management Guidelines. 2010. Revised: 06/16/2015 PLH Texas A&M Sports Medicine Student-Athlete Concussion Awareness What is a concussion? A concussion is a brain injury that: • Is caused by a blow to the head or body (from contact with another player, hitting a hard surface such as the ground or floor, or being hit by a piece of equipment such as a bat or a ball). • Can change the way your brain normally works. • Presents itself differently for each student-athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness. How can I prevent a concussion? • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and bats/sticks to the head may all cause a concussion. • Follow the NCAA and Athletics Department’s rules for safety and the rules of the sport. What are the symptoms of a concussion? You can’t see a concussion but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: Amnesia Balance problems or dizziness Feeling sluggish, foggy, or groggy Confusion Double or fuzzy vision Feeling unusually irritable Headache Sensitivity to light or noise Slow reaction time Loss of consciousness Concentration or memory problems Nausea Although most athletes that experience a concussion recover within 7-10 days, some concussions may take longer to resolve. There is evidence to suggest that sustaining a concussion or even multiple sub-concussive brain injuries may lead to long term consequences such as prolonged symptoms, psychological distress, depression, and/or Chronic Traumatic Encephalopathy (CTE). CTE is a progressive brain disease believed to be caused by repetitive trauma to the brain, including concussions or sub-concussive blows. CTE is characterized by symptoms such as memory impairment, emotional instability, erratic behavior, depression, and problems with impulse control. The disease may ultimately progress to fullblown dementia. Ultimately, sustaining a concussion could lead to death. What should I do if I think I have a concussion? Don’t hide it. Tell your Athletic Trainer and coach. Never ignore a blow to the head. Also, tell your Athletic Trainer and coach if one of your teammates might have a concussion. Report it. Do not continue to participate in a game, practice, or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your Team Physician, Athletic Trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep, and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. Exercise or activities that involve a lot of concentration such as studying, working on the computer, or playing video games may cause concussion symptoms (such as a headache or tiredness) to reappear or get worse. Get help by talking to your Athletic Trainer. IT’S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. By signing below, I acknowledge that I understand that there are certain risks involved in participating in Athletics at Texas A&M University, including those risks associated with head injuries and concussions. I agree to report all signs and symptoms of my injuries to the Sports Medicine Staff immediately. Additionally, I will help protect my teammates by reporting their signs and symptoms to the Sports Medicine Staff. I understand that each head injury is different and that each injury will be treated individually, with each return to play decision performed on an individual basis. By signing this, I agree to follow the direction of treatment and care designated by the Texas A&M Sports Medicine Staff. I understand that I must be cleared by a Texas A&M Sports Medicine Team Physician before returning to play. ______________________________ Athlete’s Name Printed _______________________________ Athlete’s Signature _______________ Date ______________________________ Parent/Guardian’s Printed (if under 18) ______________________________ Parent/Guardian’s Signature _______________ Date Revised: 06/16/2015 PLH Texas A&M University Athletics Department Student-Athlete Concussion Statement Please acknowledge each bullet point with your initials and sign below. ______ I understand that it is my responsibility to report all injuries and illnesses to my Athletic Trainer and/or Team Physician. ______ I have read and understand the NCAA Concussion Fact Sheet. ______ I have read and understand the Texas A&M Sports Medicine Concussion Awareness Sheet. After reading the NCAA Concussion Fact Sheet, and the Texas A&M Sports Medicine Concussion Awareness Sheet, I am aware of the following: ______ A concussion is a brain injury, which I am responsible for reporting to my Athletic Trainer and/or Team Physician. ______ A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. ______ You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. ______ If I suspect a teammate has a concussion, I am responsible for reporting the injury to my Athletic Trainer and/or Team Physician. ______ I will not return to play in a game or practice if I have received a blow to the head or body that results in concussionrelated symptoms. ______ Following a concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. ______ In rare cases, repeat concussions can cause permanent brain damage, and even death. ______ I am aware that I am required to complete a baseline test prior to athletic participation at Texas A&M University. This test will allow for comparison of symptoms, neurocognition, and balance if I were to become injured. ______ In the event that I am diagnosed with a concussion, I am aware that I must be re-assessed by a Team Physician once my symptoms resolve. ______ In the event that I am diagnosed with a concussion, I am aware that I must successfully complete a graduated return to play protocol prior to being cleared for return to athletic participation. ______ In the event that I am diagnosed with a concussion, I am aware that I must be medically cleared by a Team Physician prior to returning to athletic participation. ______________________________ Athlete’s Name Printed ______________________________ Athlete’s Signature _______________ Date ______________________________ Parent/Guardian’s Printed (if under 18) ______________________________ Parent/Guardian Signature _______________ Date Revised: 06/16/2015 PLH Texas A&M University Athletics Department Coaches Concussion Statement Please acknowledge each bullet point with your initials and sign below. ______ I have read and understand the Texas A&M Athletics Department Concussion Management Protocol. ______ I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet, and the Texas A&M Athletics Department Concussion Management Protocol, I am aware of the following information: ______ A concussion is a brain injury, which student-athletes should report to the medical staff. ______ A concussion can affect the student-athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. ______ I will not knowingly allow the student-athlete to return to play in a game or practice if he/she receives a blow to the head or body that results in concussion-related symptoms. ______ Student-athletes shall not return to play in a game or practice on the same day that they are suspected of having a concussion. ______ If I suspect one of my athletes has a concussion, it is my responsibility to have that athlete see the medical staff. ______ I will encourage my student-athletes to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussions. ______ Following a concussion the brain needs time to heal. Concussed athletes are much more likely to have a repeat concussion if they return to play before their symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. ______ I am aware that every first-year student-athlete at Texas A&M must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition, and balance if the student-athlete were to become injured. ______ I am aware that student-athletes diagnosed with a concussion will be re-assessed by a Team Physician once symptoms have resolved. Student-athletes will begin a graduated return to play protocol following full recovery of neurocognition and balance. ______ I am aware that student-athletes diagnosed with a concussion must be re-assessed by a Team Physician once the return to play protocol is successfully completed. ______ I am aware that student-athletes diagnosed with a concussion must be medically cleared by a Team Physician prior to returning to athletic participation. ______________________________ Printed Name of Coach Revised: 06/16/2015 ______________________________ Signature of Coach _______________ Date PLH Texas A&M University Athletics Department Athletics Administrator Concussion Statement Please acknowledge each bullet point with your initials and sign below. ______ I have read and understand the Texas A&M Athletics Department Concussion Management Protocol. ______ I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet, and the Texas A&M Athletics Department Concussion Management Protocol, I am aware of the following information: ______ A concussion is a brain injury, which student-athletes should report to the medical staff. ______ A concussion can affect the student-athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. ______ Student-athletes shall not return to play in a game or practice if he/she receives a blow to the head or body that results in concussion-related symptoms. ______ Student-athletes shall not return to play in a game or practice on the same day that they are suspected of having a concussion. ______ If I suspect a student-athlete has a concussion, it is my responsibility to have that athlete see the medical staff. ______ I will encourage student-athletes and coaches to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussions. ______ Following a concussion the brain needs time to heal. Concussed athletes are much more likely to have a repeat concussion if they return to play before their symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. ______ I am aware that every first-year student-athlete at Texas A&M must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition, and balance if the student-athlete were to become injured. ______ I am aware that student-athletes diagnosed with a concussion will be re-assessed by a Team Physician once symptoms have resolved. Student-athletes will begin a graduated return to play protocol following full recovery of neurocognition and balance. ______ I am aware that student-athletes diagnosed with a concussion must be re-assessed by a Team Physician once the return to play protocol is successfully completed. ______ I am aware that student-athletes diagnosed with a concussion must be medically cleared by a Team Physician prior to returning to athletic participation. ______________________________ Printed Name of Administrator Revised: 06/16/2015 ______________________________ Signature of Administrator _______________ Date PLH Texas A&M University Athletics Department Medical Provider Concussion Statement Please acknowledge each bullet point with your initials and sign below. ______ I have read and understand the Texas A&M Athletics Department Concussion Management Protocol. ______ I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet, and the Texas A&M Athletics Department Concussion Management Protocol, I am aware of the following information: ______ A concussion is a brain injury, which student-athletes should report to the medical staff. ______ A concussion can affect the student-athlete’s ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance. ______ You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. ______ I will not knowingly allow the student-athlete to return to play in a game or practice if he/she receives a blow to the head or body that results in concussion-related symptoms. ______ If I suspect a student-athlete has a concussion, it is my responsibility to refer that athlete to the appropriate medical staff. ______ I will encourage the student-athlete to report any suspected injuries and illnesses to the medical staff, including signs and symptoms of concussions. ______ Following a concussion the brain needs time to heal. Concussed athletes are much more likely to have a repeat concussion if they return to play before their symptoms resolve. In rare cases, repeat concussions can cause permanent brain damage, and even death. ______ I am aware that every first-year student-athlete at Texas A&M must be baseline tested prior to participation in sport. These tests allow for comparison of symptoms, neurocognition, and balance if the student-athlete were to become injured. ______ I am aware that student-athletes diagnosed with a concussion will be re-assessed by a Team Physician once symptoms have resolved. Student-athletes will begin a graduated return to play protocol following full recovery of neurocognition and balance. ______ I am aware that student-athletes diagnosed with a concussion must be re-assessed by a Team Physician once the return to play protocol is successfully completed. ______ I am aware that student-athletes diagnosed with a concussion must be medically cleared by a Team Physician prior to returning to athletic participation _____________________________ Printed Name of Medical Provider Revised: 06/16/2015 ______________________________ Signature of Medical Provider _______________ Date PLH Post-Concussion Take Home Instructions ___________________________ sustained a concussion or direct contact to the head on _____________. This is potentially dangerous or even life-threatening situation. To make sure he/she recovers, please follow these recommendations: 1. Please remind him/her to report to the Athletic Training Room tomorrow at ________ for a follow-up evaluation. 2. Please review the following symptoms. If any of these symptoms develop prior to his/her visit, please call ______________________ at ______________________ or contact the local emergency medical system, 911, or your family physician. Loss of consciousness – passed out Excessive drowsiness Increase in severity of headache Agitation or becomes easily aggravated Lack of coordination – unsteadiness Change in speech pattern – slurring 3. Inability to concentrate Blurred or double vision Unequal pupil size Dizziness Numbness and tingling anywhere Seizure activity or convulsions Vomiting Amnesia Behavior or emotional instability Pain around the neck or head Loss of bowel or bladder function Please follow the instructions outlined below. It is OK to: Take Tylenol (acetaminophen) as directed. Use ice pack on head and neck as needed. Eat a normal diet. Return to school. Go to sleep. There is NO need to: Check eyes with a flashlight. Wake up every hour. Stay in bed. Avoid strenuous mental tasks. Avoid text messaging, video games & watching TV. Do NOT use Advil, Ibuprofen, Aleve, or Aspirin. Do NOT drink alcohol. Do NOT take pain killers. Do NOT eat spicy food. Do NOT drive until symptoms resolve. Do NOT exercise or perform exertional activity Specific Recommendations: _________________________________________________________________________ Recommendations provided to: _______________________________ Signature: ______________________________ Recommendations provided by: _______________________________ Date: __________________ Time: _________ Please contact me if you have any questions. I can be reached at: ___________________________________________ Signature: ______________________________ Date: __________________ Revised: 06/16/2015 PLH Concussion Management Physician Referral Checklist Day-of-Injury Referral: 1. Loss of consciousness on the field. 2. Amnesia lasting longer than 15 minutes. 3. Glasgow Coma Scale < 13. * 4. Deterioration of neurologic function.* 5. Decreasing level of consciousness.* 6. Decrease or irregularity in respirations.* 7. Decrease or irregularity in pulse.* 8. Increase in blood pressure. 9. Unequal, dilated, or un-reactive pupils.* 10. Cranial nerve deficits.* 11. Any signs of symptoms of associated injuries, spine, or skull fracture, or bleeding.* 12. Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation.* 13. Seizure activity.* 14. Vomiting. 15. Motor deficits subsequent to initial on-field assessment. 16. Sensory deficits subsequent to initial on-field assessment. 17. Balance deficits subsequent to initial on-field assessment. 18. Cranial nerve deficits subsequent to initial on-field assessment. 19. Post-concussion symptoms that worsen. 20. Additional post-concussion symptoms as compared with those on the field. * Requires that the student-athlete be transported immediately to the nearest Emergency Department. Delayed referral (after the day of injury): 1. 2. 3. 4. Revised: 06/16/2015 Any of the findings in the day-of-injury referral category. Post-concussion symptoms worsen or do not improve over time. Increase in the number of post-concussion symptoms reported. Post-concussion symptoms begin to interfere with the student-athlete’s daily activities (i.e., sleep disturbances). PLH Concussion Management Return To Learn Management Plan Return to learn is a parallel concept to return-to-play for the concussed student-athlete. Return to learn guidelines assume that both physical and cognitive activities require brain energy, and that after a concussion, brain energy may not be available for physical and cognitive exertion because of a brain energy crisis. Return-to-learn should be managed in a stepwise program that fits the needs of the individual. For complex concussion cases at Texas A&M, the following Return to Learn Management Team will navigate the student-athlete through the Return to Learn Management Plan: Director of Sports Medicine Team Physician Senior Associate Athletics Director for Student-Athlete Services Associate Athletics Director for Athletic Training and/or Designee Associate Athletics Director for Academic Services and/or Designee Associate Director of Student Counseling Services Director of Disability Services and/or Designee Head Coach and/or Designee Like return-to-play, it is difficult to provide prescriptive recommendations for return-to-learn. However, the following return to learn guidelines should be used for complex concussion cases where academic accommodations are warranted. 1. 2. 3. 4. 5. 6. 7. 8. 9. A student-athlete is diagnosed with a concussion by a Team Physician and/or an ER physician. The student-athlete is evaluated by the Director of Sports Medicine and/or Texas A&M Team Physician. The Director of Sports Medicine and/or Texas A&M Team Physician will provide written documentation that the student-athlete be excused from academic responsibilities for the remainder of the day. The Athletic Trainer contacts Student-Athlete Services in order to notify them of the concussion diagnosis as well as to provide them with the written documentation from the physician excusing the student-athlete from academics. The Associate Athletics Director for Academic Services and/or Designee will notify the student-athletes course instructors of the class absence. Serial evaluations will be conducted by the Associate Athletics Director for Athletic Training and/or Designee as well as the Director of Sports Medicine and/or Texas A&M Team Physician, If warranted, the Director of Sports Medicine and/or Texas A&M Team Physician will make the recommendation for continued academic accommodations. Recommendations will be provided in written form to the Associate Athletics Director for Academic Services and/or Designee. Recommendations made by the Director of Sports Medicine and/or Texas A&M Team Physician may include, but ARE NOT limited to the following: • No classroom activity. • No study hall and/or individual tutoring sessions. • Modification of the student-athletes academic schedule. • The student-athlete is to remain at home/dorm if light cognitive activity is not tolerated. • Refer the student-athlete to the Director of Disability Services and/or Designee in order for academic accommodations to be developed. In the event that a student-athletes condition warrants a referral to Disability Services, the following steps will be followed: • The Director of Sports Medicine and/or Texas A&M Team Physician will provide written documentation of the concussion diagnosis. • Written documentation of the concussion diagnosis will be provided to the Associate Athletics Director for Academic Services and/or Designee. • The Associate Athletics Director for Academic Services and/or Designee will provide the written documentation to the Director of Disability Services and/or Designee. Revised: 06/16/2015 PLH The student-athlete will be required to visit with Disability Services, via telephone or in person, in order to ensure that the student-athlete wants the services. • Disability Services will assist the student-athlete in developing appropriate accommodations and/or modifications to the student-athletes class schedule and course requirements. • The Director of Disability Services and/or Designee will ensure that ALL accommodations are compliant with the Americans with Disabilities Act Amendments Act of 2008 (ADAAA. • Disability Services and Student-Athlete Services will communicate the appropriate accommodations and/or modifications with the appropriate faculty members. • The student-athlete will be referred to Texas A&M Team Physician if concussion symptoms worsen with academic responsibilities. The Team Physician will re-evaluate the student-athlete and make the appropriate medical decision(s). • A student-athlete that remains symptomatic for greater than two weeks will be referred to the Team Physician for evaluation. The Team Physician will make the appropriate medical decision(s). • The Director of Sports Medicine and/or Texas A&M Team Physician will provide written documentation once the student-athletes symptoms have resolved and they have been medically cleared to resume activities of normal living. • Written documentation of medical clearance will be provided to the Associate Athletics Director for Academic Services and/or Designee. • The Associate Athletics Director for Academic Services and/or Designee will provide the written documentation to the Director of Disability Services and/or Designee. • Disability Services determines the necessity of continued classroom modifications and maintains communication with the appropriate faculty members. 10. Sports Medicine and Student-Athlete Services maintain a high level of vigilance with all previously concussed studentathletes. • Revised: 06/16/2015 PLH Department of Athletics Sports Medicine Texas Tech University Concussion Management Plan 2015-2016 The following policy and procedures on education, baseline testing, and subsequent assessment and management of concussions, as well as return to learn and return to play guidelines, has been developed in accordance with the Big 12 and NCAA to provide quality healthcare services and assure the well-being of each student-athlete at Texas Tech. PURPOSE: Texas Tech University Athletics recognizes sport induced Mild Traumatic Brain Injuries (mTBI’s) and/or concussions pose a significant health risk for those student-athletes participating in athletics. With this in mind, Texas Tech University, along with the Big 12 and the NCAA has implemented policies and procedures to assess, identify, and manage those student-athletes who have suffered a concussion. It is also recognized baseline neuropsychological and postural stability testing can provide important comparison data when performing subsequent serial computerized neuropsychological testing as an ancillary assessment in making return to competition decisions for student athletes participating at Texas Tech University. This baseline data along with physical examination, and/or further diagnostic testing will be used in conjunction when determining timing for a student athlete to return to the classroom and to competition. CONCUSSION DEFINITION: There are more than 42 consensus-based definitions of concussion. concussion follows. Concussion is: • • • • • A recently published, evidence-based definition of a change in brain function, following a force to the head, which may be accompanied by temporary loss of consciousness, but is identified in awake individuals, with measures of neurologic and cognitive dysfunction. REDUCING HEAD TRAUMA EXPOSURE MANAGEMENT PLAN Texas Tech recognizes and follows the Inter-Association Consensus for Independent Medical Care Guidelines as well as the Year-Round Football Practice Contact Guidelines. These guidelines will be reviewed annually with the football coaching staff. Education will also be provided on reducing gratuitous contact during practice, taking the head out of contact and taking a safety first approach to sport. Annually, by signature acknowledgement of Texas Tech University Statement of Expectations, all coaches agree to promote health and safety education, a safe and constructive environment for practice/play, and that the sports medicine staff in conjunction with the medical director and team physicians have the unchallengeable authority to make all medical decisions in regard to a student-athletes’ medical care and return to play decisions. PRE-SEASON EDUCATION: All student-athletes, coaches, medical staff, and athletic directors will have annual education and/or training appropriate for their position. Once completed, all parties will sign an acknowledgement of understanding of concussion facts and the concussion management plan. This training will address signs and symptoms of concussion to increase recognition and will educate participants on methods for reporting concern for concussion to health care providers. PRE-PARTICIPATION ASSESSMENT Student-athletes will have a thorough, documented, review of their concussion and brain injury history when they first arrive on campus as part of their pre-participation physical exam. Student-athletes will sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. Baseline metrics including symptom evaluation, cognitive assessment, and balance evaluation will also be performed. This process must be completed before participation in any organized athletic activity at Texas Tech University. The team physician will determine final clearance and/or the need for additional consultation or testing. BASELINE TESTING AND POST-CONCUSSION TESTING: SCAT3 / Modified BESS: Sport Concussion Assessment Tool and Modified Balance Error Scoring System All incoming freshman and transfer student-athletes will have a baseline SCAT3 and Modified BESS test as part of their incoming pre-participation physical. SCAT3 and Modified BESS Testing results will be interpreted by the team physician in the management of the concussion and in conjunction with neuropsychological testing, and/or any further diagnostic testing to determine when it is safe for a student athlete to return to physical activity. Neuropsychological Testing: All incoming freshman and transfer student-athletes will have a baseline neuropsychological test as part of their incoming preparticipation physical. Baseline testing may be repeated periodically as needed or after a student athlete has recovered from a concussion. Currently, Texas Tech utilizes the ImPACT™ concussion management system. SIGNS AND SYMPTOMS OF CONCUSSION: Certified athletic trainers and athletic training students all need to be aware of the signs and symptoms of concussion to properly recognize and intervene on behalf of the student-athlete. These include, but are not limited to: Physical Symptoms Cognitive Symptoms Emotional Symptoms Headache Vision Difficulty Nausea/vomiting Dizziness Balance Difficulties Light sensitivity Sensitivity to noise Fatigue Loss of Consciousness Memory Loss Attention Disorder Reasoning difficulty Fogginess Irritability Sadness Feeling more emotional Nervousness Personality Change Sleep Symptoms Drowsiness Sleeping more than usual Sleeping less than usual Trouble falling asleep RECOGNITION AND DIAGNOSIS OF CONCUSSION: The recommendations in this protocol for the management of concussions are based on review of the current medical Literature (see references) and the Big 12 and NCAA policies for concussion management and are in full cooperation with Texas Tech University Athletics’ medical director, team physicians, and athletic training staff. In any circumstance where a concussion is suspected in a student-athlete, the first priority after an initial assessment for cervical spine or associated head trauma, is to remove the student-athlete from further participation until a thorough sideline assessment can be made. Initially, a SCAT-3 sideline evaluation should take place involving a certified athletic trainer and, if possible, a team physician. A sideline postural stability exam will be performed, using the modified BESS Test. Furthermore, if there is a question about the state of mental clearing it is best to err in the direction of conservative management and withhold the athlete from further participation until a physician assessment can be arranged. POST-CONCUSSION MANAGEMENT: Consideration for initiation of an emergency action plan and transportation for further medical care should be considered for any student-athlete who has a Glasgow Coma Scale (GCS) of less than 13, prolonged loss of consciousness, focal neurological deficit suggesting intracranial trauma, repetitive vomiting, persistently diminished/worsening mental status or other neurological signs and symptoms, or suspected spine injury. Emergency Action Plans for each venue are posted in visible areas at every location. Coordination with the EMS is discussed and reviewed annually in coordination with the event management staff. EMS response times for any venue on campus are within 5 minutes for any emergencies that arise during a practice. Any student-athlete identified as having a concussion, either by a team physician or a certified athletic trainer, shall be removed from play for the remainder of the day’s participation. It is necessary to schedule further evaluation with a team physician and appropriate follow-up neuropsychological testing as soon as possible upon return to campus for the studentathlete who sustains a concussion while competing in away events. When travelling, the athletic trainer may request evaluation by the host team’s team physician before travel home. Initially, the student-athlete should not be left alone. The student-athlete will receive serial monitoring of his/her mental/cognitive status to detect signs of deterioration. The student-athlete (and a companion or guardian who will be with them consistently) will be provided with a closed head injury symptom handout (see appendix) with written discharge instructions and protocol for emergency action in case of symptom deterioration. A symptom inventory shall be performed on a regular basis until an athlete has been deemed to be asymptomatic from his/her concussion. Accommodations will be made to promote physical and cognitive rest for student-athletes after a concussion. Student-athletes who have a prolonged recovery will be evaluated by the team physician for additional diagnoses and appropriate referral and management options. The Sports Medicine Staff in conjunction with the Medical Director will keep an updated list of outside consultants to be used when deemed appropriate. Additional diagnoses may include post-concussion syndrome, sleep dysfunction, migraine or other headaches disorders, and ocular or vestibular dysfunction. Final return to play decisions will still be made by the team physician or his/her designee. RETURN TO LEARN GUIDELINES: Any student-athlete who has been diagnosed with a concussion or has concussion-like symptoms will be required to follow a return to learn protocol. Unnecessary cognitive stressors should be limited including watching TV, video games, texting, and computer work. The Sports Medicine staff and/or team Athletic Trainer will notify the Director of the Learning Assistance Program/Learning Specialist of a student-athlete's concussion diagnosis or concussion symptoms. The learning specialist will coordinate the return to learn with the student-athlete. The return to learn protocol includes the following: Temporary Accommodations (up to two weeks) 1. 2. 3. 4. 5. The Learning Specialist requests documentation from Sports Medicine that includes: injury, date of injury, method of treatment, estimated time for treatment, estimated time frame for recovery and recommended medical accommodations (e.g., Staying at home, medical absence, gradual return to the classroom). Student-athletes should not attend class on the same day as his/her concussion. ***Note: Only a professor has the authority to “excuse” a student from class The Learning Specialist provides the documentation from Sports Medicine to the Athletic Academic Advisor. The Athletic Academic Advisor provides guidance to the Student-Athlete in contacting Professors/Instructors regarding the student’s injury, recommended classroom absences, and any arrangements for making up missed assignments. If symptoms worsen with progression of academic challenges, the student-athlete will be re-evaluated by the team physician. The Sports Medicine staff will notify the Director of the Learning Assistance Program/Learning Specialist when the student-athlete has been cleared medically. Long Term Accommodations If the student-athlete will not be cleared medically after two weeks, the Sports Medicine Staff will notify the Director of the Learning Assistance Program/Learning Specialist that long-term support is needed. A multi-disciplinary approach will be considered and the following will also be provided to the student-athlete: a. Student-athlete will meet with the Learning Specialist to complete an application for Student Disability Services (SDS) b. c. i. A student must register with Student Disability Services and file appropriate documentation to be eligible for academic accommodations. (Texas Tech Operating Policy 34.22: Establishing Reasonable Accommodation for Students with Disabilities) The Learning Specialist emails, scans, or faxes the student-athlete’s application and the medical documentation to SDS. i. The Learning Specialist in conjunction with SDS will ensure compliance with Americans with Disabilities Act Amendments Act, ADAAA. The Learning Specialist schedules the private student-athlete intake meeting with Student Disability Services Associate Director i. Student Disability Services Intake Meeting - In addition to receiving the letter of accommodation, the associate director explains the students’ rights and responsibilities, academic expectations, and general guidelines about utilizing temporary academic accommodations. ii. The Letter of Accommodation is saved in student-athlete’s file in the Marsha Sharp Center (MSC). The university-approved mechanism for establishing reasonable accommodation is written notification in the form of a Letter of Accommodation from Student Disability Services. The Letter of Accommodation indicates to faculty that the student has given proof of her/his disability and that the accommodation noted is considered appropriate and reasonable. No further proof of disability should be required of the student. Students presenting other kinds of verification should be referred to Student Disability Services for the appropriate identification. No requirement exists that accommodation be made prior to completion of the approved university process. (Texas Tech Operating Policy 34.22: Establishing Reasonable Accommodation for Students with Disabilities) RETURN TO PLAY GUIDELINES: Any student-athlete who has been diagnosed with a concussion is required to follow a return to play protocol after receiving clearance from the team physician. The team physician will decide if outside consultation is necessary and will make the appropriate referrals at that time. The team physician will utilize all available information (symptom evaluation, cognitive and physical evaluation, balance assessment, neurocognitive testing, and/or other diagnostic testing) to determine clearance. The return to play protocol will include the following: Upon cognitive and/or physical exertion, a student-athlete must remain asymptomatic and with no new symptoms associated with his/her concussion. They will be supervised and progressed as follows: o o o o o Light aerobic exertion (e.g. walking, swimming, exercise bike) Sport specific activity Non-contact training drills Contact drills/practice Return to game activity (per clearance by team physician or team physician’s designee) If a student-athlete has a return of symptoms or develops new symptoms during any part of the progression, the student-athlete will drop back to the last asymptomatic level for 24hrs and begin again. The student-athlete must be re-integrated academically before final return to play clearance is granted. Clinical evaluation of post-concussive symptoms, prior concussion history, neurological examination, and any outside diagnostic testing deemed necessary will be utilized by the team physician in establishing a timeline for a student-athlete to return to activity. It is important to note this timeline could last from a period of days to weeks or even months, and could possibly result in eventual medical disqualification from Texas Tech University Athletics. All cases will be handled on a caseby-case basis. The decision by the Team Physician for all cases of an athlete’s return to activity is final. Medical clearance to return to competition is based on current best practices, existing evidence based information and consensus statements, clinical examination, and completion of all required testing. Medical clearance does not guarantee against future adverse outcomes or eventual complications. APPENDICES: NCAA/CDC Concussion Fact Sheet for Athletes NCAA/CDC Concussion Fact Sheet for Coaches Texas Tech University Concussion Education Acknowledgement SCAT3 Sideline Evaluation Sheet Texas Tech University Post Concussion Take Home Sheet Texas Tech University Symptom Inventory Sheet REFERENCES: 1. NCAA Sports Medicine Handbook, 25th Ed. Guideline 2I. Sports-related Concussion. Indianapolis, IN; August 2014. Pp 54-64. Available at: www.ncaapublications.com/productdownloads/MD15.pdf. 2. NCAA Independent Medical Care Guidelines. Accessed at http://www.ncaa.org/health-and-safety/independentmedical-care-guidelines. 3. NCAA Football Practice Guidelines. Accessed at http://www.ncaa.org/health-and-safety/football-practice-guidelines. 4. McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258. 5. McCrory P, et al. SCAT3. Br J Sports Med 2013;47:259-262. 6. Guskiewicz KM. Assessment of postural stability following sport-related concussion. Curr Sports Med Rep 2003;2: 24–30. 7. Riemann BL, Guskiewicz KM. Effects of mild head injury on postural stability as measured through clinical balance testing. J Athl Train 2000;35(1):19-25. 8. Guskiewicz K, Bruce S, Cantu R, et al. Postural stability assessment following concussion: one piece of the puzzle. J Athl Train 2004; 39(3): 280-297. 9. Harmon, KG, Drezner, JA, Gammons, M, et al. AMSSM position statement: concussion in sport. Br J Sports Med 2013;47:15-26. 10. Kissick J, Johnstone K. Return to play after concussion.. Clin J Sport Med Nov 2005;12(6):426-431. 11. Broglio SP et al. National Athletic Trainers’ Association position statement: management of sport concussion. J Athl Train 2014; 49:245-265. 12. Guskiewicz K, Putukian M. Standardized assessment and return to play. Safety in College Football Summit. Presented January 23, 2014, Atlanta, GA. 13. NCAA Sports Medicine Handbook, 25th Ed. Guideline 2I. Sports-related Concussion. Indianapolis, IN; August 2014. Pp 54-64. Available at: www.ncaapublications.com/productdownloads/MD15.pdf. 14. Carney N, Ghajar J, Jagoda A et al. Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery, September 2014;75(3):S3-S15. 15. NCAA/CDC Concussion Fact Sheets for Athletes and Coaches. Available at: http://www.ncaa.org/health-andsafety/medical-conditions/printable-resources. UCLA SPORTS MEDICINE Concussion Management Plan _____________________________________________________________________________ The administrative staff, coaches, and healthcare providers of the UCLA Department of Intercollegiate Athletics are committed to affording UCLA student-athletes with access to healthcare providers who will provide a high standard of care for the broad range of illnesses and injuries that may occur during the time in which they are participating at UCLA. To this end, the Department recognizes the importance of properly identifying and treating athletes who sustain a concussive brain injury. The Department also supports measures aimed at education and prevention of such injuries In accordance with institutional and NCAA policy, this document will delineate the components of our management plan for athletes who suffer a concussion. Key Elements of the Concussion Management Plan Include: 1. Student-athletes will be provided educational material on concussions. Student-athletes will sign a statement in which the student-athlete indicates that they have received & reviewed the educational materials related to concussion and that they accept responsibility for reporting their injuries and illnesses to the sports medicine staff, including signs and symptoms of concussions. 2. Coaches and the Director of Athletics will be provided educational material on concussions and information describing the Concussion Management Plan. They will sign a statement acknowledging they have read and understood this information. 3. UCLA Sports Medicine team physician staff within the Athletic Department has the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, including those with concussion, as he or she deems appropriate. 4. An athlete exhibiting an injury that involves significant symptoms, long duration of symptoms or difficulty with memory function OR an athlete diagnosed with a concussion should not be allowed to return to play during the remainder of that day. 5. Student-athletes with symptoms or signs suggestive of a concussion will be evaluated by a team physician. 6. Final authority for return-to-play shall reside with the treating team physician. The treating team physician may specifically designate another team physician or certified athletic training (ATC) staff to assist in implementing return to play measures. 7. The evaluation, continued management, and clearance of the student-athlete with a concussion will be documented in the student-athlete’s UCLA medical record. Student-Athlete Care Concussion Revised 4/2015 UCLA SPORTS MEDICINE 8. The Team Physicians and Athletic Trainers will review all elements of this plan annually. Changes will be made to the plan as directed by the Head Team Physician or Director of Sports Medicine. Each will sign a statement acknowledging they have read and understand the plan. UCLA Concussion Management Plan – Administrative Aspects 1. All UCLA student-athletes will receive a statement in which the student-athlete accepts responsibility for reporting their injuries and illnesses to the medical staff, including signs and symptoms of concussions. During the review and signing process student-athletes will be provided educational material on concussions. (see appendix A) 2. The UCLA Sports Medicine Staff (ATC staff and team physician staff) will continue to maintain Emergency Action Plans that includes a plan of response for concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapse. These plans are reviewed annually and after each time the plans are used by the Sport Medicine staff. 3. The UCLA Department of Intercollegiate Athletics recognizes that athletics healthcare providers have the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. These healthcare providers are the Certified Athletic Trainers(ATC) who are under the direction of The Director of Sports Medicine, Mark Pocinich, MS ATC and team physicians, who are under the direction of Head Team Physician, , Dr. John DiFiori. Coaches do not provide supervision for these healthcare providers, nor do they have hiring or firing authority over the healthcare staff. 4. The UCLA Department of Intercollegiate Athletics will maintain on file this document that describes the team physician–directed concussion management plan that specifically outlines the roles of athletics healthcare staff. 5. The Director of Athletics and coaches within the Department are required to receive and acknowledge they understand the Concussion Management Plan, their role within the plan and that they received and reviewed education about concussions. 6. The UCLA Department of Intercollegiate Athletics healthcare providers (ATC staff, physical therapists, psychologists, nutritionists, and physicians) are expected to practice within the standards as established for their professional practice. The UCLA Department of Intercollegiate Athletics will maintain on file a healthcare plan that includes equitable access to UCLA Sports Medicine staff for each NCAA sport. Student-Athlete Care Concussion Revised 4/2015 UCLA SPORTS MEDICINE UCLA Sports Medicine - Clinical Management of Concussion General Information 1. Concussion definition: “A concussion is a complex physiologic process affecting the brain induced by traumatic biomechanical forces” (CIS 2008 Consensus Statement) Clinically, this manifests in symptoms (e.g. headache), signs (e.g. loss of balance), altered brain function (e.g. confusion, poor memory) and/or abnormal behavior (e.g. more emotional or irritable). Concussions frequently occur without any loss of consciousness. 2. Student-athletes, coaches, certified athletic trainers, and team physicians should be familiar with the symptoms and signs of a concussive brain injury. These symptoms and signs include: On the Field Findings Initially may display one or more of the following: Concussion Signs Concussion Symptoms • • • • • • • • • • • • • • • • Appears dazed Confused about play Answers question slowly Forgets plays prior to hit (Retrograde amnesia) Forgets plays after hit (Anterograde amnesia) Irritability, emotional lability – tearfulness, giddiness, flattened affect Loss of consciousness Seizures Headache Nausea/vomiting Balance problems Blurred vision Photosensitivity Phonophobia Feeling sluggish Feeling foggy 3. UCLA Concussion Management Plan staff and roles: a. Student-athlete – 1) understanding of signs/symptoms of concussion. 2) reporting to ATC staff or team physician should they experience such symptoms, 3) understanding and abidance of rules in place to protect against head and neck injury b. Coaching staff - 1) understanding of signs/symptoms of concussion. 2) recognition of student-athletes with symptoms or signs of possible concussion, removing the student-athlete from play, and reporting of such to ATC staff or team physician. 3) promoting safe play and enforcing existing rules that Student-Athlete Care Concussion Revised 4/2015 UCLA SPORTS MEDICINE c. d. e. f. g. h. prohibit play which endangers the student-athlete, including those related to the prevention of head and neck injury. ATC staff – 1) concussion identification and initial assessment at venue, 2) emergency management if needed, 3) assists team physician staff in monitoring of recovery. 4) promoting safe play, including rules that protect the student-athlete from head and neck injury. Team physician staff – 1) concussion identification and initial assessment at venue, 2) emergency management if needed, 3) responsible for overall management of recovery and determination of return to play, 4) promoting safe play, including rules that protect the student-athlete from head and neck injury. Neurologic consultants – available upon request by team physician to assist in concussion management. Neuropsychologic consultants – available upon request by team physician to assist in concussion management. Sports psychologist – available upon request by team physician to assist in concussion management. Academic Staff – Development of individualized return to learn plan in collaboration with the sports medicine team, athletics staff and university resources. Baseline Assessments 1. All student-athletes will receive a preparticipation evaluation that includes questions regarding a history of prior concussion, head injury, and symptoms suggestive of concussion. Student-athletes with a concerning history of prior head injury, even if asymptomatic, may require further evaluation as deemed appropriate by the team physician staff. In addition, all student-athletes will receive a baseline assessment that includes a computerized neuropsychological examination, symptom checklist, cognitive assessment and balance evaluation prior to their participation. Based on the history of concussion(s), those student-athletes will be reassessed for baseline testing based on the medical teams recommendations Student-Athlete Care Concussion Revised 4/2015 UCLA SPORTS MEDICINE On the Field Initial Assessment and Management 1. Any student-athlete, who experiences signs or symptoms of a concussion, should seek assistance from the ATC staff or team physician at the venue. 2. A coach who observes a student-athlete exhibiting symptoms or signs suggestive of a concussion, should immediately remove the athlete from play and notify a member of the Sports Medicine Staff (ATC or physician). 3. If a member of the Sports Medicine Staff observes a student-athlete to be exhibiting symptoms or signs suggestive of a concussion, they should remove the athlete from play and proceed with further evaluation. 4. The Sports Medicine Staff will then proceed with an initial assessment to exclude more serious head injury and/or cervical spine injury, as well as maxillofacial and dental trauma. 5. Once this assessment has been completed, the Sports Medicine Staff will then begin a concussion evaluation, unless other medical concerns take priority. This initial concussion evaluation will include: a. The use of a concussion symptom checklist. b. An assessment of memory and neurocognitive function. c. A neurologic exam that includes an assessment of balance/cerebellar function. 6. A student-athlete who is symptomatic or has difficulty with memory function should not be allowed to return to play for the remainder of that same day and should be evaluated by a team physician. 7. A student-athlete diagnosed with a concussion should not be allowed to return to play for the remainder of that day and should be evaluated by a team physician. 8. If a head injury has occurred and the diagnosis is unclear, even if asymptomatic at that point, the student-athlete should be removed from play and evaluated by a team physician. 9. After the initial assessment is performed, student-athletes who are not cleared to return to play should receive regular monitoring of symptoms at the venue by the Sports Medicine Staff to observe for any worsening of their medical condition including the following: Student-Athlete Care Concussion Revised 4/2015 UCLA SPORTS MEDICINE Signs of Deteriorating Neurologic Function • • • • • • • • Seizures Impaired consciousness Focal neuro signs Repeated vomiting Increasing slurring of speech, confusion Severe worsening headache Severe irritability Glasgow Coma Scale < 13 10. If a student-athlete exhibits signs of deteriorating neurologic status, the EMS system should immediately be activated, as directed by the appropriate Emergency Action Plan, to transport the student-athlete to an emergency room and emergency care provided at the site until EMS arrives. 11. For concussed student-athletes deemed stable to return to their residence the day of injury, they and their families and/or teammates will be provided with verbal and written instructions for monitoring for the development of concerning symptoms and the appropriate contact information for UCLA Sports Medicine Staff and the EMS. Guidelines for concussion management and return to play 1. Student-athletes diagnosed with a concussion will be under the care of a team physician. 2. Student-athletes with a concussion who remain stable will receive ongoing follow up to observe for recovery, to rule out complications and to determine return to play. 3. The return to play will follow a supervised step wise approach with an initial resting period of no less than 24 hours, followed by gradual increases in activity. 4. The determination of the student-athlete’s level of activity during the recovery process is at the discretion of the team physician. Some cases may require a more gradual and prolonged recovery than others. 5. Symptoms and signs will be assessed and monitored using the UCLA Sports Medicine Concussion Evaluation Form. (see Appendix A) 6. The initial phase will involve rest from all physical and cognitive stress. This may include avoidance of video games (and other electronic stimuli), review of game film, class work and exams. This may include remaining in their place of residence (dorm/apt/home) to allow cognitive rest. Sports Medicine personnel will communicate with the appropriate academic staff, under the direction of the Director Student-Athlete Care Concussion Revised 4/2015 UCLA SPORTS MEDICINE of Academic Services in athletics, to establish an individualized return to learn plan based on their recovery. This plan will be compliant with ADAAA and involve all appropriate academic modifications as directed by the sports medicine and academic team members (which includes athletics, OSD, and the University/local ADAAA office). Student –athletes that develop prolonged symptoms (>2weeks) will be reevaluated by the team physician and the appropriate sports medicine personnel to adjust the overall recovery and return to learn plans. 7. This rest phase will continue until the symptoms and signs resolve, and the studentathlete remains asymptomatic for 24 hours. 8. Once asymptomatic for 24 hours, the team physician may advance the student-athlete as follows: a. Brief cardiovascular exertional challenge (20-30 minutes of cycling or elliptical machine or similar). b. After repeat examination, if he/she remains asymptomatic, the team physician may then advance the level of non-contact activity to more intense and sport specific levels. Cardiovascular activity may advance as tolerated. c. After repeat examination, if the student-athlete remains asymptomatic, the team physician may advance the level of activity to a full non-contact training session. Resistance training may resume at this time. d. After repeat examination, if the student-athlete remains asymptomatic, a repeat computerized neuropsychological exam may be implemented prior to proceeding with a full contact practice. If the computerized neuropsychological examination demonstrates an acceptable result, the physician may advance the student-athlete to full contact training. e. After repeat examination, if he/she remains asymptomatic, the student-athlete may be cleared by the team physician for full competition. 9. Each phase will typically occur over a 24 hour period, or longer, if deemed necessary by the treating physician. 10. If an athlete has symptoms recur during the activity progression, they should revert back to full rest and then resume progress after asymptomatic for a full 24 hours. Progress at that point may require a more gradual progression of activity levels. 11. Because many factors may affect the management of concussions (eg. prior concussions, learning disabilities, migraine headaches, sleep dysfunction), it is emphasized that ultimately the phases of return to play are implemented based upon the clinical judgment of the treating physician. 12. The UCLA team physician staff has neurological, neurosurgical and neuropsychological consultants available for additional assistance in the care of Student-Athlete Care Concussion Revised 4/2015 UCLA SPORTS MEDICINE concussed student-athletes. Such consultations are at the discretion of the team physician. 13. UCLA Sports Medicine Staff will document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion. Summary of Concussion Management Plan 1. Baseline evaluation – All Student-Athletes a. PPE screening of concussion - Including educational program and signed acknowledgement from Student athletes, coaches, Dir of Athletics, Team physicians and ATC’s b. Baseline NP testing 2. Concussion diagnosed or suspected – student-athlete removed from play and evaluated. a. Assess ABC’s b. Assess for cervical spine injury c. Assess for maxillofacial trauma d. Implement emergency management via EAP if indicated 3. If no other injury takes precedence begin sideline assessment of concussion. 4. Once concussion diagnosed, student-athlete is removed from play the remainder of that day and receives serial monitoring by appropriate sports medicine personnel to observe for any deterioration of neurologic status or prolonged recovery (> 2wks). 5. Sports Medicine communicates with academic personnel regarding return to learn plan. Includes steps to ensure the cognitive rest takes place in the appropriate environment. 6. Stepwise return to play: a. Rest at least 24 hours and until asymptomatic b. Brief cardiovascular challenge c. Sport-specific activities, increased cardiovascular training d. Non-contact training e. Full contact training f. Return to competition Student-Athlete Care Concussion Revised 4/2015 University of Utah Sports Medicine Concussion Management Plan University of Utah Sports Medicine Concussion Management Plan 1. Overview 1.1. In response to the growing concern over concussion in athletics and the memorandum issued by the NCAA (dated April 30, 2010) requesting that “institutions shall have a concussion management plan on file”, the following document serves as such. 1.2. The following components will be outlined as part of a comprehensive concussion management plan: 1.2.1. Concussion Overview (section 2) 1.2.2. Concussion Education for Student-Athletes (section 3) 1.2.3. Concussion Education for Coaches and Staff (section 4) 1.2.4. Emergency Action Plan (section 5) 1.2.5. Pre-season concussion assessment (section 6) 1.2.6. Concussion action plan (section 7) 1.2.7. Appendix A: Personnel Roles 1.2.8. Appendix B: Immediate Post Concussion Instructions 1.2.9. Appendix C: Symptom Diary and checklist 1.2.10. Appendix D: Return to School recommendations 1.2.11. Appendix E: Concussion Awareness Letter to Teacher/Administrator 1.2.12. Appendix F: Return to Play Protocol 2. What is a Concussion 2.1. Concussion, or mild traumatic brain injury (mTBI), has been defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” Although concussion most commonly occurs after a direct blow to the head, it can occur after a blow elsewhere that is transmitted to the head. 2.2. The following signs and symptoms are associated with concussions: Loss of consciousness (LOC) Disequilibrium Confusion Feeling ‘in a fog’, ‘zoned out’ Post-traumatic Amnesia (PTA) Vacant stare, ‘glassy eyed’ Retrograde Amnesia (RGA) Emotional lability Disorientation Dizziness Delayed verbal and motor responses Slurred/incoherent speech Inability to focus Visual Disturbances, including light sensitivity, blurry vision, or double vision Headache Excessive Drowsiness Nausea/Vomiting University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 1 of 12 University of Utah Sports Medicine Concussion Management Plan 3. Concussion Education for Student Athletes 3.1. During the orientation and signing process student-athletes will be presented with a discussion about concussions. Student-athletes will also be introduced to the concussion education (Video, handouts, NCAA Concussion fact sheet, policy, educations links, etc.) available on the Canvas web site. 3.2. The discussion will also include an emphasis that purposeful or flagrant head or neck contact in any sport should not be permitted and can result in serious life threatening injury. 3.3. The University of Utah Athletic Department shall require student-athletes to sign a statement or completing the quiz on Canvas, in which student-athletes accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. 4. Concussion Education for Coaches and Staff 4.1. The University of Utah Athletic Department will educate coaches, Directors of Athletics, Team Physicians and Athletic Training staff concerning concussions by presenting a discussion on concussion and/or have them review the concussion education (Video, handouts, NCAA Concussion fact sheet, policy, educations links, etc.) available on the Canvas web site. 4.2. The coaches will also have their role within the plan described, outlined in detail in Appendix A. Briefly, their role is to one remove any student-athlete that shows any sign of concussion, make sure that they are evaluated by the appropriate health care professional, and to only allow the student-athlete to return to play after receiving clearance from the appropriate health care professional. 4.3. The University of Utah Athletic Department shall require coaches, Directors of Athletics, Team Physicians and Athletic Training staff to sign a statement or completing the quiz on Canvas, in which they accept the responsibility for their role and completing their education. 5. Emergency Action Plans 5.1. Emergency action plans for each venue are posted on the wall and/or in the emergency binder located in each Athletic Training Room. The emergency action plans are designed to help in response to student-athlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses. These plans are reviewed at the beginning of each year during the orientation seminar. 6. Pre-season concussion assessment 6.1. All Student Athletes will receive pre-season baseline assessments, which consist of brain injury and concussion history during Pre Participation Physical, ImPact and BESS Testing. The team physician will make the final pre-participation clearance determination. 6.2. Baseline testing will consist of: University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 2 of 12 University of Utah Sports Medicine Concussion Management Plan 6.2.1. Standardized Symptom Checklist 6.2.1.1. This will be obtained as part of ImPACT testing (see 6.2.2 below) 6.2.2. Computerized Neuropsychological Testing with ImPACT. 6.2.2.1. ImPACT is a computerized program designed to measure specific brain functions that may be altered after a concussion. The program is designed such to allow athletes to be tested pre-season so that post injury performance may be compared to the athlete’s own baseline. 6.2.2.2. ImPACT may be administered by the athletic trainers in a controlled computer lab like environment. 6.2.2.3. ImPACT baseline data will be reviewed by the Athletic Training Staff. Abnormal test results will be referred to the team physician for consultation. 6.2.2.2.1. Scenarios where the baseline will be repeated and continued abnormal test results will then be consulted with the Team Physician: 6.2.2.2.1.1. Single composite score on Impact testing below the 10th percentile 6.2.2.2.1.2. An Impulse Control Composite score on ImPact testing above 20 6.2.2.2.2. Scenarios where consultation with the Team Physician will be appropriate: 6.2.2.2.2.1.An individual with diagnosed mental health disorder, learning disability, or reporting a history of 3 or more previous concussions 6.2.3. Standardized Balance Assessment with the Balance Error Scoring Scale (BESS) 6.2.3.1.BESS is an easily performed measure of balance that has been validated as an effective means to grade postural stability and is a useful part of objective concussion assessment. 6.2.3.2.BESS may be administered similar to the SCAT 3 version by a qualified athletic trainer or other healthcare provider. 6.3. Results of a student-athlete’s baseline testing shall be kept on file in a secure location. 7. Concussion Action Plan 7.1. When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, the athlete shall be removed from practice or competition and University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 3 of 12 University of Utah Sports Medicine Concussion Management Plan evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. 7.2. The sideline evaluation will be done with the Sports Concussion Assessment Tool (SCAT 3); digital smart phone application or paper version. 7.2.1.The SCAT 3 is comprised of a symptom checklist, standard and sport specific orientation questions, the Standardized Assessment of Concussion (SAC), and an abbreviated form of the Balance Error Scoring Scale (BESS). 7.2.2. Student-athlete will also be assessed for head and neck pathologies. 7.3. A student-athlete diagnosed with a concussion shall be withheld from the competition or practice and will not return to activity for the remainder of that day. 7.4. The student-athlete should receive serial monitoring for deterioration. Athletes will be provided with written instructions upon dismissal from practice/game, preferably with a roommate, guardian, or someone that can follow the instructions provided (See Appendix B for a copy of discharge instructions). 7.4.1.The athlete will report symptoms daily at the discretion of the health care provider (See Appendix C for a copy of symptom diary and checklist). 7.4.2.Athletes will be transported by EMS to the Hospital if any of the following signs and symptoms are present: prolonged period of loss of consciousness (longer than 1 minute); focal neurological deficit; repetitive emesis; persistently diminished or worsening mental status or other neurological signs or symptoms; and potential spine injury. 7.5. Consultation with the team physician will occur within 24 hours of a studentathlete sustaining a suspected concussion. In cases where the student-athlete may be in an off-campus, non-local location, this consultation may occur by telephone between the Athletic Trainer and Physician. 7.6. Subsequent management of the student-athlete’s concussion shall be under the discretion of the treating physician, but may include the following: 7.6.1. Repeat ImPACT testing between 24-72 hours post injury, regardless of symptomatic status 7.6.2. Clinical assessment of balance and symptoms, with comparison to baseline data 7.6.3. Appropriate medication management of symptoms, where appropriate 7.6.4. Provision of recommendations for adjustment of academic coursework, including the possible need to be withheld from coursework obligations while still symptomatic (See Appendix D for list of possible accommodations required) will be made by the Team Physician. Typically if a student athlete cannot tolerate light cognitive activity, he or she should remain at home. 7.6.5. Direction of return to play protocol, to be coordinated with the assistance of the Athletic Trainers (see Appendix F for return to play protocol) University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 4 of 12 University of Utah Sports Medicine Concussion Management Plan 7.6.6. Referral to other Allied Health Professionals for treatment will be at the discretion of the team physician 7.6.7. Any athlete with prolonged recovery will be referred back to the physician for further evaluation and care. 7.6.8. A multi-disciplinary team consisting of team physician, athletic trainer, psychologist/counselor, neuropsychologist, academic counselor, learning specialists, faculty athletic representative, and representative of the office of student services for disability services will be consulted, as appropriate, for care of prolonged or complex concussions. 7.7. Final authority for Return-to-Play shall reside with the team physician or the physician’s designee. 7.8. The incident, evaluation, continued management, and clearance of the studentathlete with a concussion will be documented. University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 5 of 12 University of Utah Sports Medicine Concussion Management Plan APPENDIX A: Personnel Roles - Coach: o Remove any student-athlete that shows any sign of concussion o Make sure that they are evaluated by the appropriate health care professional o Allow the student-athlete to return to play after receiving clearance from the appropriate health care professional o Take a safety first approach to practice and competition. Teach and enforce proper contact techniques to reduce head trauma. Reduce gratuitous contact during practice. - Certified Athletic Trainer: o Remove any student-athlete that shows any sign of concussion o Perform the initial concussion evaluation and subsequent evaluations as physician desires o Supervise activities during the return to play protocol, including exertion tests o Make proper referral to physician, provide go home instructions to responsible care giver when athlete goes home o Allow the student-athlete to return to play after receiving clearance from the Physician - Physician: o During Pre-Participation Exam, the physician will address questions on form concerning concussion history. Team physician will also determine participation clearance. o When present, remove any student-athlete that shows any sign of concussion. o When present, perform the initial concussion evaluation and subsequent evaluations as needed. o Make proper referral to specialists when needed. o Direct the Certified Athletic Trainer in caring for the Student–Athlete. o Determine when the student-athlete can return to play and return to learn. - Physician Assistant: o Fulfill the role of the team physician as directed by the team physician. - Neuropsychologist: o Interpret abnormal baseline ImPACT scores and administer any other additional tests, when referred to by attending physician. University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 6 of 12 University of Utah Sports Medicine Concussion Management Plan o When referred to, interpret post-injury ImPACT scores and provide recommendations for concussion management in consultation with the treating physician. - Other Health Professionals: o Consulted by Physician to aid in diagnosis and treatment of concussions University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 7 of 12 University of Utah Sports Medicine Concussion Management Plan APPENDIX B: Immediate Post Concussion Instructions The following instructions are to be given to each athlete after sustaining a concussion, as identified in section 7.4 HEAD INJURY PRECAUTIONS Our physicians do not feel that hospitalization is necessary at the present time. The following instructions should be observed for the first 24 hours: 1. Diet – drink only clear liquids for the first 8-12 hours and eat reduced amounts of foods thereafter for the remainder of the first 24 hours. Avoid alcohol, tobacco, and drug use as these will affect your symptoms and healing. 2. Pain Medication – do not take any pain medication except Tylenol. Adults should take Tylenol every 4 hours as needed. 3. Activity – activity should be limited for the first 24 hours, usually this means no work for adults and classroom activity for student-athletes. Avoid loud music, computer use, video games, watching TV and texting. 4. Observation – several times during the first 24 hours: a. Check to see that the pupils are equal. Both pupils may be large of small, but the right should be the same size as the left. b. Check the athlete to be sure that he-she is easily aroused; that is, responds to shaking or being spoken to, and when awakened, reacts normally. c. Check for and be aware of any significant changes. (See #5 below) 5. Significant changes Conditions may change within the next 24 hours. Contact your athletic or go to the nearest Emergency Room if any of the following occur: a. Persistent or projectile vomiting b. Unequal pupil size (see 4a above) c. Difficulty in being aroused d. Clear of bloody drainage from the ear or nose e. Continuing or worsening headache f. Seizures g. Slurred speech h. Can’t recognize people or places – increasing confusion i. Weakness or numbness in the arms or legs j. Unusual behavior change – increasing irritability k. Loss of consciousness 6. Improvement The best indication that an athlete who has suffered a significant head injury is progressing satisfactorily is that he/she is alert and behaving normally. Athletic Trainer Phone #_________________________ University Hospital ER# 801-581-2291 University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 8 of 12 University of Utah Sports Medicine Concussion Management Plan Appendix C: Symptom Diary and Checklist Sufficient copies to be given for student-athlete to rate symptoms a minimum of daily. Concussion Symptom Chart Date/Time Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble Falling Asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual Problems Total Symptom Score Rank symptoms 0 to 6, 0 being no symptom and 6 being severe Do these symptoms worsen with physical activity? (Y/N) Worsen with mental activity? (Y/N) University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 9 of 12 University of Utah Sports Medicine Concussion Management Plan Appendix D: Return to School Recommendations In the early stages of recovery after a concussion, increased cognitive demands, such as academic coursework, as well as physical demands may worsen symptoms and prolong recovery. Student-athletes will be re-evaluated by the team physician if symptoms worsen with academic and/or ADL challenges. Accordingly, a comprehensive concussion management plan will provide appropriate provisions for adjustment of academic coursework on a case by case basis. The following provides a framework of possible recommendations that may be made by the managing physician (check all that apply): ___ May return immediately to school full days ___ No return to school. Return on (date) ____________ ___ Return to school with supports as checked below. Review on (date) _________ ___ Shortened day. Recommend ____ hours per day until (date) _________ ___ Shortened classes (i.e. rest breaks during classes). Maximum class length: _____ minutes ___ Allow extra time to complete coursework/assignments and tests ___ Lessen homework load by ______%. Maximum length of nightly homework: _____ minutes ___ No significant classroom or standardized testing at the time ___ No more than one test per day ___ Take rest breaks during the day as needed ___ Referral to Learning Specialist through Academic Advisors ___ Referral to Office of Student Services for disability services ___ Referral to ADAAA office Center for Disability Services 200 S. Central Campus Dr. RM. 162 Salt Lake City, UT 84112 801-581-5020 801-581-5487 fax Inform the teacher(s), Academic Advisors, and administrator(s) about your injury and symptoms. School personnel should be instructed to watch for (Appendix E is a sample letter): - Increase problems with paying attention, concentrating, remembering, or learning new information - Longer time needed to complete tasks or assignments - Greater irritability, less able to cope with stress - Symptoms worsen (e.g., headache, tiredness) when doing schoolwork University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 10 of 12 University of Utah Sports Medicine Concussion Management Plan Appendix E: Concussion Awareness Letter to Teacher/Administrator The University of Utah Sports Medicine and Student Services/Academic Departments would like to inform you that _______________ sustained a concussion during ________on __/__/__. He/she was evaluated by_______________, MD, team physician. ________ will undergo additional concussion testing today. A concussion or mild traumatic brain injury can cause a variety of physical, cognitive, and emotional symptoms. Concussions range in significance from minor to major, but they all share one common factor — they temporarily interfere with the way your brain works. We would like to inform you that during the next few weeks this athlete may experience one or more of these signs and symptoms. Headache Balance Problems Diplopia - Double Vision Photophobia – Light Sensitivity Misophonia – Noise Sensitivity Feeling Sluggish or Groggy Difficulty Concentrating Nausea Dizziness Confusion Difficulty Sleeping Blurred Vision Memory Problems As a department, we wanted to make you aware of this injury and the related symptoms that the student athlete may experience. Although the student is attending class, please be aware that the side effects of the concussion may adversely impact his/her academic performance. Any consideration you may provide academically during this time would be greatly appreciated. We will continue to monitor the progress of this athlete and anticipate a full recovery. Should you have any questions or require further information, please do not hesitate to contact us. name, Credentials title University of Utah Office: 801-58X-XXXX Name@huntsman.utah.edu Thank you in advance for your time and understanding with this circumstance. University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 11 of 12 University of Utah Sports Medicine Concussion Management Plan APPENDIX F: Return to Play Protocol It is expected that athletes will start in stage 1 and remain in stage 1 until symptom free. The patient may, under the direction of the physician and the guidance of the athletic trainer, progress to the next stage only when assessment battery has normalized, including symptom assessment, cognitive assessment with ImPact, and balance assessment with the BESS. Utilizing this framework, in a best case scenario of a patient sustaining a concussion and being asymptomatic by the next day, will start in Stage 1 at post injury day 1 and progress through to stage 6, as long as they are asymptomatic. If they become symptomatic they will progress from stage 1. There may be circumstances, based on an individual’s concussion severity, where the return to play protocol may take longer. Under all circumstances the progression through this protocol shall be overseen by the managing team physician. Each student-athlete with a concussion will be personally evaluated by a physician in clinic at least one time during the process. When the athlete has successfully passed through stage 5 and has previously been evaluated by the physician, a verbal clearance may be obtained by the Athletic Trainer from the attending team physician. Otherwise, a physician visit is required before such clearance to return to play will be granted. Stage 1. No structured physical or cognitive activity 2. Light Aerobic physical activity 3. Sport Specific exercise without head impact 4. Non-contact sport specific training drills with progressive resistance training 5. Full contact practice 6. Return to Play Functional Exercise or Activity Only basic activities of daily living (ADLs), including limited schoolwork, where indicated Light exercise at 50-70% maximum heart rate (walking, biking) Sport specific exercise at 70100% estimated heart rate Non-contact sport specific drills Aerobic activity at 70100% estimated maximum heart rate; resistance training. Will progress from moderate to full exertion based on being asymptomatic Resume all drills and full contact Regular practice and game competition Objective Rest and recovery, avoidance of overexertion Ensure tolerance of raising heart rate above rest Ensure tolerance of regular exercise Tests Administered before advancing to next stage Initial Post-injury test battery: -Symptom checklist -ImPact -BESS -Symptom checklist -Symptom checklist Ensure tolerance of all regular activities short of physical contact -Symptom Checklist Ensure tolerance of physical contact Ensure Tolerance of full activity -Medical clearance by team physician -Educate to report any symptoms or change in behavior University of Utah Sports Medicine Concussion Management Plan - 2015 Updated 6/15 Page 12 of 12 Vanderbilt Sports Medicine Concussion Management Guidelines The following guidelines have been developed to aid the Vanderbilt Sports Medicine staff in the evaluation and management of the Vanderbilt University intercollegiate student-athlete who has sustained a concussion. These guidelines are derived from current evidence-based practice and are recommended as a minimum standard of care, allowing the Sports Medicine staff to manage concussions individually as the situation warrants. The progression of a student-athlete with a diagnosed concussion will include cognitive and physical exertion in a stepwise process to ensure a safe return to full participation in academics and athletics. Concussion Management Healthcare Providers  The following healthcare professionals will be utilized in the management of concussion: Team Physician, Certified Athletic Trainer, Neurosurgeon* *other healthcare providers may be consulted on a case by case basis at the discretion of the Team Physician Baseline Testing and Procedures Concussion Baseline [performed BIENNIALLY*]  Concussion Baseline Report Form [Appendix A]  Post-Concussion Symptom Scale (PCSS) (C. Randolph et al 2009) [Appendix B]  Modified Balance Error Scoring System (M-BESS) (Riemann & Guskiewicz 2000) [Appendix C]  ImPACT® Baseline Neurocognitive Testing [Appendix D] *A new baseline will be obtained every two years. If a concussion is sustained during season; a new baseline will be obtained prior to the next playing season, traditional or non-traditional. Concussion Education [performed ANNUALLY]  NCAA Educational Material for Student-Athletes [Appendix E]  Concussion Acknowledgement and Signature Form: Student-Athlete [Appendix F]  NCAA & Vanderbilt University Educational Material for Coaches/Athletics Support Staff [Appendix G]  Concussion Acknowledgement and Signature Form: Coaches/Athletics Support Staff [Appendix H]  Concussion Acknowledgement and Signature Form: Medical Provider [Appendix I] Time of Injury  Concussion Injury Report Form [Appendix J]  Post-Concussion Symptom Scale (PCSS)  Modified Balance Error Scoring System (m-BESS)  Educate the student-athlete on the importance of cognitive rest which includes limiting or removing cell phone use/texting, video games/television, and attending classes/academic work (d’Hemecourt 2011; Kissick & Johnston 2005; Doolan et al 2012). Recommendations  If the student-athlete is diagnosed with a concussion they will be withheld from competition or practice and not return to activity for the remainder of that day (NCAA Executive Committee Policy April 2010).  If the student-athlete is asymptomatic under normal conditions and following functional exertion testing the following day, they should be re-evaluated for return to participation.  If the student-athlete is still symptomatic under normal conditions and/or following functional exertion testing, they should not return to participation until cleared through the subsequent outlined procedures.  Cognitive rest is an essential component of the recovery process. Academic accommodations may be necessary as part of the treatment plan. Post-Concussion Follow-Up [within 24 hours post-injury]  Medical assessment with Team Physician or the physician’s designee (Certified Athletic Trainer).  Post-Concussion Symptom Scale (PCSS)  Modified Balance Error Scoring System (m-BESS)  Determination of the student-athlete’s ability to attend class is contingent on symptom evaluation during the post-acute phase. Notify Assistant Director for Student Academic Services if accommodations are warranted. Concussion Management Guidelines REV 20150713 Page 1 of 34 Post-Concussion ImPACT® Test Guidelines  The decision of which phase to ImPACT® test a student-athlete will be at the discretion of the Team Physician on a case by case basis to evaluate neurocognitive function.  Student-athletes must have completed an ImPACT® test that is reviewed by the Team Physician before being released to Phase 5 full practice participation with contact. Phase 0 - Cognitive Exertion   The student-athlete will follow a supervised return-to-learn process to allow proper cognitive recovery and integration back into their full academic work load. This process will include a team-based approach involving the Team Physician, Athletic Trainer, and the Vanderbilt Academic Support Center staff.  Student-athletes who demonstrate a trending decrease in symptomology may be returned to class on an individual basis.  Student-athletes that have an increase in symptoms upon returning to class may require adjustments as needed based on symptom exacerbation.  For those student-athletes who experience continued symptoms and or prolonged academic difficulties, academic accommodations will be made available on an individual basis through the Vanderbilt Academic Support Center.  Under the guidance of Vanderbilt Academic Support Center, additional campus resources are available through the Vanderbilt Equal Opportunity, Affirmative Action, and Disability Services Department. Stepwise return to sport progression will proceed to Phase 1 when the student-athlete is asymptomatic and has successfully returned to their full academic work load. Phase 1 - Aerobic Exertion    Post-Concussion Symptom Scale (PCSS) Functional exertion test  Bike 20 minutes at seventy percent (70%) of predicted maximum heart rate (PMHR)  Rest for 15 minutes  Monitor symptoms  Incremental Treadmill Test 20 minutes (Leddy et al 2010) [Appendix K] Stepwise return to sport progression will proceed to Phase 2 if student-athlete is asymptomatic at the current level. If any post concussive symptoms occur, reassess the following day and repeat phase. Phase 2 - Functional Testing Progression     Monitor symptoms Initial Functional Exertion: duration approximately 10- 15 minutes with 5 minutes rest post session  Scissor step/quick step  Jogs  Lateral shuffle  Backpedal  Sprints Advanced Functional Exertion: duration approximately 10- 15 minutes with 5 minutes rest post session  Sit-ups  Burpees  Push-ups  Sprints  Sprints with intermittent push-ups  Four corners with 90 degree spin Stepwise return to sport progression will proceed to Phase 3 if student-athlete is asymptomatic at the current level. If any post concussive symptoms occur, reassess the following day and repeat phase. ** Student-athlete may begin limited weight lifting if asymptomatic depending on the sport requirements Concussion Management Guidelines REV 20150713 Page 2 of 34 Phase 3 - Sport Specific Exertion       Monitor symptoms Initial Sport-Specific Exertion: duration approximately 10-15 minutes with 5 minutes rest post session  Moderate aerobic exercises specific to sport  Monitor symptoms  Progression depends on student-athlete remaining asymptomatic Intermediate Sport-Specific Exertion: duration approximately 10-15 minutes with 5 minutes rest post session  Progressively difficult aerobic exercises specific to sport  Monitor symptoms  Progression depends on student-athlete remaining asymptomatic Advanced: duration approximately 10-15 minutes with 5 minutes rest post session  Demanding aerobic exercises specific to sport  Monitor symptoms  Progression depends on student-athlete remaining asymptomatic Sport-Specific Exertion Guidelines Appendix L - Baseball Appendix T - Soccer Appendix M - Basketball Appendix U - Softball Appendix N - Bowling Appendix V - Swimming Appendix O - Football OL/DL Appendix W - Tennis Appendix P - Football RB/TE/LB/WR/DB Appendix X - Track & Cross Country Appendix Q - Football QB/Special Teams Appendix Y - Volleyball Appendix R - Golf Appendix Z - Wrestling Appendix S - Women’s Lacrosse Stepwise return to sport progression will proceed to Phase 4 if student-athlete is asymptomatic at the current level. If any post concussive symptoms occur, reassess the following day and repeat phase. Phase 4 - Return to Limited Drills and Non-Contact Practice     Monitor symptoms Non-contact training drills dependent upon sport Stepwise return to sport progression will proceed to Phase 5 if student-athlete is asymptomatic at the current level. If any post concussive symptoms occur, reassess the following day and repeat phase. Consult Team physician for full clearance Phase 5 - Return to Full Practice Participation with Contact   Post-Concussion Symptom Scale (PCSS) Completion of Phase 5 without the recurrence of symptoms would result in release to full contact participation without restriction. Concussion Management Guidelines REV 20150713 Page 3 of 34 References Baker, JG, et al. Principles of return to learn after concussion. International J Clinical Practice. November 2014; 68(11):1286-1288. Brown, NJ, et al. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133(2):e299-e304 d'Hemecourt P. Subacute symptoms of sports-related concussion: outpatient management and return to play. Clin Sports Med. 2011; 30: 63-72. Doolan A, Day D, Maerlender A, Goforth M, Brolinson P. A review of return to play issues and sports-related concussion. Ann Biomed Eng. 2012; 40(1): 106-113. Halstead, ME, et al. Returning to learning following a concussion. Pediatrics. 2013; 10.1542/peds.2013-2867. Johnston K, Bloom G, Ramsay J, Kissick J, Montgomery D, Foley D, Chen J, Ptito A. Current concepts in concussion rehabilitation. Curr Sports Med Rep. 2004;3:316-323. Kissick J and Johnston K. Return to play after concussion. Clin J Sport Med. 2005; 15(6): 426-431. Leddy J, Baker J, Kozlowski K, Bisson L, Willer B. Reliability of a graded exercise test for assessing recovery from concussion. Clin J Sport Med. 2010; 21(2): 89-94. National Collegiate Athletic Association. 2011–2012 NCAA Sports Medicine Handbook. 22nd ed. Indianapolis, IN: National Collegiate Athletic Association; 2012. McAvoy, K. Providing a continuum of care for concussion using existing educational frameworks. Brain Inj Prof; [Internet] 2012: 9(1): 26-7. http://issuu.com/bipmagazine/doc.... McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Br J Sports Med. 2013;47:250–258. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus statement on concussion in sport: the 3rd international conference on concussion in sport held in Zurich, November 2008. Br J Sports Med. 2009; 43(Supp I):i76-i84. Piland SG, Robert WM, Ferrara M, Peterson C. Evidence for the factorial and construct validity of a self-report concussion symptoms scale. J Athl Train. 2003;38(2):104-112. Randolph C, Millis S, William BB, McCrea M, Guskiewicz KM, Hammeke TA, Kelly JP. Concussion symptom inventory : an empirically derived scale for monitoring resolution of symptoms following sport-related concussion. Archives of Clinical Neuropsychology. 2009; 24, 219-229. Riemann BL, Guskiewicz KM. Effects of mild head injury on postural stability as measured through clinical balance testing. J Athl Train. 2000;35(1):19-25. Concussion Management Guidelines REV 20150713 Page 4 of 34 APPENDIXA Vanderbilt Athletic Training Concussion Baseline Report Form Name Medical Record Number Sport Date BP Pulse Patient History Please list any concussions or head injuries you have had: Date Were you knocked out: Yes No Did you have memory loss: Yes No Date Were you knocked out: Yes x" No Did you have memory loss: Yes x" No Date Were you knocked out: Yes No Did you have memory loss: Yes No What Were your major with earlier concussions and how long did they last? Duration Duration Duration Have you ever been diagnosed with or treated for: El Headaches El ADI-ID El Migraine Headaches El Anxiety Depression El Meningitis El Seizures El Brain Surgery El Alcohol r" Drug Abuse Dyslexia Autism Learning Disability Have you ever: Had speech therapy El Repeated a grade El Taken Special Education classes Has anyone in your family had: Alzheimer?s Disease El Dementia El Nligraine Headaches Research Acknowledgement I understand that: These tests are baseline tests only. This means that they will only be used to get a ?nonnal? 1mm baseline in case I need to be tested for a future concussion. Vanderbilt may use results from this testing for research purposes. Before any results from my testing are used for research, any personal information that could link me to these results will be com pl eter removed. If I have a concussion during the athletic season, and if I have or BESS testing, Initial Vanderbilt may use results from this testing for research purposes. Before any results from my testing are used for research, any personal information that could link me to these results will be completely removed. Print Name Sign Name Date VANDERBILT UNIVERSITY MEDICAL CENTER Concussion Management Guidelines REV 20150713 Page 5 of 34 APPENDIXA Name Medical Record Number Sport Checklist (To be completed by patient) plom Non Mild Moder ate Severe Headache 0 2 3 4 5 6 Nausea 1 2 3 4 5 6 Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise 0 2 3 4 5 6 Irritability Sadness Feeling more emotional 2 3 4 5 6 Numbness or tingling Feeling slowed clown 0 2 3 4 5 6 Feeling mentally foggy Dif?culty concentrating Difficulty remembering Visual Problems Total Score Balance Error Scoring System (BESS) (To be completed by evaluator) Errors: Scorecard (#errors): 1. Moving the hands off of the iliae crest DOUble Leg 3131103 lfect together): 2. Opening eyes 3. Step, Swian or fan Single Leg Stance (non?dominam foot): 4. Abduction or ?exion of the hip beyond 30 degrees 5. Lifting the forefoot or heel off of the testing surface Tammi] Stance ("On?domnam font back): 6. Remaining out of the proper testing position 2* 5 see ?Rich foot was tasted: TOTAL Each of the 20 second Irials is scored by counting Ihe errors aecLuleated by the L. Len Rig!? subject. Maximum number of errors for any single condition 10. (Guskiewiez) Comments: Evaluator Date VANDERBILT ?7 UNIVERSITY MEDICAL CENTER Concussion Management Guidelines REV 20150713 Page 6 of 34 APPENDIX B Post-Concussion Symptom Scale (PCSS) Address each symptom based on how you have felt on an average 24 hour period during the last 7 days. Rate your symptoms on a scale of 0 to 6. Zero (0) means you have never experienced the symptom, 1 means you experienced the symptom briefly, 3 means the symptom has been present for about half of the preceding 24-hour period, and 6 means the symptom has been continuous through preceding 24 hour period(Piland et al 2003). Concussion Management Guidelines REV 20150713 Page 7 of 34 APPENDIX C Modified Balance Error Scoring System (m-BESS) Significantly higher postural instability in Mild Head Injury subjects revealed through the clinical test battery with 3 stances on firm surface elicited significant differences through day 3 post injury, and may be a useful clinical procedure to assist in return to play decisions (Bell et al 2011,Riemann & Guskiewicz 2000).        Athlete Position  Shoes off  Roll pant legs above ankles  Feet narrowly together  Hands on the iliac crests  Eyes closed Test Procedures / Patient Instructions  Test begins when the patient closes his/her eyes  Patient is instructed to make any necessary adjustments in the event that they lost their balance and to return to the testing position as quickly as possible Test #1- Double Leg Stance (feet together) Test #2- Single Leg Stance (non-dominant foot; free leg should be bent to 90 degrees) Test #3- Tandem Stance (non-dominant foot in the rear; weight evenly distributed)  20 seconds per test  Each test is performed on a firm surface Balance Errors  Hands lifted off of iliac crests  Opening eyes  Step, stumble, or fall  Moving hip into more than 30 degrees of flexion or abduction  Lifting forefoot or heel  Remaining out of testing position for more than five (5) seconds BESS Scoring  The number of balance errors (1 point per error) on each of the three (3) tests is added together for a total BESS Score.  If a subject commits multiple errors simultaneously, only one error is recorded.  Maximum number of errors for any single condition is ten (10).  If subject cannot maintain testing procedure for a minimum of five (5) seconds, they are assigned the highest possible score, ten (10), for the testing condition. Concussion Management Guidelines REV 20150713 Page 8 of 34 APPENDIX ImPact Concussion Testing Instructions ?If using a laptop. be sure to use a mouse rather than the track pad. Using track pad instead of the mouse will skew the results of reaction time tests - If using a laptop, make sure the laptop is plugged in and charging - Make sure all other programs are closed, this includes other internel windows that are not part of the lmPact website Open your web browser and go to: Click on "Customer Log-in" Enter your email in the email section For password, type your assigned password from lmPact Click on the ?Start New Test? icon 1n the drop down box next to: "Please pick the organization you would like the test taker to be tested under? Select your sport Click on the "launch Baseline Test? tab. This is the first tab on the left. 8. Select the language to be tested in 9. From this point, follow instructions as prompted on screen a. The ?rst area to fill out is the "Sport and Health History? including: i. General information ii. Education Sport iv. Concussion History v. Other Medical History b. The second section is the "Current and Conditions? i. This is to be filled out as you feel right now, while taking the test c. The third and final section is the "Neurocognitlve Testing" section i. Follow the instructions for each section within the testing Concussion Management Guidelines REV 20150713 Page 9 of 34 APPENDIX CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A WHAT ARE THE OF A A concussion is a brain injury that: I5 (?l'sul by Hm" 1? he? ?r You can?t see a concussit?m. but you might notice some ofthe Ilr?m? ?'llh I?Ii?l'cr- hard 5??th sum right away. Other can show up hours or days after the injury. as the ground. ice or ?oor. or being hit by a piece ofequipment Cnmussim include. such as a bat. lacrosse stick or field hockey ball. Amnesia. 0 (Ian change the way your brain normally Works. (Ian range from mild to severe. Headache. Presents itself differently for each athlete. LOSS 0 (Ian occur during practice or competition in ANY sport. . ?up,ch problems or dizziness. Can happen even if you do not lose consciousness. Double m. yum, ?5pm. . Sensitivity to light or noise. HOW CAN I PREVENT A . Nausea (feeling that you might vomit). Basic steps you can take to protect yourself from concussion: Feeling sluggish. loggy or groggy. Do not initiate contact with your head or helmet. You can still get Feeling unusually irritable. a concussion if you are wearing a helmet. Concentration or memory problems (forgetting game plays. facts. AVoid striking an opponent in the head. Undercutting. flying meeting times). elbows. stepping on a head. checking an unprotected opponent. Slowed reaction time. and sticks to the head all cause concussions. liollow your athletics department's rules for safety and the rules of the sport. Practice good sportsmanship at all times. 0 Practice and perfect the skills ofthe sport. lixercise or activities that involve a lot ofconcentration. such as studying. Working on the computer. or playing video games may cause concussion (such as headache or tiredness) to reappear or get worse. WHAT SHOULD I DO IF I THINK I HAVE A Don?t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also. tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with 'Ihe sooner you get checked out. the sooner you may be able to return to play. Get checked out. Your team physician. athletic trainer. or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance. sleep and classroom performance. Take time to recover. If you have had a concussion. your brain needs time to heal. While your brain is still healing. you are much more likely to have a repeat concussion. In rare cases. repeat concussions can cause permanent brain damage. and even death. Severe brain injury can change your whole life. BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. lior more information and resources. visit and mt to an) tonnm?n ml or st'rrm' on page should not t?mfvm'mt?rlt tlu' (it'l?t't'mm uj'tln' m' [Wm/tit m? Concussion Management Guidelines REV 20150713 Page 10 of 34 APPENDIX Vanderbilt Sports Medicine Vanderbilt University Concussion Acknowledgement Form As a student-athlete at Vanderbilt University, I acknowledge that I have a direct responsibility to be honest and forthcoming by reporting all injuries or illnesses to the Vanderbilt Sports Medicine staff (athletic trainers or team physicians). I further understand and acknowledge that participation in my sport may result in a head injury or concussion. The Sports Medicine staff at Vanderbilt University has provided me with educational materials regarding concussions and I have read them. Specifically, I agree the following to be true: I have read and understand the Concussion Fact Sheet provided to me Initial and have been given an opportunity to ask questions about concussions and anything I?m not clear about regarding this issue. A concussion is a brain injury, whichI am responsible for Initial immediately reporting to my athletic trainer or team physician. A concussion can affect my ability to perform everyday activities, Initial and affect reaction time, balance, sleep, and classroom performance. If I suspect a teammate has a concussion, I am responsible for Initial reporting it to my athletic trainer or team physician. Student Athlete Printed Name Student Athlete Signature Date Witness Date VANDERBILT UNIVERSITY MEDICAL CENTER Concussion Management Guidelines REV 20150713 Page 11 of 34 APPENDIX THE FACTS - A concussion is a brain injury. - All concussions are serious. 0 (Ioncussions can occur wilhoul loss of consciousness or other obvious signs. Concussions can occur from blows to the body as well as to the head. Concussions can occur in any sport. - Recognition and proper response to concussions when they first occur can help prevent further injury or even death. - Athletes can still get a concussion even ifthey are wearing a helmet. Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries. depending on the sport. SIGNS AND 0 Loses consciousness (even brie?y). - Shows behavior or personality changes. 0 Can?t recall events before hit or fall. 0 Can't recall events after hit or fall. . Concussion Management Guidelines REV 20150713 CONCUSSION A FACT SHEET FOR COACHES Athletes may not report their for fear of losing playing time. Signs Observed By Coaching Staff Reported By Student-Athlete 0 Appears dazed or stunned. Headache or ?pressure? in head. Is confused about assignment or position. 0 Nausea or vomiting. 0 Forgets plays. 0 Balance problems or dizziness. 0 Is unsure of game, score or opponent. 0 Double or blurry vision. 0 Moves clumsily. - Sensitivity to light. 0 Answers questions slowly. - Sensitivity to noise. 0 Feeling sluggish, hazy, foggy or groggy. 0 Concentration or memory problems. 0 Confusion. 0 Does not ?feel right." WHAT IS A A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an ?impulsive? force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat. lacrosse stick or field hockey ball. RECOGNIZING A POSSIBLE CONCUSSION To help recognize a Concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; -AND- 2. Any change in the student-athlete?s behavior, thinking or physical functioning (see signs and Page 12 of 34 APPENDIX Vanderbilt University Concussion Education Coaches Athletics Support Staff In addition to the Concussion Fact Sheet torCoachEJ the followi'lg 'I'Ifonnition will provide educational insight mm the Concussion Mmagement Guidelines utilized tor?nl'anderhit 111m guidel'n? we recommended as a standard of are, allci-vlling= the Sports Medicine sta?to manage concussions individually as the situation wa?u'lts- The progression of a student-athlete a diagnosed concussion will include cognitive and physical exertion ii a stepwise process to ensure asafe retum to full participation amdemiLs and athletics. Baseline TEEN-E Concussion BoseiinefBienniotiyJ Concussion Baseline Fleport Form Post-Concussion Bale Modi?ed Balance Scoring System Baseline Neurocognitive TEting Concussion EdocotioniAnnuotl'yJ NCAA Eduiational Material torS?tudent?Ad'lleta Concussion Acknowledgement and Signature Form NCAA Educational Material for CoachEIS-upport??la? Concussion Acknowledgement and Signature Form Iteturn to Play Protocol Phase Cognitive Exertion I Cognitive rat is an essential corrponent of the recovery process; Andemic adjustments and accommodations may be nec?sil'y The time ?amefor rat and continuation of cognitive activities are dependent upon Each individual will respond uniquely 31d therefore must he managed on an individual case basis the student-athlete is tori-4 hou's while tutlill'IIg full aEidernic work load they proceed to Phase 1 Phase I Aerobic Exertr'on I Smtionary Bite tEting I Incremental Treadmil Phase 2 Testing Progression I Initial Functional Esertion? ljnearrnovernenis only I Advanced Functional Esertion? line: and Elevation chil'lge incorporated movements I 1I'lreigl'lt IiFting rnay Phase 3 Sport Speri?c Exertr'on I Increas'ng aerobic dernand dur'rlg each stage of this phase ofeitercises speci?c to sport il'ld position I Initial 5port~5peciic Eitertion I Intennediate Sport-Bped?c Etertion I Advanced 5port~5peci?c Eitertion Phase Hewrn to limited Drills ond Hon-Contoct Practice I Hon-contact uain'ng drills dependent upon sport I Town Physician consultation PhoseE?H'ewrn to Fuii Forticipo'tion with Contact I Completion of PhaseE w'thout recllTence resul'ls i1 release to full pil'tit'pation w'thout restriction Concussion Management Guidelines REV 20150713 Page 13 of 34 APPENDIX Vanderbilt Sports Medicine Vanderbilt Universityr Concussion Achiowledgeinent Form: Coaches 3: Atl?etios Support Staff I have read endunderstandthe NCAA Concussion Fact Sheet and Vanderbilt Concussion prouidedto Ine andhawbeenginensnoppommityto as]: questions about concussions and anything I'mnot clear about regaining this issue. agreemefollowingtohetme: Aoonoussionisabrsininjmy. m? athlete?ginaway. IfIsusp-oot asmdent-athleatehas aooneussiorelanlrosponsihle forremmringhiml'hor m? from activity In}; tennis? m? a blow to its: head or hotlyr ?iat resultediu signs or consistent 1with concussion m? nnedieal staff, orsjiniptolns ofoonoussions. Following a oonmssion?sehrainneeds linleto heal- Iimdeistand?ut shsdent?a?iletes are nnlehmorelikewto to play or praciiee before resolve. Ihaveresd?iesigns 11mm:- Eigl'hnn Dita ?it-nu Dita L-rm- Concussion Management Guidelines REV 20150713 Page 14 of 34 APPENDIX I Vanderbilt Sports Medicine Vanderbilt U?iVEl'Eiil'y Concussion Achiowledgement Form: Medical Provider Ihs?oeresd Concussion Fact Sheet Concussion Fact Shoot Concussion Mamgemcnt I sgreoth-ofollowingtohonne: m? sthleto?gi?smy. forremosrnighm'h?' m? orsyniptoms consistentw'i?i concussion. m? to rosolw- psrlicipstion in sport. Rc-bssolinc assessments w?lho p-PsfoinneadlJionniall}I orprior to diagnosedwi?is concussiondming season. Wall-1&1? Dita own-Ens Concussion Management Guidelines REV 20150713 Page 15 of 34 Vanderbilt Athletic Training Concussion Injury Report Form Name Nledical Record Number Sport Date BP Pulse El New Injury Date Activity: Practice El Competition El Other Mechanism of Injury: Contact (Player) El Contact (Equipment) Contact (Ground) CI Other Amnesia Present: Yes i No El Antero grade El Retrograde Duration Follow-Up Date ofInitial Injury Days Post-InjuryWeeks Post-Injuryptom Checklist {To be completed by patient) ptom Non Mild Moder ate Severe Hea daehe 0 1 2 3 4 6 Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual 0 2 3 4 5 6 Sleeping less than usual Drowsiness 2 3 4 5 6 Sensitivity to light Sensitivity to noise 0 2 3 4 5 6 lrritability Sadness Nervousness 1 2 3 4 5 6 Feeling more emotional 1 2 3 4 5 6 Numbness or tingling Feeling slowed down Feeling mentally foggy Dif?culty concentrating Dif?culty remembering 1 2 3 4 5 6 Visual Problems Total Score Balance Error Scoring System (BESS) (To be completed by evaluator) Errors: Scorecard (#errors): I . Moving the hands off of the iliac. crest Double Leg Stance {feet together): 2. Opening eyes 3_ Step: summer 01. fall Single Leg Stance (non-dominant foot): 4. Abduction or ?exion of the hip beyond 30 degrees a 5. Lifting the forefoot or heel off of the testing slut'aee Tandem 512mm: mon?dmmnam fem back): 6. Remaining out of the proper testing position ?2 5 sec ?hm foot was leswd: TOTAL Each of the '20 second trials is scored by counting the errors accumulated by the L. Le" Rig!? subject. Maximum number ol?errors for any single condition 10. (Guskiewiez) Comments: Evaluator Date VANDERBILT UNIVE RSITY MEDICAL CENTER Concussion Management Guidelines REV 20150713 Page 16 of 34 APPENDIX K BALKE TEST-TREADMILL The Balke Treadmill Test was developed as a clinical test to determine peak VO2 in cardiac patients, though it can also be used to estimate cardiovascular fitness in student-athletes. For the concussion protocol it will be used to determine if the student-athlete is able to physically exert without symptom exacerbation (Leddy et al 2010). Equipment required: treadmill, stopwatch, heart monitor (optional), electrocardiograph (optional) Recommendations  Student-athlete is asymptomatic prior to treadmill test  Test will be stopped immediately is the student-athlete has symptom exacerbation  Test will be stopped if the athlete becomes too fatigued to continue and the time noted  Student-athlete should be monitored throughout the entire treadmill test for symptoms and fatigue Procedure: The student-athlete walks on a treadmill to exhaustion, at a constant walking speed while gradient/slope is increased every one or two minutes. The athletic trainer or physician starts the stopwatch at the beginning of the test and stops it when the subject is unable to continue.  The treadmill speed is set at 3.3 mph, with the gradient starting at 0%.  After 1 minute it is raised to 2%, then 1% each minute thereafter.  Duration is a maximum of 20 minutes unless symptom exacerbation or fatigue occurs. Concussion Management Guidelines REV 20150713 Page 17 of 34 APPENDIX L SPORTS SPECIFIC EXERCISES – BASEBALL  Initial     4 Jogging poles Throwing 60-90 feet Ground Balls/Defensive Work Swings Off a Tee in Cages  Intermediate  Running Bases  Long Toss 90-150 feet  Defensive Specific Drills – Catchers Drills, Infield Drills, Outfield Drills,  Front Toss or Side Toss in Cages  Advanced  Defense Diving, Catchers Blocking  Live Batting Practice Concussion Management Guidelines REV 20150713 Page 18 of 34 APPENDIX M SPORTS SPECIFIC EXERCISES - BASKETBALL    Initial  10 laps around floor—sprint straight away/slide baseline  Sprints full court  Start and stops  Backpedal  lateral Shuffle  Power skips Intermediate  Sprints  Defensive zigzag  Speed Hurdles  Square drill  Shooting/post drills—timed Advanced  Mican drill with weighted ball  Intervals 10 x 40 sec duration w/minute rest  Each interval contains various movements  Lateral shuffle  Sprints  Change of direction  Jumping  Backpedal Concussion Management Guidelines REV 20150713 Page 19 of 34 APPENDIX N SPORTS SPECIFIC EXERCISES - BOWLING  Initial  Floor throws without ball  Floor throws with ball  Intermediate  End position throws with ball  Half speed approach  Advanced  ¾ speed approach with ball  Approach with throw  Progress from bowling frames to entire game Concussion Management Guidelines REV 20150713 Page 20 of 34 APPENDIX O SPORTS SPECIFIC EXERCISES - FOOTBALL OL/DL  Initial     Stance/Starts Run Blocking/Run Rush Sets Pass Blocking/Pass Rush Sets Boards/Bags – Footwork and Handwork  Intermediate  Cone Drill  Run Block/Run Rush vs. Dummies  Pass Block/Pass Rush vs. Dummies  OL Sandbags/ DL handwork with swims and rips  Advanced  Pass Set to Run block on Sled  Bag Drill Read – Pass or Run  4-pt Stance vs. Sled  Dummy weaves out of stance with hip flips (DL)  Push Pull Power Hops (OL) Concussion Management Guidelines REV 20150713 Page 21 of 34 APPENDIX P SPORTS SPECIFIC EXERCISES - FOOTBALL RB/TE/LB  Initial     Stance/Starts Pass Routes – Check Down/Flats OR Pass Reads Run Drills/Run Blocking/Run Reads Boards/Bags – Footwork and Handwork  Intermediate  Cone Drill  Pass Routes w/ Ball OR Pass Read w/Ball  Pass Block/Pass Rush vs. Dummies  Advanced  Run Block vs. Sled  Bag Drills – Step-over/Shuffle  Stance vs. Sled SPORTS SPECIFIC EXERCISES - FOOTBALL WR/DB  Initial  Stance/Starts/Reads  Run/Pass Block – Footwork (WR)  Short Route/ Short Route Read  Intermediate  Cone Drill  Short Routes w/ Ball  Pass Read w/ Ball  Long Route Read (DB)  Advanced  Long Routes w/ Ball  Run Block vs. Dummy (WR)  Run Read/Shed Dummy (DB)  Pass Block vs. Dummy (WR)  Pass Read Block vs. Dummy (DB) Concussion Management Guidelines REV 20150713 Page 22 of 34 APPENDIX Q SPORTS SPECIFIC EXERCISES - FOOTBALL QB/SPECIAL TEAMS  Initial      Quarterbacks Stationary Throwing Run Play Footwork Pass Drop Footwork Specialists Stance and Approach Approach w/ Dry Kick  Intermediate  Cone Drill Quarterbacks  Rollout Footwork  Pass Drop w/ Throws  Throws from Knees Specialists  Catch and Run  Kick without Pressure  Advanced Quarterbacks  Pressure Pass Drop w/ Throws  Knees to Upright Throws  Bucket Throws Specialists  Fake Kick/Punt and Run  Running Punt  Dropped Ball Grab and Punt Concussion Management Guidelines REV 20150713 Page 23 of 34 APPENDIX R SPORTS SPECIFIC EXERCISES - GOLF  Initial  Putting stroke without ball contact  Short game stroke without ball contact  Intermediate  Putting stroke with ball contact (short to long)  Short game with ball contact (short to long)  Dry swings with irons and drivers without ball contact  Advanced  Practice range with irons and driver  Follow with putting green scenarios  Progress from holes to rounds Concussion Management Guidelines REV 20150713 Page 24 of 34 APPENDIX S SPORTS SPECIFIC EXERCISES - WOMEN’S LACROSSE  Initial       2 laps around the field (jog sideling, sprint end line) From end line to restraining line (~30 yards): High knees down, butt kicks back Lateral shuffle down and back Forward power skips down, backward skips back Carioca down and back  Intermediate  From end line to restraining line (~30 yards):  Sprint down and back, 10 jumping jacks  Shuffled down and back, 10 push ups  Carioca down and back, 10 burpees  Advanced  Box drill  Sprint 10 yards, side shuffle left 10 yards, back pedal 10 yards, side shuffle right 10 yards  Sprint 10 yards, drop step shuffle left 10 yards, sprint 10 yards, drop step shuffle right 10 yards  Sprint 10 yards and rotate to the right 270 degrees in place (will end up making a left hand turn), repeat for completion of 1 box. Progress to 2 boxes in series  1 vs. 1’s  Attacker  Start at the top of the 12m arc, drive to goal and shoot  Add use of defender, no bump or contact made  Gradually defender can add more pressure  Defender  Start at the 8m arc and follow an attacker as they drive to goal and shoot  Gradually defender can add more pressure as they become comfortable with footwork  Allow attacker to incorporate some type of dodge move  Midfielder: Both Attacker and Defender 1 vs. 1’s simulations Concussion Management Guidelines REV 20150713 Page 25 of 34 APPENDIX T SPORTS SPECIFIC EXERCISES - SOCCER  Initial            Goalkeeper 10 yard lateral shuffles for time Goalkeeper power jumps Kneeling dives one side at a time Stationary catches Punts Lay down dive stops Intermediate  T-drills  (Constant movement) partner passing – inside foot, top foot, thigh-foot, chest-foot  Backpedal – sprint 10yds & pass ( utilize different passing styles)  5yd headers / 10yd headers       Jog-sprint-jog width of field (60yds) x4 Run-change directions to a backpedal-run width of field x2 Agility warm-up (toe touches, skips, carioca, etc.) Covers (passing drills but no headers) Goalkeeper T-drills (starting from ground) Repetitive kneeling dives back and forth to each side Corner kick clearances Goal kicks with placement Shuffle catches continuously side to side Advanced  Direction drill (large and small grid)  T-drills (increase complexity)  Cone drill with dribbling, making a move to a sprint (and shoot if forward)  Step back and sprint drill with variety of passing (incorporate headers)  Forwards: 10 ball repetitive shooting w/ continuous running  Midfielders & Defenders: head long ball clearances while sprint & cut back      Goalkeeper Timed Illinois test Pole agilities with reaction catches Hurdle agilities with reaction catches Standing dives Mix up saves (tips, diving, catching, punching) Concussion Management Guidelines REV 20150713 Page 26 of 34 APPENDIX U SPORTS SPECIFIC EXERCISES – SOFTBALL  Initial     4 Jogging poles Throwing 45-60 feet Ground Balls/Defensive Work Swings Off a Tee in Cages  Intermediate  Running Bases  Long Toss 60-90 feet  Defensive Specific Drills – Catchers Drills, Infield Drills, Outfield Drills,  Front Toss or Side Toss in Cages  Advanced  Defense Diving, Catchers Blocking  Live Batting Practice Concussion Management Guidelines REV 20150713 Page 27 of 34 APPENDIX V SPORTS SPECIFIC EXERCISES - SWIMMING  Initial 1000 yards w/ in-pool starts      Intermediate 1500 yards w/ in-pool starts     5-100 yard swims using front crawl, 5 – 100 yard swims using preferred stroke If swimmer’s preferred stroke is front crawl, then 500 yards should be swum using butterfly and/or breast stroke. Have swimmer focus on breathing during right and left strokes rather than unilateral breathing Use open turns; do not have swimmer use flip turns 500 yards front crawl and 800 yards preferred stroke  If swimmers preferred stroke is front crawl, 500 yards should be swum using 1 or more of the following strokes: butterfly, breast, and back stroke 200 yard IM should be swam at end of practice regardless of preferred stroke Incorporate flip turns Advanced 2000 yards w/ starting block starts   600 yards front crawl and 1000 yards preferred stroke  If swimmers preferred stroke is front crawl, 600 yards should be swum using 1 or more of the following strokes: butterfly, breast, and back stroke 400 yard IM should be swam at end of practice regardless of preferred stroke Concussion Management Guidelines REV 20150713 Page 28 of 34 APPENDIX W SPORTS SPECIFIC EXERCISES - TENNIS  Initial      3 laps around 3 Courts – sprint straight-away, slide baselines Sprints from baseline to net at angles (back left, center, back right) Backpedal from net at angles (front left, front center, front right) Lateral Shuffles across court Line hops (back/forth, side/side, alternating back/forth)  Intermediate  Sprints to net for volley  Defensive back pedal for overhead  Squat Jumps  Timed serves (5 in 15 seconds)  Advanced  Court zippers w/ line touch  Ball-fed backhand, forehand, sprint for volley x 5  Defensive position from ground – service returns Concussion Management Guidelines REV 20150713 Page 29 of 34 APPENDIX X SPORTS SPECIFIC EXERCISES - TRACK & FIELD, CROSS COUNTRY Begin with a normal warm up for specific event  Sprints: Goals – Rapid acceleration/deceleration; Rapid vertical level change; Plyometric power; Increased exertion over short distance.  In’s/Out’s  3pt./2pt. Stance Starts  Block Starts  Weighted Jumps  Progressive Running  Hurdles: Goals – Incorporate forward flexion/trunk rotation  Same as sprints  Active hurdle stretch drill  Jumps [Long, Triple]: Goals – Incorporate aerial/landing impact component  Same as sprints  Double leg  Single leg jumping progression  Jumps [High, Pole-vault]: Goals – Incorporate Inversion (Upside Down)  Same as sprints  Bridge ups  Walk overs  Bar Hangs  Mat Drills (Tumbling/Landing)  Throws: Goals – Incorporate Strength/Power Component and Valsalva  Medball Thrust  One Arm Toss  Serratus Punches  Distance Track, Cross Country: Goals – Running Progression  Lower intensity exertion over long distance  Progress Endurance/Time/Intensity of Exertion Concussion Management Guidelines REV 20150713 Page 30 of 34 APPENDIX Y SPORTS SPECIFIC EXERCISES – VOLLEYBALL  Initial         Jog 4 laps around the court 4 laps of forward sprint, lateral shuffle, backward run, lateral shuffle Agility warm up (skips, carioca, etc) Ground serving Front row players (outsides, middles, setters) Block moves and approaches without a ball Hitting while standing on a box Back row players (defensive specialists, liberos, serve receivers, all-around players) Passing to setter target from a toss, down ball and free ball in a small radius Setters Setting against the wall  Intermediate  Peppering with a partner  Jump serving, if applicable Front row players  Blocking drills with a ball  Hitting drills with a ball from full approach at the 10 ft line Back row players  Run throughs, no diving  Passing from serve receive, no diving Setters  Setting from a toss to target spots for hitters  Advanced Front row players  Blocking against live hitting  Attacking against blockers  Block with transition to attack Back row players  Defense with diving  Serve receive with diving Setters  Setting from a pass to targets  Transitions from serve to defensive position to digging a ball Concussion Management Guidelines REV 20150713 Page 31 of 34 APPENDIX Z SPORTS SPECIFIC EXERCISES - WRESTLING  Initial          Jogging 5-10 minutes around mats alternating 1 minute clockwise 1 minute counter clockwise Walk through stand up drill w/o partner Shadow Drilling (slow paced- emphasize proper technique) Takedowns, escapes, carries, sweeps Utilize stationary bike interval sprints for 1-2 minutes to increase/simulate aerobic activity No Throws Push-ups Crunches Burpees  Intermediate  CW/CCW jogging w/ 10 intermittent 10 second sprints  Explosive stand up drill w/ partner applying minimal resistance  Utilize stationary bike interval sprints for 1-2 minutes to increase/simulate aerobic activity  Sprawl Drill  Shadow Drilling (fast paced)  Advanced  CW/CCW jogging w/ 10 intermittent 15 second sprints  Explosive stand up drill w/ partner applying moderate resistance  5 hand fight drills for 20 seconds (avoid head contact)  Pummel Drill (moderate intensity, avoid head contact)  Partner Drills (moderate intensity, no throws)  5 Dummy throws onto soft mat (if available) Concussion Management Guidelines REV 20150713 Page 32 of 34 Concussion Management Process Baseline Concussion Testing, Signed Acknowledgement, and Education Must Be Completed Prior to Participation Traumatic Event Examination, Cognitive Evaluation, and Functional Testing Normal? NO YES No Return to Play for the Remainder of that Day Return to Play Concussion Management Guidelines REV.20150713 Page 33 of 34 Management of Athlete with Identified Concussion Athlete with Identified Concussion Indications for Further Diagnostic Testing at Physician's Discretion Medical Assessment with Team Physician or Physician's Designee Demonstrated Trending Decrease in Symptomatology? NO YES STOP & Reassess Following Day Cognitive Exertion Normal? Concussion Management Guidelines REV.20150713 NO YES STOP & Reassess Following Day Stepwise Return to Sport Progression Medical Clearance by Team Physician Full Participation without Restrictions Page 34 of 34 UVA Sports Medicine Concussion Management Guidelines Updated May, 2015 1. The University of Virginia shall have on file an annually updated emergency action plan (EAP) for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses. The athletics healthcare providers and coaches shall review and practice the plan at least annually. The Athletics Sports Medicine Department will maintain a list of staff that have completed the requirement on file. 2. The University of Virginia shall require student-athletes to sign a statement (Assumption of Responsibility to Report Injuries) in which student-athletes accept the responsibility for reporting their injuries and illnesses to the sports medicine staff, including signs and symptoms of concussions. 3. The University of Virginia’s Student Athletes, Coaches, Team Physicians, Athletic Trainers and Directors of Athletics will receive education about concussions annually in order to fully understand the concussion management plan and their role within the plan. The Athletics Compliance Office will maintain a list of student athletes and staff that have acknowledged that they had read and understood the concussion materials. 4. The University of Virginia’s sports medicine staff members shall be empowered with the unchallengeable authority to disqualify and determine management and return-to-play of any ill or injured student-athlete as he or she deems appropriate. 5. The University of Virginia shall implement a pre-participation baseline neurocognitive assessment (ImPACT testing) on each student-athlete. Baseline measures should include a brain injury and concussion history, symptom evaluation, cognitive assessment, and balance evaluation. This baseline information will be used post-injury at appropriate time intervals to help assess progress in the resolution of impairment related to the concussion. The Team Physician will determine preparticipation clearance and/or the need for additional consultation or testing. 6. When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, the student-athlete shall be immediately removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. A concussion should be assumed when unsure and waiting for a final diagnosis (“when in doubt, sit them out”). 7. Any student-athlete that exhibits signs, symptoms or behaviors consistent with a possible concussion should be held immediately from further participation to allow assessment and monitoring by the team’s athletic trainer or team physician. These symptoms include but are not limited to: a. Altered level and/or loss of consciousness b. Confusion, as evidenced by disorientation to person, time, or place; inability to respond appropriately to questions; inability to process information correctly and/or respond appropriately to analytical questions; or inability to remember assignments and/or plays; c. Amnesia (antegrade and/or retrograde; immediate or delayed); d. Abnormal neurological examination (i.e. abnormal pupillary response, persistent dizziness or vertigo, abnormal balance, etc.) e. New and persistent headache, particularly if accompanied by photosensitivity or other visual disturbances, tinnitus, nausea, vomiting, or dizziness; and/or f. Emotional lability 8. A student-athlete diagnosed with a concussion shall be immediately withheld from competition or practice and shall not return to activity for the remainder of that day. Student-athletes that sustain a concussion outside of their sport will be managed in the same manner as those sustained during sport activity. A thorough history and assessment including the Sport Concussion Assessment Tool 3 (SCAT3) will be implemented. This assessment should include symptom assessment, physical and neurological exam, cognitive assessment, balance exam, and evaluation for cervical spine trauma, skull fracture and intracranial bleed. A team physician must assess the student-athlete within 24-72 hours of the initial injury. 9. The student-athlete should be monitored closely post-concussion for physical or neurological deterioration. The Emergency Action Plan for that facility should be initiated in the event the student athlete’s post-concussion evaluation presents any of the following significant conditions: Glasgow Scale <13, prolonged loss of consciousness, focal or neurological deficits, repetitive emesis, persistently diminished or worsening mental status, or indications of a spine injury. 10. Student-athletes diagnosed with a concussion are provided with detailed written instructions upon departure from the sports medicine department. Whenever feasible, they will be discharged from sports medicine care with a roommate or guardian. Driving restrictions may be imposed at the discretion of the physician. 11. Physical and cognitive rest is recommended during the first 24 hours following a concussion. The student-athlete should be monitored for recurrence of symptoms with activities of daily living exertion as well as cognitive tasks such as reading, working on a computer, classroom work, or taking a test. Academic advisors should be notified of the student-athlete’s concussion. 12. The team physician may choose to obtain radiologic imaging or specialist referral for more extensive neurological or neurocognitive testing with individuals presenting significant or persisting symptoms. Return to activities will follow medical guidelines established by the Athletics Department Medical Director or treating physician. 13. The Athletic Trainer or team physician will perform daily re-assessments for persisting symptoms and re-administer the SCAT3 and ImPACT tests as clinically indicated. Re-assessment by a physician will be required for a student-athlete with prolonged recovery in order to consider other additional diagnosis and best management options. Additional diagnoses include, but are not limited to: Post-concussive syndrome Sleep dysfunction Migraine or other headache disorders Mood disorders such as anxiety and depression Ocular or vestibular dysfunction Return to play shall follow a medically supervised stepwise process as noted below. Final authority for return to play shall reside with the team physician or the physician’s designee. Return To Play Algorithm In order to be considered for return to play, the student-athlete must follow the outlined guidelines for management of his/her injury: • Be fully asymptomatic at rest, with exertional testing, and with supervised non-contact and contact sports-specific activities. • Be within normal baseline limits on all post-exertion neurocognitive assessments. • Be cleared for participation by the University of Virginia Team Physician and/or his/her designee. Step-Wise Return to Sport Hierarchy • No physical activity/ complete rest • Low levels of cardiovascular physical activity, provided symptoms do not come back during or after the activity (15 – 20 minutes) E.g. walking, light jogging, light stationary bike. • Non-contact sports-specific training or physical activity with limited head and body movement (15 – 20 minutes) E.g. moderate jogging, moderate weightlifting, technique practice. • Heavy non-contact physical activity/ training drills with progressive resistance training. E.g. Sprinting, High intensity stationary bike, non-contact sports specific drills. • Full contact controlled training/practice. • Return to competition/ full training. 14. Athletics staff, student-athletes and officials will continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be encouraged or permitted, and current rules of play should be strictly enforced. 15. “Return to Learn” Guidelines: • Along with the restriction of physical activity when a concussion has occurred, the limitation of cognitive demands via “cognitive rest” is an essential component of optimal care of the student athlete. When a student athlete suffers a concussion, the Athletic Trainer will notify the Academic Affairs staff member for that sport. The student athlete will be advised to avoid any non-essential mental activities including texting, emailing, reading or computer work. In the event of substantial symptoms, total rest from cognitive stress is recommended for at least 24 hours following the injury. • The symptom status of the student athlete will be assessed daily and if significant symptoms including, but not limited to, headaches, confusion, difficulty concentrating, or sensitivity to light or noise are present, then the team physician will be notified. At the discretion of the treating physician, the student athlete may be advised to avoid going to class on that day. • In the event that the physician advises the student athlete not to attend class, the medical staff will communicate this decision to the academic support person in the Athletics Academic Affairs Office who will immediately notify the Association Dean (College of A&S) or the relevant dean in another undergraduate school. The student athlete will be advised to communicate this restriction to their professors. Athletics Academic Affairs personnel will be the point persons for communication with the academic dean if any academic adjustments need to be implemented. The academic dean will be informed of the medical recommendation and will be kept updated on the status and progress of the student athlete through the medical staff or Athletics Academic Affairs personnel. • The Dean will communicate with their respective class faculty regarding the medical status of the student athlete. The overseeing physician will guide the reintegration of the student athlete back into his/her academic work with updates provided as the medical status changes. As each concussion is a unique injury, the timeline for such reintegration is variable and will be inherently different for each student athlete. As such, student athletes will not be held to a rigid time frame for return to academic work. • In the event of a delay in the resolution of symptoms, the physician will utilize consultations with a Neuropsychologist and/or Learning Needs Specialist to determine if any academic accommodations are indicated. • In extreme cases where the student athlete’s condition may necessitate long term academic modifications, the Student Disability Access Center, in conjunction with input from the treating physician, Dean, and Learning Needs Specialist, will be incorporated to determine the best course of action for present or future academic involvement. Department of Athletics PERFORMANCE & SPORTS MEDICINE Eddie Ferrell Training Room 160 Jamerson Center (0502) Blacksburg, Virginia 24061 540/231-7742 Fax: 540/231-7335 E-mail: ab8631@vt.edu www.hokiesports.com Virginia Tech Sports Medicine Concussion Management Policy POLICY STATEMENT: This policy ensures and communicates complete and comprehensive procedures for the management of a student-athlete who may have sustained a concussion. PURPOSE: To provide and communicate to sports medicine staff with regards to each individual’s responsibility related to the management of a student-athlete who may have sustained a concussion. ENTITIES TO WHOM THIS POLICY APPLIES: Virginia Tech Sports Medicine Staff including Physicians, Certified Athletic Trainers and Athletic Training Students. PROCEDURE: 1) All Virginia Tech student-athletes are required to sign a statement in which the student-athlete accepts the responsibility for reporting their injuries and illnesses to the institutional medical staff, including the signs and symptoms of concussions. During the review and signing process the student-athletes will be presented with the NCAA Concussion Fact Sheet for Student-Athletes. 2) All Virginia Tech Athletic Department coaches, sport administrators, sports medicine staff, and athletes are required to sign a statement in which they accept the responsibility for reporting signs and symptoms of concussions. During the review and signing process they will be presented with the NCAA Concussion Fact Sheet. a. The Director of Sports Medicine will work with Compliance to coordinate the distribution, educational session, signing, and collection of the necessary documents. The Director of Sports Medicine will turn the signed documents over to the staff athletic trainer where they will be kept in the student-athlete’s medical file. b. The Director of Sports Medicine will coordinate the signing of the aforementioned documents on an annual basis. c. A copy of the Virginia Tech Concussion Policy will also be distributed through the Policies and Procedures manuals for each of the athletic training facilities and athletics department staff policies and procedures. d. The Director of Sports Medicine will coordinate an annual meeting each May with all involved parties to review and update the Concussion Policy with the medical staff. Any changes to the policy st will be effective August 1 of that year. 3) Virginia Tech Athletics will have on file and posted electronically an annually updated emergency action plan for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress, and sickle trait related symptoms. 4) Virginia Tech will have on file an appropriate health care plan that includes equitable access to athletics healthcare providers for each sport. 5) Virginia Tech Athletics healthcare providers should be empowered to have unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. For example, a countable coach should not serve as the primary supervisor for an athletics healthcare provider nor should they have sole hiring or firing authority over that provider. V I R G I N I A P O L Y T E C H N I C I N S T I T U T E A N D S T A T E U N I V E R S I T Y An equal opportunity, affirmative action institution 6) Virginia Tech shall have on file a written team physician-directed concussion management plan that specifically outlines the roles of athletics healthcare staff (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neuropsychologist). 7) Institutions should document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion. 8) Although sports currently have rules in place; athletics staff, student-athletes and officials should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced. Virginia Tech Sports Medicine Concussion Management Plan Virginia Tech Sports Medicine Baseline Testing 1) Virginia Tech Athletics will record a baseline assessment for all student-athletes prior to their first practice. The same baseline assessment tools will be used post-injury at appropriate time intervals. The baseline assessment will include the following variables. a. Symptom Checklist b. SCAT3 Form c. IMPACT *Exception of M/W swimming, M/W golf, M/W track and cross country will not be using IMPACT. 2) If a student athlete sustains a concussion, they will meet with a team physician prior to the start of the next calendar year to determine if they have any ongoing issues or symptoms related to their head injury. 3) The team physician will refer the student athlete for further treatment as necessary. Virginia Tech Sports Medicine Concussion Assessment When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, the athlete shall be removed from practice or competition and evaluated by a Virginia Tech Athletics healthcare provider. NO athlete suspected of having a concussion is permitted to return to play while symptomatic! 1) Virginia Tech Athletics healthcare providers will practice within the standards as established for their professional practice (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neurologist, neuropsychologist). 2) A student-athlete suspected of sustaining a concussion will be evaluated by the Virginia Tech Athletics healthcare providers using a clinical evaluation as well as the Sport Concussion Assessment Tool (SCAT3). Should the team physician not be present, the athletic trainer will notify the team physician ASAP to develop an evaluation and treatment plan. The presence or absence of symptoms will dictate the inclusion of additional neurocognitive and balance testing. 3) Athletes that demonstrate a Glasgow Coma Scale < 13, prolonged loss of consciousness, focal neurological deficit, repetitive emesis, worsening mental status or other neurological symptoms, or spine injury should be transported to the nearest emergency medical center as directed by the Emergency Action Plan. V I R G I N I A P O L Y T E C H N I C I N S T I T U T E A N D S T A T E U N I V E R S I T Y An equal opportunity, affirmative action institution 4) Once the student-athlete is symptom free at rest, the athletic trainer, following consultation with the team physician, will conduct follow up Impact testing as directed. If requested by the team physician testing may be conducted while the athlete is still symptomatic. 5) A student-athlete diagnosed with a concussion shall be withheld from the competition, practice, and class and will not return to activity for the remainder of that day. 6) The student-athlete should receive serial monitoring for deterioration. Athletes should be provided with the “Concussion Injury Advice” sheet located on the SCAT3 upon discharge; preferably with a roommate, guardian, or someone that can follow the instructions. 7) The student-athlete should be evaluated by a team physician as outlined within the concussion management plan. Once asymptomatic and post-exertion assessments are within normal baseline limits, return to play should follow a medically supervised stepwise process. Virginia Tech Sports Medicine Concussion Return to Play 1) At the time of injury, a clinical evaluation is performed, symptoms checklist and SCAT3 conducted and Team Physician notified. 2) After the initial clinical evaluation, the symptom checklist should be repeated followed by referral to the team physician if indicated. 3) First day post injury, the student-athlete should have a follow up clinical evaluation and symptom checklist completed. 4) Follow-up clinical evaluations and symptom checklists are completed daily until the athlete is asymptomatic with cognitive and physical rest. 5) Once the athlete is asymptomatic at rest: a. Complete post traumatic Impact testing and compare to baseline. b. Complete symptom checklist c. Clinical evaluation including Neuropsychological assessment 6) Upon satisfactory completion of the above variables, the physician can direct the athletic trainer to initiate the 5-step graduated exertional RTP protocol. a. No activity - complete and cognitive rest until asymptomatic. Objective is rest and recovery. b. Light aerobic exercise – 20 minute stationary bike at 10-15 mph. Objective is to increase heart rate. c. Sport-specific exercise – 20 minutes of individual drills, running team drills, etc. Objective is to add body weight movement. d. Non-contact training drills – 20 minutes of more advanced drills like passing drills, etc. May add resistance training. Objective is to add coordination and cognitive load with exercise. e. Full contact practice – participate in normal training activities. Objective is to restore confidence and allow assessment of functional skills by coaching staff f. Return to play. 7) Student-athletes with prolonged recovery should be evaluated or referred by the team physician for the potential additional diagnosis and best management options. a. Additional diagnoses included but are not limited to post-concussion syndrome, sleep dysfunction, migraine or headache disorders, mood disorders such as anxiety and depression, and ocular or vestibular dysfunction. IF AT ANY POINT DURING THIS PROCESS THE ATHLETE BECOMES SYMPTOMATIC THE ATHLETE SHOULD BE RE-ASSESSED DAILY UNTIL ASYMPTOMATIC. V I R G I N I A P O L Y T E C H N I C I N S T I T U T E A N D S T A T E U N I V E R S I T Y An equal opportunity, affirmative action institution 8) Final determination of return-to-play is made from the team physician or medically qualified physician designee. 9) All documentation pertaining to the student-athlete’s concussion assessment will be included in the student-athletes medical record. Virginia Tech Sports Medicine Concussion Return to Academics Protocol Virginia Tech Sports Medicine staff will work diligently to educate coaches, academic staff, and athletes on the importance of a safe return to the classroom for any concussed athlete. Certain activities that take place in a classroom may exacerbate an athlete’s symptoms, which could ultimately lead to a delayed recovery and/or return to play. 1) Once an athlete is diagnosed with a concussion they should be withheld from classroom activities for the remainder of the day. 2) The athletic trainer responsible for the injured student athlete should send a letter to the SAASS representative for their sport who will help navigate the return-to-learn process for the student athlete. a. This letter will dictate the name of the athlete, the date of injury, and the signs and symptoms that are present or may arise. b. The athletic trainer will provide SAASS with any medical documentation that is needed to confirm the diagnosis of a concussion. 3) If the athlete has been previously diagnosed with any mental condition (ADHD, depression, anxiety, etc.) they will be referred to Sports Psychology for consultation. 4) If the student-athlete cannot tolerate light cognitive activity, he or she should remain at home or in the residence hall as directed by the team physician or physician’s designee. 5) Once the student-athlete can tolerate cognitive activity without return of symptoms, he/she should return to the classroom/studying as tolerated. At any point, if the student-athlete becomes symptomatic, or scores on clinical measures decline, the staff athletic trainer and/or team physician should be notified and the studentathlete’s cognitive activity reassessed by the team physician. 6) The extent of academic adjustments needed should be decided by a multi-disciplinary team that may include the team physician, athletic trainer, SAASS representative, coaches, instructors, sports psychologist, and the office of disability services representatives as needed. The level of multi-disciplinary involvement should be made on a case-by-case basis. 7) Modifications to the student athlete’s schedule/accommodations will be made for up to two weeks with the help of the athlete’s SAASS representative. 8) Cases that cannot be managed through schedule modification/academic accommodations should utilize campus resources consistent with ADAAA including learning specialists and the office of disability services. Reducing Head Trauma Exposure Management Plan Virginia Tech is committed to reducing exposure to head trauma through extensive clinical research and the most current safe teach techniques pertaining to each sport 1) Virginia Tech Sports Medicine will ensure adherence to the Inter-Association Consensus: Year-Round Football Practice Contact Guidelines and Independent Medical Care Guidelines. 2) Sports medicine staff will educate athletes and coaches on the importance of taking the head out of contact and reducing gratuitous contact during practice. 3) Management of head trauma injuries will always take the safety first approach. June 3, 2015 V I R G I N I A P O L Y T E C H N I C I N S T I T U T E A N D S T A T E U N I V E R S I T Y An equal opportunity, affirmative action institution WAKE FOREST SPORTS MEDICINE Concussion Safety Protocol Pre-Season Education: 1. Prior to each season each team will meet with their speci?c athletic trainer and will be provided with the NCAA Concussion Facts Sheet. The athletic trainer will discuss the facts sheet and address any questions. 2. The following parties will be provided the NCAA Concussion Facts Sheet: Coaches, team physicians, athletic trainers and directors of athletics 3. Each party will provide a signed acknowledgement of having read and understood the concussion material (see Pages The signed acknowledgement forms will be kept and maintained with Athletics Compliance. Pre-Participation Assessment: 1. Each student-athlete will receive at least one pre-participation baseline concussion assessment. The concussion assessment will address the following: a. Brain injury and concussion history evaluation from SCAT 3 c. neurocognitive computer testing d. BESS Balance testing 2. The team physician determines pre-participation clearance and/or need for additional consultation or repeat testing. Recognition of Diagnosis of Concussion: 1. Any student-athlete with the behaviors consistent with a concussion will go through the following: a. Will be immediately removed from practice or competition. b. Will be evaluated by the ATC or team physician with concussion experience using the SCAT 3. The SCAT 3 assessment tool consists of the following: i. assessment ii. Physical exam Neurological exam iv. Cognitive assessment v. Balance exam vi. Clinical assessment for cervical spine trauma, skull fracture and intracra nial bleeding. c. Will not return to practice/play for that calendar day if concussion is con?rmed. WAKE FOREST SPORTS MEDICINE Post-Concussion Management: 1. If any of the following are present, the athletic trainer will initiate the facility emergency management plan, including transportation for further medical care, for any of the following: a. Glasgow Coma Scale 13 Prolonged loss of consciousness Focal neurological de?cit suggesting intracranial trauma Repetitive emesis Persistently diminished/worsening mental status or other neurological Spine injury 2. if the student-athlete is not experiencing that elicit activation of the emergency management plan, the athletic trainer will hold the student-athlete out of practice/competition and will notify the team physician for further directive. This evaluation period will continue until the athletic trainer or team physician does not suspect that their concussion will worsen to the point that advanced medical support should be called. They should be under the direct supervision for at least 30 minutes following the initial concussion. a. During this time, the student-athlete will be under the direct supervision from the athletic trainer, team physician, coach, or responsible adult. 3. Once it is deemed that the student-athlete is stable and is at no further risk, the student-athlete will be given a Head Injury Information Card (see attachment). The instructions will be reviewed with the student-athlete and the athletic trainer/physician. If necessary, the instructions will also be explained to a roommate, parent, guardian, or someone who can monitor the student- athlete. At this time, the athletic trainer should determine a time for a follow-up evaluation. 4. The student-athlete will be re-evaluated once a day by the athletic trainer or team physician. The athletic trainer will evaluate the student?athlete?s daily and a graded checklist will be completed prior to full clearance. a. These evaluations will continue until the student-athlete becomes free or the decision to be evaluated by a physician is made. b. Appropriate medical documentation will be entered in the student-athlete?s medical ?le. 5. If a student-athlete has prolonged recovery, the team physician may consider additional diagnosis and best management options. Additional diagnoses include, but are not limited to: a. Post-concussion Sleep dysfunction Migraine or other headache disorders Mood disorders such as anxiety and depression Ocular or vestibular dysfunction. EDP-D WAKE FOREST SPORTS MEDICINE Return to Play: 1. Each student-athlete with a concussion must undergo a supervised stepwise progression management plan directed by the team physician with expertise in concussion management. The progression management protocol may be directly supervised by the athletic trainer with daily updates relayed to the team physician. Minimum time periods for each phase may be longer depending on initial presentation and subsequent course. a. Phase One - Complete Rest i. Must be for a minimum 24 hours, preferably a full calendar day especially if more than the simplest of concussions ii. May be longer than one day if initial high severity and/or burden Minimum rest period estimation determined by team physician at initial evaluation and communicated directly to athletic trainer who will then communicate plan with coach and student-athlete. iv. Physical rest - no exceptions v. Mental rest - may be adjusted if 1. No homework/studying or team meetings or ?lm review sessions 2. No class attendance vi. Note written by physician and communication with Of?ce of Academic Affairs and athletics academic advisor for sport, if needed. b. Phase Two - Once a student-athlete reports he/she is i. Obtain post-injury computer test ii. Re-evaluation by physician, including assessment of test results Light aerobic exercise without resistance training (ie. walking, stationary bike) iv. This step to last one calendar day minimum. The length of this phase may be possibly longer and should be determined by team physician and communicated to the athletic trainer. c. Phase Three - Light strength training] sport speci?c drills. i. 50% strength training activity ?rst ii. May add sport speci?c drills if student-athlete remains - easy to complex drill activities No risk of contact and the student-athlete will not be included with full team participation iv. Non-contact drills only; no pads d. Phase Four - Non-contact practice with progressive resistance training. The student- athlete is not to be placed in any scenarios or situations where he/she could have contact or take any blows to the head or body. e. Phase Five - Unrestricted full contact practice with no restrictions f. Phase Six - Return to competition, pending clearance from team physician. 2. If at any point the student-athlete becomes (ie. more than baseline), or scores on clinical/cognitive measures decline, the team physician shall be noti?ed and the student-athlete?s cognitive activity will be reassessed. 3. Final determination of return to play is made by the team physician. 3 WF WAKE FOREST SPORTS MEDICINE 4. The WFU medical staff will document all concussion, along with all follow-up appointments, all testing performed (including exertional testing), and when the student-athlete was cleared for return-to-play. Return -to-Learn 1. The Of?ce of Academic Affairs and the Director of Student Health Services will be noti?ed by the team physician of the student-athlete?s concussion, with permission for release of information from the student-athlete. This information will be relayed by the Of?ce of Academic Affairs to the professors and advisors of the student-athlete. The medical staff shall also notify advisors within Student-Athlete Services. There will be no classroom activities on the same day as the concussion. 2. A multi?disciplinary team will navigate the more complex cases of prolonged return to learning. This team may include, but not limited to: a. Team physician (the primary point person who will coordinate all activities) b. Athletic trainer c. Mental health professionals - counselors d. consultant e. Academic counselor or learning specialist f. Course instructor(s) g. College administrators h. Coaches 3. Full compliance will be met with the 4. An individualized plan will be created for prolonged returning to learn student-athletes that includes: a. Remaining at home/ dorm if the student-athlete cannot tolerate light cognitive activity b. Gradual return to classroom/studying as tolerated c. Modi?cation of schedule/academic accommodations for up to two weeks, as indicated with assistance from the athletic trainer and team physician 5. Re-evaluation by team physician if concussion worsen with academic challenges. 6. The team physician and pertinent members of the multi-disciplinary team will re-evaluate student-athletes wo have ongoing for more than 2 weeks 7. For cases that cannot be managed through schedule modi?cations, campus will be utilized. Such resources include learning specialists. Reducing Exposure to Head Trauma 1. Wake Forest University Sports Medicine is committed to creating a culture of reducing exposure to head trauma. We will do by adhering to the following principles: 3. Adherence to Inter-Association Consensus: Year-Round Football Practice Contact Guidelines Adherence to Inter-Association Consensus: Independent Medical Care Guidelines Reducing gratuitous contact during practice Taking a ?safety first? approach to sport 4 WAKE FOREST SPORTS MEDICINE e. Taking the head out of contact f. Coaching and student-athlete education regarding safe play and proper technique. University of Washington LEI Concussion Management Plan PE 1 University of Washington Concussion Management Plan The University of Washington, Department of Intercollegiate Athletics (ICA) is committed to ensuring the health and safety of its student-athletes. To this end, and in accordance of NCAA Autonomy Conference concussion Management Protocol, will adopt the following Concussion Management Plan (CMP). This plan will set forth how student-athletes exhibiting signs and of concussions and student-athletes diagnosed with concussions will be managed. Concussions are a potentially serious injury to the brain. Most concussions do not involve a loss of consciousness. of concussion include, but are not limited to dizziness, headache, feeling "out of it? or ?foggy?, vision changes, sensitivity to light or noise, balance problems and other Student-athletes are obligated to report any signs or concerns of possible concussion to the University of Washington athletic trainers and/or team physicians. Concussions frequently occur in sport and repetitive concussions have been related to long term changes in brain function. The University of Washington is committed to student-athlete health and safety and the components of the University of Washington Concussion Management Plan are listed below: Concussion Management Plan Personnel The University of Washington coaches, student-athletes, strength coaches, athletic trainers, team physicians, academic service providers and any other department personnel have a responsibility to protect student-athlete health and safety, and therefore should report any signs and of concussion to the University of Washington medical staff. The University of Washington concussion management plan (CMP) personnel includes the athletic training staff and team physicians. These personnel will have unchallengeable authority when making return-to-play decisions for concussed student-athletes. Education: Student Athlete Responsibility As a part of the CMP and NCAA recommendations all student-athletes, coaches, team physicians, ATCs, and Directors of Athletics will be provided the NCAA Concussion Information Fact Sheet and be required to sign an acknowledgement, on an annual basis during their pre- participation exam, that they have been provided, have read and understand the Fact Sheet and its contents. This signed acknowledgement will be ?led in the student-athlete?s medical record. Acknowledgement forms for athletic department personnel will be kept in a centralized ?le in the athletic training room. FE- 2 Pre-Participation Assessment: PPE All student-athletes must undergo a pre-participation exam (PPE) on matriculation to the university and an annual interim medical history. As part of the initial PPE a series of questions related to brain injury and prior concussion history will be asked/answered. CMP Team Physicians will determine pre-participation clearance status for University of Washington student-athletes. Baseline Balance Evaluation 1. A one-time baseline evaluation including (cognitive) and a SCAT3 which includes evaluation, cognitive assessment, and balance evaluation (modi?ed Balance Error Scoring System testing will be completed prior to participation in ALL varsity sports: a. Baseline SCATB testing will also be performed on all Cheer/POM/Mascot participants Recognition and Diagnosis: Signs present/identi?ed 1. If an athlete, teammate, coach, of?cial or member of medical staff identi?es signs or of possible concussion the student-athlete will be removed from participation and evaluated by the CMP medical staff (ATC or team physician with experience in the evaluation of concussion). a. The initial evaluation will include assessment of consistent with concussion, physical or neurological impairment, cognitive status, balance, cervical Spine injury, fracture and intracranial bleeding. 2. If a team physician is not present, the ATC may allow the athlete to continue play if there is no suspicion for concussion. If the ATC suspects a concussion is possible, then the athlete will not return to play until they have been evaluated by a team physician. 3. The appropriate emergency action plan (EAP) will be activated if the student-athlete exhibits any of the following signs and are present: Glasgow Coma score less than 13; prolonged loss of consciousness; focal neurological de?cit suggesting intracranial trauma; repetitive emesis; persistently diminished or worsening mental status or other neurological signs or or potential spine injury. When a Concussion is Diagnosed 1. Once a student-athlete is diagnosed with a concussion they shall be withheld from practice or competition and not return to activity for at least the remainder of that day. The student-athlete will not participate in practice or competition until they have been evaluated by a team physician. The student athlete will be advised to not return to class that day if they are diagnosed with a concussion. 2. An evaluation by a CMP team physician will be arranged. 3. Student-athletes diagnosed with a concussion will continue to receive serial monitoring by a member of the CMP medical staff for deteriorating neurologic pg. 3 4. 5. Once a student-athlete diagnosed with a concussion is deemed safe for athletic training room discharge, they will be provided a copy of the Concussion Information: Home Instruction Sheet (appendix A) detailing what to do in the event that their deteriorate. a. A roommate, parent, guardian, or other responsible adult will also be provided the same Home Instruction Sheet on how to recognize deteriorating that would warrant further action or transportation of the student-athlete to the Emergency Room. The discharged student-athlete will have a follow-up appointment scheduled with the CMP medical staff if possible within 24-48 hours. Ongoing 8: Follow Up Care 1. The studentsathlete will have daily assessment by the CMP medical staff, and all student-athletes diagnosed with a concussion will be evaluated by a team physician prior to initiating a return-to-play progression. Athletes with persisting and/or prolonged recovery will see the team physician on an as needed basis to ensure proper evaluation for additional diagnosis, management and best management Options. While the student-athlete is physical and mental rest will be encouraged and the student?athlete will be held from all team training, practice and competition and academic activity will be modi?ed as needed to minimize Follow-up testing SCATB, BESS) may be performed at the request of the CMP team physician. Once the student-athlete has returned to baseline (no longer exhibiting any attributed to their injury), they will be cleared by a CMP team physician to initiate a medically supervised and individualized return to play protocol. Return-to-Play It is important to recognize each return?to-play plan will be individualized and directed by the CMP team physician. The graduated RTP protocol will have elements speci?c to each sport at the University of Washington incorporated into each step: 1. Light aerobic exercise such as walking, swimming or riding a stationary bike for at least 15 minutes. No resistance training is permitted. If with light aerobic exercise, then; Mode, duration and intensity-dependent exercise based upon Sport. If with exertion, then; Sport-speci?c activity with no head impact. If with sport-Speci?c activity, then; Non-contact sport drills and resumption of progressive resistance training. If with non?contact drills and resistance training, then; Full?contact practice. If with full-contact practice, then; Return-to?play. Medical clearance will be determined by the team physician/physician designee, or athletic trainer in consultation with a team physician. as '1 *If at any point the student-athlete becomes (more than baseline), the CMP team physician will be noti?ed and adjustments made to the return to play progression. Return-to-Learn Returning to academics after a concussion is a parallel concept to returning to play after concussion. After concussion brain energy may not be available to perform normal cognitive exertion and function. The return-to-learn (RTL) concept should follow an individualized and step-wise process directed by a multidisciplinary team and should be individualized to the injured student-athlete. At the University of Washington the multidisciplinary team may include, but not be limited to team physician, athletic trainer, consultant, faculty athletics representative, learning specialist, academic counselor, course instructor, athletic administrator, coaches and possibly the Of?ce of Disability Resources for Students (DRS). The following RTL guidelines will be followed for student-athletes diagnosed with a concussion at the University of Washington: 1. Once a student-athlete has been diagnosed with a concussion he/she shall not be required to attend any classroom activity on the same day. The athletic trainer working with the student-athlete will communicate directly with the Director of Learning Resources within ICA about the injury and subsequent restrictions. 2. If the student-athlete cannot tolerate light cognitive activity he or she should be advised to remain at home or in the residence hall in order to rest. 3. Once the student-athlete can tolerate cognitive activity without return of (new or recent), he/she should return to the classroom in a graduated fashion. 4. If at any point during the RTL process the student-athlete's return or their cognitive measures decline, a representative from the Student Athlete Academic Services team will contact the primary athletic trainer for that sport who will arrange for an evaluation by a CMP team physician. Academic Accommodations All academic accommodations/schedule modifications for student-athletes with concussions will be made through a multidisciplinary approach with Student Athlete Academic Services (SAAS) coordinating any recommended accommodations with the Of?ce of Disability Resources for Students and in compliance with the 1. The Director of Learning Resources and/or the Associate Athletic Director for Student Development will coordinate learning specialists, academic advisors, and tutor services consistent with recommended modi?cations. 2. In cases where extended academic accommodations/schedule modifications (greater than 2 weeks) are recommended, re-evaluation by a CMP team physician and possibly other members of the multi-disciplinary team shall occur. Contact with the of?ce of Disability Resources for-Students will be made by the Director of Learning Resources. a. Of?ce of Disability Resources may be reached at 206-543-8924 and . ns- 5 Reducing Exposure to Head Trauma The University of Washington Department of Intercollegiate Athletics (ICA) is committed to student-athlete health and safety. To that end ICA will be proactive in efforts to minimize exposure to head trauma. The following procedures are currently in place at the University of Washington: 1. As a member of the Pac-12 Conference the Fae-12 Conference Football Practice Policy will be followed. 2. Concussion Fact Sheets are made available to student-athletes at the time of the annual health examination. 3. Concussion Fact Sheets will be made available to coaches, sport administrators, team physicians, athletic trainers and strength 8: conditioning coaches. 4. An annual concussion education will occur for all sport coaches. PE- 5' UNIVERSITY OF WASHINGTON Concussion Information: Home Instruction Sheet Name Date You've had a head injury/concussion and need to monitor your closely for the next 24-48hrs WATCH FOR ANY OF THE FOLLOWING PROBLEMS: Worsening headache Stumbling/loss of balance Vomiting Weakness In one arm/leg Decreased level of Consciousness Blurred Vision Dilated Pupils Increased irritability Increased Confusion It is OK to: There is no need to: DO NOT: Use Tylenol (acetaminophen) Check eyes with alight DRINK ALCOHOL Use an ice pack to head/neck for Wake up every hour DRIVE A CAR comfort Stay in bed USE ASPIRIN, ALEVE, ADVII. OR Eat a light meal OTHER NSAID PRODUCTS Go to sleep Special Recommendations: If any of these problems develop, call your athletic trainer or physician immediately. Athletic Trainer Phone Physician Phone You need to be seen for a follow-up examination at at: Recommendation provided to By (Athlete name) Athlete Signature Signature pa. 7 Signs or of Concussion Identi?ed 1F Initial Evaluation Concussion suspected 'll' Remove from activity academics Notify coach, SA, team physician, SAAS 1F Concussion not suspected "l Return to activity Schedule CMP Team Physician Eval academic recommendations to SAAS Home Instruction Sheet 4- Follow up Appt Scheduled within 24-48hrs Daily Assessment (X2) until *update academic recommendation SA w/ persisting will be scheduled to see team physician 'update academic recommendation 'l with CMP team physician for clearance to begin RTP 8: RTL progression ?ll' RTP progression - SA must remain to progress to each next step return SA cleared by CMP team physician for participation FE- 9- Washington State University Athletics Concussion Safety Protocol May 1, 2015 Washington State University Department of Athletics is committed to the identification, evaluation and management of concussions along with reducing the exposure to head injuries. The following protocol outlines the steps taken to ensure the safety of our Student?Athletes at Washington State University. To ensure best practices, standard of care and compliance in the management of concussions the following steps will take place: 1.) .PRE SEASON EDUCATIONProvide NCAA fact sheets and the WSU Concussion Safety Protocol to the following: Director of Athletics, Team Physicians, Certified Athletic Trainers, Coaches, Strength Coaches, Equipment Operations Staff, and Student- Athletes. Those listed above will sign an acknowledgment form indicating they have received this NCAA fact sheet. Student~Athletes will read and sign a concussion acknowledgment form which includes their responsibility of reporting any signs and of a concussion they may have. Certified Athletic Trainers will review concussion education materials with Student-Athletes on assigned teams. Each coaching staff and all strength coaches will attend an education session conducted by Team Physicians during which this protocol will be reviewed and then each coach will sign a document acknowledging he/she has read the concussion material. Full time equipment operations staff will annually inspect, recondition and fit each player in a NOCSAE football helmet. In addition, Student-Athletes will review and sign the "Players Daily Helmet inspection Checklist" and Football Helmet Warning Statement." ASSESSMENT: 8) bl Each Student?Athlete will have a pre-participation baseline assessment (such as lm Pact). This test or another appropriate test may be used at the appropriate time post injury. This test will include brain injury and concussion history, evaluation, cognitive assessment, balance evaluation. Team Physicians will determine pre?participation clearance and/or the need for additional consultation or testing. Baseline re-assessments will take place every two years or six months post-concussion, or as determined by the Team Physician. RECOGNITION AND DIAGNOSIS OF CONCUSSION: a) When a Student-Athlete exhibits signs, or behaviors consistent with a concussion, the athlete shall be removed from practice or competition. 4.) 5-) 6.) The Student-Athlete shail then be immediately evaluated by an athletic healthcare provider (Team Physician and/or Certified Athletic Trainer) with experience in the evaluation and management of concussions. b) c) This evaluation will inClude: assessment, physical and neurological exam, cognitive assessment, balance exam, clinical assessment for cervical spine trauma, skull fracture and intracranial bleed. d) Student?Athletes diagnosed or suspected of having a concussion shall not return to activity for the remainder of that day. As soon as possible post injury, a standardized tool for evaluation will be conducted and documented (such as SCAT 3 or checklist) by a Certified Athletic Trainer with the sport. 6) POST-CONCUSSION MANAGEMENT: a) Athletic Training Services will have on file annually an updated emergency action plan for each athletics venue to respond to Student?Athletes? catastrophic injuries and illnesses, including concussions. b) Transportation for further medical care is recommended for any of the following: Glasgow Coma Scale <13, prolonged LOC, focal neurological deficit suggesting intracranial trauma, repetitive emesis, persistently diminished/worsening mental status or other neurological spine injury. The Student-Athlete will receive serial monitoring for deterioration following the injury. The mechanism for this is periodic follow ups by Certified Athletic Trainer and or Team Physician on the sideline, locker room, Athletic Training facility and/or until final diagnosis or plan is made. c) d) Once the SCAT 3/ or checklist is complete, follow up instructions on the management of concussion will be given in hard copy to the Student-Athlete and a roommate, guardian or someone able to assist the Student-Athlete with following the instructions. e) The Student-Athlete will then be referred to a Team Physician for follow up evaluation. f) While the Student-Athlete is enrolled at WSU the Team Physician will continue to follow up and re-evaluate to look for possible prolonged recovery issues and/or additional diagnosis that may include PCS, sleep dysfunction, migraine or headache disorders, mood disorders such as anxiety and depression and ocular or vestibular dysfunction. RETURN TO PLAY: Final authority for return to play shall reside with the Team Physician or the Physician?s designee. 3) Once the Student-Athlete is and post-exertion assessments are within normal baseline limits, return to play shall follow a medically supervised stepwise process. b) c) The Student ?Athlete progresses to each step listed without worsening or new light aerobic exercise w/o resistance training, non?contact practice with progressive resistance training, sport-specific exercise and activity without head impact, unrestricted training and return to competition. RETURN TO LEARN: a) The point person who will navigate the return to learn plan with the Student-Athlete will be the Associate Director of Athletics for Student-Athlete Development (Academics). b) The Team Physician will coordinate return to learn planning with the assistance ofthe person named above. c) d) el f) s) h) The multi-disciplinary team may include: Team Physician, Team Certified Athletic Trainer, Academic Advisor, Learning Specialist, and Mental Health Professional. Student?Athletes will not return to the classroom on the same day of suffering a concussion. And, an individualized plan determined by Team Physician with input from the multidisciplinary team will be implemented that includes: remaining at home/residence hall if Student-Athlete cannot tolerate light cognitive activity and a gradual return to classroom [studying as tolerated. Cognitive restriction may include the following as deemed appropriate: restrictions upon returning to the classroom for time to be determined, restrictions to attending team meetings, practices and film sessions, access to technology and restricting work or other non?sport activities. Modification of schedule/academic accommodations for up to two weeks, or as determined by the Team Physician after consulting with members of the multi-disciplinary team. lie-evaluation by Team Physician will occur if worsen with academic challenges. Re-evaluation by Team Physician and members of multi?disciplinary team will also take place, as appropriate for Student-Athletes with greater than two weeks, or as deemed necessary by the Team Physician. For cases that ca n?t be managed through appropriate schedule modifications and specific academic accommodations further campus or community resources will be engaged and will be consistent with These may include: Learning Specialist, University Access Center, office. 7.) REDUCING EXPOUSURE TO HEAD TRAUMA: Adherence to the followingInter-Association Consensus: Year-Round Football Practice Contact Guidelines. (See Attached) Inter-Association Consensus: Independent Medical Care Guidelines. (See Attached} NCAA and Pac-12 Conference Practice Rules. Nationally recognized helmet safety guidelines. Take a safety first approach to practice and take the head out of contact. Reduce gratuitous contact during practice. Coach and teach techniques that prioritize health and safety. ADMINISTRATIVE: Institutional plan submitted to Concussion Safety Protocol Committee by May 1. Dr. Hainline, NCAA Chief Medical Officer) Written certificate of compliance signed by Director of Athletics. (see attached] Forward the WSU Concussion Safety Protocol to the following: Compliance Staff, Senior Staff, Athletic Council, Team Physicians, Athletic Training Staff, Equipment Operations Staff, Academic Support Services Staff, Mental Health and Wellbeing Staff, All Sport and Strength Coaches Updated West Virginia University Intercollegiate Athletics Concussion Management Plan I. Purpose The West Virginia University Department of Intercollegiate Athletics (Department of Intercollegiate Athletics) is committed to the safety and well-being of its student-athletes. It is committed to the prevention, identification, evaluation and management of concussions. Therefore, the Department of Intercollegiate Athletics, in accordance with NCAA Concussion Policy and the Big 12 Conference Concussion and Management Policy, has adopted a team physician-directed Concussion Management Plan for its student-athletes who exhibit signs, symptoms or behaviors consistent with a concussion. The plan addresses the removal from practice and/or competition, evaluation by an experienced healthcare provider, and the criteria for medical clearance to return to activity. II. Responsibility Department of Athletics administration, team physicians, athletic trainers, coaches, and support staff collaboratively share responsibility in the proper execution of this plan. III. Definition of Concussion In accordance with the 4th International Conference on Concussion in Sport (2012), a cerebral concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Common elements of concussions include: IV. • May be caused by a direct blow to the head or elsewhere on the body with an ‘impulsive’ force transmitted to the head. • Typically results in a rapid onset of short-lived impairment of neurologic function that resolves spontaneously. • May result in neuropathological changes, but acute clinical symptoms largely reflect a functional disturbance rather than structural injury. • Result in a graded set of clinical symptoms that may or may not involve loss of consciousness. • Resolution of the clinical and cognitive symptoms typically follows a sequential course, but post-concussive symptoms may be prolonged. • No abnormality is evident on standard structural neuroimaging studies. Education The medical staff will annually educate student-athletes, coaches, and administrators on the recognition, management, and reporting of concussions. During this period, the {W0023674.1} 1 West Virginia University Intercollegiate Athletics Concussion Management Plan Department of Intercollegiate Athletics Concussion Management plan will be reviewed and the NCAA Concussion Fact Sheet will be distributed to all parties (Appendix). Coaches will sign a statement confirming receipt of the educational material and acknowledgement of their responsibilities in reporting concussions to the medical staff (Appendix). Student-athletes will sign the WVU Notice of Risk, which includes a statement of their injury reporting responsibilities in addition to a listing of the common signs and symptoms of concussion (Appendix). The Department Intercollegiate Athletics medical staff (team physicians, staff athletic trainers, graduate assistant athletic trainers) and department administrators (Athletics Director and associates) will meet annually for education on the recognition and management of concussions within the department. Signed attendance at this education session will be mandatory. The Concussion Management Plan will be updated as appropriate based on this review process. V. Pre-participation Assessment All student-athletes will undergo a baseline concussion assessment utilizing the X2 Integrated Concussion Examination (ICE) program (a SCAT3 based protocol) that includes a concussion history, symptom checklist, cognitive assessment, and balance evaluation. The team physician will determine pre-participation clearance and/or the need for additional consultation or testing. VI. Recognition, Diagnosis, and Management of Concussions Concussions may cause abnormalities in clinical symptoms, physical signs, behavior, balance, cognition, and/or sleep (Table 1). Table 1. Signs and Symptoms of Concussion Physical Cognitive Emotional Sleep Headache Feeling “in a fog” Irritable Drowsiness Nausea or vomiting Amnesia Nervous Sleep more Balance disturbance Confusion Sad/depressed Sleep less Sensitivity to light or noise Disorientation Emotional labiality Dazed or vacant stare Difficulty concentrating Loss of consciousness Delayed verbal responses {W0023674.1} 2 West Virginia University Intercollegiate Athletics Concussion Management Plan Any student-athlete exhibiting signs and symptoms of a concussion will be immediately removed from play and evaluated by a physician or certified athletic trainer. A complete physical and mental status examination will be performed by the athletics healthcare provider with the results compared to the student-athlete’s baseline measurements as recorded in the X2 ICE program. Any student-athlete diagnosed with a concussion shall not return to activity for the remainder of that day. The student-athlete will be serially monitored by an athletics healthcare provider for deterioration and will be provided with written instructions if discharged home after suffering a concussion (Appendix). Activation of the on-site Department of Intercollegiate Athletics Emergency Action Plan will occur for any student-athlete exhibiting a Glasgow Coma Scale <13, prolonged loss of consciousness, repetitive emesis, focal neurological deficits, progressive or worsening signs and symptoms, and/or signs and symptoms of associated injuries (e.g. neck injury). Student-athletes who experience a concussion associated with loss of consciousness, worsening signs/symptoms, and/or post-concussive signs/symptoms lasting greater than 24 hours will be referred to a physician and will not be allowed to return to activity until cleared by the physician. VII. Return to Activity Any student-athlete suffering a concussion must have returned to his/her baseline level of symptoms, cognitive function, and balance before starting any exertional activity. Student-athletes who have returned to baseline status must complete a return-to-play activity progression before returning to full, unrestricted activity (Table 2). Table 2. Return-to-play activity progression Step 1: Light aerobic exercise. No resistance training. Step 2: Increased intensity of exertive activity. Step 3: Sport specific activity/drills with no head contact. Progressive resistance training. Step 4: Full competitive practice. Step 5: Return to game/competition. The student-athlete must remain at his/her baseline status during each activity and for 24 hours following the step before progressing to the next level. If signs/symptoms occur during a step, the student-athlete will revert back to the previous level for a minimum of 24 hours before attempting the progression again. {W0023674.1} 3 West Virginia University Intercollegiate Athletics Concussion Management Plan Post-concussion neuropsychological testing using the ImPACT testing system will be performed as appropriate prior to the final step to aid in clearance decisions. In highly select settings, the return-to-play progression may need to be modified in a more individualized approach under the guidance of the team physician. Medical clearance following a concussion will be determined by the team physician or athletic trainer in consultation with the team physician. The Department of Intercollegiate Athletics team physician will have the final and unchallengeable authority to determine management and return to play for a concussed student-athlete. VIII. Multiple Concussions Any student-athlete suffering two or more concussions within the same calendar year will not be eligible to return to activity until evaluated and cleared by the team physician. Psychological consultation and counseling will be obtained on a case-by-case basis as deemed appropriate by the team physician. IX. Return to Academics Concussed student-athletes will complete a return to academics progression in parallel with his/her return to activity program. Relative cognitive rest through the minimizing of stressors such as video games, reading, texting, watching television, and listening to music through headphones should begin immediately following the diagnosis of a concussion, including no classroom activity on the day of injury. Student-athletes who cannot tolerate light cognitive activity will remain at home or in the residence hall. Attendance at sport practices and/or meetings should not be expected. Student-athletes who tolerate light cognitive activity without symptoms can return to the classroom in graduated increments while working closely with an advisor in the Department of Intercollegiate Athletics Office of Academic Services. Those experiencing an increase in post-concussion symptoms during academic challenges will be reevaluated by the team physician. The amount of time needed for a student-athlete to avoid class or homework will be individualized. A multi-disciplinary team that may include the team physician, athletic trainer, psychologists, academic advisors, and coach will be utilized as appropriate to determine the extent of academic adjustments. Student-athletes experiencing cognitive difficulties for longer than two weeks postconcussion will be medically re-evaluated and may need more extensive academic accommodations. In such cases, a referral will be made to the WVU Office of Accessibility Services (OAS) in conjunction with the student-athlete’s continued interaction with the Office of Academic Services. OAS will ensure management is in {W0023674.1} 4 West Virginia University Intercollegiate Athletics Concussion Management Plan compliance with the Americans with Disabilities Act Amendments Act of 2008 (ADAAA). X. Concussion Prevention and Head Trauma Reduction Although complete elimination of concussion risk in collegiate athletics is impossible, the Department of Intercollegiate Athletics is committed to the practicable minimizing of exposure to head trauma through adherence with the NCAA Year-Round Football Practice Contact Guidelines. A conservative “safety-first” approach will be followed in all sports when any significant abnormality is detected following a head injury. {W0023674.1} 5 West Virginia University Intercollegiate Athletics Concussion Management Plan APPENDIX CONCUSSION A fact sheet for student-athletes What are the symptoms of a concussion? What is a concussion? A concussion is a brain injury that: • Is caused by a blow to the head or body. – From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. • Can change the way your brain normally works. • Can range from mild to severe. • Presents itself differently for each athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness. You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time. How can I prevent a concussion? Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. What should I do if I think I have a concussion? Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. It’s better to miss one game than the whole season. When in doubt, get checked out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services. 7 West Virginia University Intercollegiate Athletics Concussion Management Plan Coach Acknowledgement of Education and Reporting I have reviewed the WVU Department of Intercollegiate Athletics Concussion Management Plan and have been provided with the NCAA Concussion Fact Sheet. I understand the importance of proper recognition and management of concussions and will not knowingly allow a student-athlete to return to play in a game or practice if he/she has received an injury that results in concussion‐related symptoms. I further acknowledge that should I recognize one of my student-athletes exhibiting any behaviors consistent with a concussion, it is my responsibility to have that student-athlete evaluated by the medical staff. I am aware that student-athletes with a concussion must be cleared by an athletic trainer or physician prior to returning to active sports participation. Further, I acknowledge and agree that the concealment of a concussion or concussion related symptoms is unacceptable and may be punishable if such concealment is later revealed or determined to have occurred. __________________________________________ Signature of Coach ________________________ Date __________________________________________ Printed Name of Coach _________________________ Sport {W0023666.1} 8 WVU INTERCOLLEGIATE ATHLETICS I. NOTICE OF RISK & POTENTIAL CONSEQUENCES I, __________________________________ (print name), verify that I have been informed that I may be injured while participating in intercollegiate athletic practice or competition. I understand that it is possible that I may sustain an injury which may result in permanent disability, paralysis, or possibly death. I understand that paralysis may include loss of movement, feeling, and use of my arms, legs, and trunk. I further understand that paralysis may involve complete loss of sexual function, and/or bowel and bladder control which would require the use of external aids, attached or inserted into my body for the collection and removal of body wastes. I understand that paralysis and its effects could last my entire lifetime. In addition, I understand that an injury to any of my body joints (i.e. ankle, knee, hip, spine, shoulder) may result in disfiguration, loss of movement, strength or feeling which may last my entire lifetime. I understand that it is my responsibility to adhere to all rules and regulations of my chosen sport and to follow the West Virginia University Department of Intercollegiate Concussion Management Plan (“CMP”). I understand that infraction of the rules or violating the CMP may result in injury to me or my opponent. I also understand that no modification of protective equipment or uniform should be made. In addition, I understand that it is my responsibility to report faulty or poor-fitting equipment immediately to the coach, equipment manager, or athletic trainer. I understand that all injuries are to be reported to the athletic trainer and that I am responsible for the follow-up care and treatment of my injuries under the athletic trainer’s supervision. Under no circumstances should injuries be concealed. This includes signs/symptoms associated with cerebral concussion. These signs and symptoms can include loss of consciousness (getting ‘knocked-out’), headache/pressure in head, sensitivity to light, visual disturbances, amnesia/difficulty with memory, confusion/difficulty in concentrating, fatigue/feeling slowed-down/ or ”in a fog”, dizziness, nausea/vomiting, sleep disturbances, irritability, mood changes/more emotional, or nervousness. I accept these risks of participation in ________________ (sport) during the 20___ -20___ season. II. CONSENT TO EXAMINATION AND TREATMENT I, ________________________________ (print name), consent to the examination and treatment by health care providers of the West Virginia University Department of Intercollegiate Athletics. I realize that students who are supervised by other health care providers may perform my treatment. I authorize West Virginia University Department of Intercollegiate Athletics to release my medical records and any other information relating to my care (specifically including information related to psychiatric, substance abuse, or HIV treatment) to any person, company or agency who may need them for treatment, payment, or other health care operations as outlined in the West Virginia University Department of Intercollegiate Notice of Privacy Practices. By signing below, I declare that I have read and understand this NOTICE OF RISK & POTENTIAL CONSEQUENCES and CONSENT TO EXAMINATION AND TREATMENT document. I also acknowledge that I have been given opportunity to ask questions about this document. ____________________________________________ Student-Athlete Signature {W0023670.1} 9 _______________ Date West Virginia University Department of Intercollegiate Athletics Concussion Home Instruction Sheet You have experienced a concussion or head injury and need to be watched closely for the next 24-48 hours. Symptoms of a concussion often appear immediately, but some may not be noticed for hours or days following the injury. Watch for any of the following problems: • Repeated vomiting • Headache that gets worse or does not go away • Loss of consciousness or unable to stay awake during times you would normally be awake • Becoming more confused, restless, or agitated • Convulsions or seizures • Difficulty walking or difficulty with balance • Weakness or numbness • Difficulty with your vision If you experience any of these symptoms contact the athletic training room or go to an emergency room immediately. Do not conceal symptoms or problems. While at home it is safe to: • Take Tylenol • Go to sleep • Eat a light meal DO NOT: • Drink Alcohol • Take aspirin, ibuprofen, naproxen or similar products Getting plenty of rest helps the brain to heal. While at home avoid activities that are physically demanding or require a lot of thinking or concentration, such as playing video games. You should also avoid places with loud noises. Contact your athletic trainer tomorrow and update him/her on your current status: Name: _______________________________Phone Number: ______________________ {W0023667.1} 10 University of Wisconsin – Madison Division of Intercollegiate Athletics Concussion Management Plan University of Wisconsin – Madison Division of Intercollegiate Athletics Concussion Management Plan Education 1. The sports medicine staff (licensed athletic trainers and team physicians) will review the NCAA regulations and recommendations on concussions. 2. Coaches, Team Physicians, Athletic Trainers, and Directors of Athletics will receive concussion education materials provided by the NCAA. 3. Coaches, Team Physicians, Athletic Trainers, and Directors of Athletics will be required to sign an acknowledgement of having read and understood the NCAA concussion education materials that they have been provided, and accept responsibility for reporting symptoms of a concussion experienced by a student-athlete that they may witness. 4. All student-athletes will receive educational materials provided by the NCAA and a presentation on concussion by a member of the athletic training staff. All student-athletes will sign an acknowledgement form that states they have received concussion education and understand the importance of immediately reporting symptoms of head injury/concussion to the sports medicine staff. Baseline Assessment 1. All student-athletes will complete baseline concussion assessment based on NCAA guidelines including: brain injury and concussion history, symptoms evaluation with the SCAT3 symptoms checklist, cognitive assessment utilizing Standardized Assessment of Concussion (SAC) and ImPACT, and balance evaluation utilizing the Balance Error Scoring System (BESS). 2. Team physicians will determine pre-participation clearance and/or the need for additional consultation or testing for each student-athlete. Student-athletes involved in the following higher risk contact/limited contact sports will undergo baseline testing prior to any organized practice and at a minimum of every two years during their athletic career. Contact/limited contact sports include: football, men’s and women’s soccer, men’s and women’s basketball, men’s and women’s ice hockey, softball, wrestling, volleyball, diving and pole vault student-athletes. . Management of Concussion Injury 1. Any student-athletes suspected of having a concussion or reporting concussion like symptoms, will be removed from activity and evaluated by a licensed athletic trainer or physician member of the sports medicine staff utilizing symptoms assessment (SCAT3 symptoms checklist), physical and neurological exam, cognitive assessment (SAC), and balance exam (BESS). The evaluation will also include clinical assessment for cervical spine trauma, skull fracture, and intracranial bleed when indicated. If the evaluation results in concern for a concussion, the student-athlete will be removed from athletic and classroom activity for the remainder of that day. 2. The department Emergency Procedure Plan will be utilized for any student athlete that has: a Glasgow Coma Scale of <13, prolonged loss of consciousness, focal neurological deficit, repetitive emesis, persistently diminished or worsening mental status, or possible spine injury (Appendix 1). 3. Student-athletes suspected of having a concussion and another responsible adult, will be provided and review the handout “Concussion Information for Student-Athletes and Family/Friends” following their evaluation. Student-athletes will be advised of the importance of being supervised by a responsible adult for the remainder of the day. Arrangements will be made for follow-up of the student-athlete the next day (Appendix 2). 4. Student-athletes suspected of having a concussion, will be referred to a physician for consultation and further evaluation. Student-athletes may be provided the “Documentation of Concussion” letter to outline any suggested temporary academic accommodations that may be necessary as a result of their concussion. Student-athletes will be expected to return to academics prior to returning to athletic participation (Appendix 3). 5. Student-athletes with a concussion, will undergo serial monitoring utilizing a graded symptom checklist. 6. Student-athletes with symptoms lasting longer than 72 hours will be followed by a physician weekly or as determined by the physician. 7. When a student-athlete’s concussion-related symptoms have improved, the student athlete will undergo concussion testing for comparison to their baseline concussion assessment. Student-athletes may begin the sport specific portion of the return-to-play progression after resolution of concussion related symptoms, a normal physical exam, when performing at or above pre-injury levels on all objective concussion assessments, and consultation with a physician. 8. Return-to-play progression from concussion injury will include the following six stages. The typical time frame consists of 24 hours between stages. Student-athletes must complete each stage without return of symptoms to progress to the next stage. If activity at any stage results in a return of symptoms or decline in test performance then the activity should be halted immediately and restarted 24 hours later if symptoms are resolved. Return-to-play is case dependent and the directing physician can shorten or lengthen the time frame when appropriate based on the individual student-athlete. Review by a physician will occur prior to participation in unrestricted activity. Stage 1 – No activity State 2 – Light exercise: <70% of age-predicted maximal heart rate Stage 3 – Sports–specific activities without the risk of contact from others Stage 4 – Noncontact training or practice involving others and resistance training Stage 5 – Unrestricted/Contact training or practice Stage 6 – Return to play Management of Individuals with Prolonged Concussion Symptoms The majority of student-athletes with concussion have symptoms improve at a steady rate, in cases when symptoms persist: 1. Student-athletes should be considered for referral to multi-disciplinary practitioners for specific evaluation of their symptoms. 2. Results of the student-athletes evaluation can be utilized in seeking academic accommodations due to their injury if the need exists. Return to Learn Management Plan The Assistant AD for Academic Services is designated as the point person within athletics who will navigate, along with others listed below, the return-to-learn plan with the student-athlete. The Multi-Disciplinary Team that is charged with additional help to navigate the more complex cases of prolonged return-to-learn include (as each case dictates):  Team Physician  Athletic Trainer (ATC)  Psychologist/Counselor  Neuropsychologist consultant  Faculty Athletic Representative(s)  Sport Academic Advisor  Course Instructor(s)  School/College Administrators  Disability Resource Center (McBurney)  Coach(es) Return to learn progression from concussion injury will be in compliance with ADAAA. It will include the following stages: Stage 1: Onset of concussion injury  No classroom activity on same day as concussion  Academic point person (or sport academic advisor) receives notification from sports medicine/medical staff of injury and prescribed cognitive rest/Individualized Initial Plan (IIP) (i.e. no reading, television, computers, cell phone, etc.)  Faculty are notified (as timely as possible) of injury to student-athlete and of the prescribed cognitive rest/IIP and approximate time frame of recovery/absence period o IIP to include the following: 1) Remaining at home/dorm if SA cannot tolerate light cognitive activity. 2) Gradual return to classroom/studying as tolerated o Stage 2: Continuation of concussion injury  Academic advisor and faculty member have communicated and established basic plan for return to learn. Student-athlete recovery proceeds per established protocol.  Academic point person (or sport academic advisor) receives updated notification from sports medicine/medical staff of return to learn progress and additional/continued prescribed cognitive rest/Individualized Initial Plan (IIP)  Faculty notified of additional updates Gradual return planned Extended absence from learning (>1 week)  Faculty notified of planned return to learn date/time details  Modification of schedule/academic accommodations for up to 2 weeks  Regular check-in meetings from advisor with SA and faculty member of assignments and progress for each class  Re-evaluation by team physician and members of multi-disciplinary team  Engage campus resources for cases not managed through schedule modification/ academic accommodations (consistent with ADAAA and to include both Learning Specialists and McBurney Center staff)  Re-evaluation by team physician if concussion symptoms worsen with academic challenges Reducing Exposure to Head Trauma The following steps will be taken to emphasize ways to minimize head trauma exposure: 1. Concussion education presentations to student athletes will emphasize and encourage the utilization of proper technique of the individual sport and the importance of taking the head out of contact in collision sports. 2. Coaches adhere to relevant live contact practice NCAA legislation for preseason, in-season, postseason, bowl and spring practice. 3. Coaches will be provided Inter-Association Consensus statements that exist pertaining to their sport that attempt to identify ways to reduce head trauma exposure (Appendix 4). 4. Coaches will be provided the Independent Medical Care Guidelines (Appendix 5). Revised: 4-24-2015 Appendices Index Appendix 1……………………………………………………………………………………………………. Emergency Procedure Plan Appendix 2………………………………………… Concussion Information for Student-Athletes and Family/Friends Appendix 3…………………………………………………………………………………..…………… Documentation of Concussion Appendix 4………………………………………………………………………………………………..…. Football Practice Guidelines Appendix 5…………………………………………………………………..……………….. Independent Medical Care Guidelines Appendix 1 SPORTS MEDICINE Emergency Procedures Emergency Table of Contents Introduction ..................................................................................................................... 4 Emergency Planning ...................................................................................................... 5 Know Your Location ...................................................................................................... 8 Non-SOC Events ........................................................................................................... 10 Camp Randall Stadium-Main Turf ......................................................................... 10 Camp Randall Stadium- Weight Room ................................................................. 10 Camp Randall Stadium-Wrestling Room .............................................................. 12 Camp Randall Memorial Shell ................................................................................ 12 Camp Randall-North Practice Field ....................................................................... 13 Field House ................................................................................................................ 13 Goodman Softball Diamond and Goodman Softball Training Complex ......... 14 Kellner Hall ............................................................................................................... 14 Kohl Center Arena .................................................................................................... 15 Kohl Center-Main Floor/Athletic Training Room/Weight Room/Locker Rooms ..................................................................................................................................... 15 Kohl Center-Nicholas Johnson Pavilion Gym....................................................... 16 LaBahn Arena Complex ........................................................................................... 16 McClain Facility ........................................................................................................ 17 McClimon Outdoor Track &Field/Soccer Complex ............................................. 17 Natatorium ................................................................................................................ 18 Nielsen Tennis Facility ............................................................................................. 18 Porter Boat House ..................................................................................................... 19 SERF – Pool ................................................................................................................ 19 Thomas Zimmer Championship Cross Country Course ..................................... 20 2 University Bay Fields ............................................................................................... 20 University Ridge Golf Course/Indoor Training Center ....................................... 21 Eagle’s Nest Ice Arena.............................................................................................. 21 SOC-covered events (as designated by athletic administration policies) .............. 22 Emergency Care and First Aid .................................................................................... 24 Know Who to Call ........................................................................................................ 31 Licensed Staff Athletic Trainers .................................................................................. 32 Sport Coverage.............................................................................................................. 33 Acknowledgements ...................................................................................................... 34 3 Introduction What is the purpose of this emergency guide? The purpose of this guide is to provide a reference and guide for University of Wisconsin staff to facilitate appropriate emergency situation management. Who is this emergency guide created for? This manual is most beneficial to those that are certified in First Aid and CPR; however, if one is not certified, there are contact phone numbers to aid in appropriately managing an emergency. Athletic training students, licensed staff athletic trainers, strength coaches, sport coaches, and many others interacting with the athletic environment will be using this guide. How should one use this guide?  For every practice and competition, an emergency plan should be in place – Use the checklists in the first section to help  Review the information so it is familiar to help in an emergency situation  Keep it available as a resource checklist and phone reference when an emergency occurs  Post it by a phone for emergency use What is included in this guide?  A section to help establish an emergency plan  A section that includes addresses and closest phone contacts in case of an emergency for all the various team practice and competition locations  A section with reference lists for o Potential emergencies o Signs and symptoms o Emergency action plans  Most treatment plans are reference lists for those certified in First Aid or CPR. **If you are not certified, know how to get in contact with a certified medical staff so they can establish a treatment plan for the emergency. (Either 911 or a licensed staff athletic trainer)  Phone Directory on the back pages 4 Emergency Planning Identifying a Life Threatening Emergency What is an emergency…  Any life-threatening situation  No breathing  No pulse  Unconscious  Uncontrolled bleeding – heavy, steady, or spurting  Loss of feeling (numbness) or ability to move What to do…  CALL 911  If certified in First Aid or CPR, give appropriate care  Call a licensed staff athletic trainer as soon as possible  Maintain body position of athlete Identifying a Non-Life Threatening Situation Requiring Urgent Care What is a non-life threatening situation…  Inability to walk or bear weight – especially if associated with immediate swelling and bruising  Severe and prolonged abdominal pain (over 1 hour)  Uncontrolled bleeding – moderate blood loss  Severe headache not alleviated by medication  Prolonged/frequent vomiting and diarrhea together  Unexplained and significant numbness, weakness, or sensation difficulties in arms or legs  Fever over 101°F - combined with abdominal pain  Fever over 101°F - combined with inability to touch chin to chest due to neck pain  Blow to head/shoulders combined with headache What to do…  Contact a licensed staff athletic trainer as soon as possible  If certified in First Aid or CPR, give appropriate care  Refer to UWHC Emergency Department 600 Highland Avenue Madison, WI 53792 (608) 262-2398 (Emergency Room) 6 Establishing an Emergency Plan Home and Away Events Prior to activity, determine the following: 1. Closest phone and phone number at the event 2. Locate availability of responsible medical personnel 3. Address and specific ambulance entrance to facility or field 4. Determine number to emergency services (i.e. 911) 5. Who will call emergency number 6. Who will meet the ambulance 7. Where will the injured athlete be taken (Home events direct to UW Hospital) 8. Who will accompany the injured athlete Calling 911 Provide dispatcher with the following information: 1. Your name and position with the University 2. The name and location of emergency 3. Brief description of the emergency 4. Current care being rendered and by whom 5. Location of the injured person 6. Directions for easy medical personnel access 7. Telephone number from which you are calling 8. Request: “A PARAMEDIC SQUAD” be sent. (otherwise only campus police squad car is sent) 9. Be ready to review all information provided 10. Hang up when dispatcher indicates you should. 7 Know Your Location Camp Randall Stadium & Stadium Complex Camp Randall Stadium and the Stadium Complex include the following facilities:  Kellner Hall  Field House  McClain Center  Camp Randall Memorial Shell  North Practice Field Camp Randall Stadium and the Stadium Complex are controlled under two centers based on the events/activities that are taking place at that time. These are the Stadium Command Center (SCC) and the Stadium Operations Center (SOC). Stadium Command Center SCC is the central communications center for Camp Randall Stadium for normal stadium activities and events that do not require SOC.  SCC is located in the Athletic Operations Building (AO Building) at 25 N. Breese Terrace.  SCC is open from 6 am – 2 am Monday through Friday and 6 am – 10 pm Saturday and Sunday.  Telephone number: 262-8065  SCC is SOC when SOC is not operational.  There is an AED located inside on the wall next to the office door. Stadium Operations Control SOC is the central communications center for the Stadium Complex for football game day and other designated stadium events. These areas include the facilities listed above. Any communication with emergency personnel will be routed through SOC to determine the quickest response to the victim(s).  SOC is located on the north end of the fourth level of the Press Box.  Telephone number: 262-9130 Command Center Designation  Football game day and other designated stadium events covered by Stadium Operations Center (SOC)  Other events not covered by Stadium Operations Center (SOC) 9 Non-SOC Events Camp Randall Stadium-Main Turf     Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Stadium Command Direct someone to meet EMS Address: 25 North Breese Terrace; 53711 Entrance: AO Building parking lot AED is available:  Stadium Command Center – wall next to lobby  Gate 1 Welcome Center – inside glass vestibule  Hall of Champions Welcome Center – wall to the right of front desk Camp Randall Stadium- Weight Room     Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Stadium Weight Room Offices Direct someone to meet EMS & use call box at gate to call Stadium Command to open gate Address: 1475 Engineering Drive; 53711 Entrance: Through Gate 3 to glass entry doors AED is available:  Hall of Champions Welcome Center – wall to the right of front desk  Mueller Sports Medicine Center, cubbies next to front entrance  Sport Performance Lab inside Mueller Sports Medicine Center 10 Camp Randall Stadium- Fetzer Center & Football Offices     Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Academic Offices Direct someone to meet EMS & use call box at gate to call Stadium Command to open gate Address: 1475 Engineering Drive; 53711 Entrance: Through Bennett Student-Athlete Performance Center Main Doors, elevator to floor needed AED is available:  3rd floor of Fetzer Center at bottom of stairwell  8th Floor in kitchen area of football offices  Hall of Champions Welcome Center – wall to the right of front desk  Sport Performance Lab inside Mueller Sports Medicine Center 11 Camp Randall Stadium-Wrestling Room    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Wrestling Offices 262-3586 Stadium Command 262-8065 Direct someone to meet EMS Address: 1440 Monroe St; 53711 Entrance: Have someone meet EMS at Gate 1 (Lot 18). Bring them in through Badger Alley using the Heritage Hall elevator located at Section V. AED is available:  Wrestling Athletic Training Room  Stadium Command Center – wall next to lobby  Gate 1 Welcome Center – inside glass vestibule  Hall of Champions Welcome Center – wall to the right of front desk Camp Randall Memorial Shell    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Main Entrance Front desk Direct someone to meet EMS Address: 1430 Monroe St; 53711 Entrance: Main entrance through Lot 18 AED is available:  Main entrance lobby  Running Track 12 Camp Randall-North Practice Field    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Hall of Champions Welcome Desk Direct someone to meet EMS at Lot 17 service road gate (Call button opens / Knox Box) Address: 1475 Engineering Drive, 53711, Entrance: South Gate to North Practice Field AED is available:  North Concourse, middle of north wall between the West and East Gate  Hall of Champions Welcome Desk Field House    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Training Room Office 263-6748 Volleyball Team Locker Room 263-6944 Direct someone to meet EMS Address: 25 North Breese Terrace; 53711 Entrance: Gate D (Parking Lot #19/AO Building parking lot) AED is available:  Volleyball Athletic Training Room  Stadium Command Center – wall next to lobby  Gate 1 Welcome Center – inside glass vestibule 13 Goodman Softball Diamond and Goodman Softball Training Complex    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Indoor Training Center East Wall 262-4222 Goodman Training Room 265-0699 Maintenance Office Press Box Direct someone to meet EMS Address: 1010 Highland Ave; 53705 Entrance: Direct someone to meet EMS at gated entrance in Lot 82 off of Highland Ave, west side of Nielsen Tennis Center AED is available:  Softball Indoor Training Center East Wall  Press box  Athletic Training Room Kellner Hall    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Welcome Center Lobby Direct someone to meet EMS Address: 1440 Monroe St; 53711 Entrance: Main entrance through Lot 18 AED is available:  Gate 1 Welcome Center Lobby  Level 3 Hallway  Level 5 Lobby 14 Kohl Center Arena  The Kohl Center Arena events are controlled under the Arena Control Center.  The Arena Control Center is located in The Kohl Center, 601 West Dayton St., 53715; Utilize East Campus Mall Drive to enter Loading Dock/Arena Control Center area.  Arena Control Center is open from 5:30am to 2:00am on weekdays and 7am to midnight on weekends. This is subject to change with the Kohl Center event schedule.  Telephone number: 608-265-4704.  All emergency situations involving participants will be handled and directed by Athletic Training Staff and/or Physician Staff on the courts or ice rink  All athletic related extraction will take place as stated in the Emergency Plan  All other Kohl Center emergencies will be handled through Event Management and the Arena Control Center. Kohl Center-Main Floor/Athletic Training Room/Weight Room/Locker Rooms    Assess situation and provide necessary emergency care Call 911 Radio Arena Control – Arena Control will call 911 Phone: Arena Control 265-4704 Athletic Training Room 265-5698 Cell phone Direct someone to meet EMS at Arena Control Address: 105 East Campus Mall; 53715 Entrance: Arena Control AED is available:  Outside Arena Control office  Gates A, B, and C  Mezzanine Elevator Lobby  Coaches Offices Lobby 15 Kohl Center-Nicholas Johnson Pavilion Gym    Assess situation and provide necessary emergency care Call 911 Radio Arena Control – Arena Control will call 911 Cell phone to call 911 – then notify Arena Control that EMS was called Phone Arena Control 265-4704 South Wall in Gym 265-3566 Cell Phone Direct someone to meet EMS at Arena Control Address: 105 East Campus Mall; 53715 Entrance: Arena Control AED is available:  Pavilion gym wall near main entrance from Gate B ticket lobby  Outside Arena Control office  Gate B  Mezzanine Elevator Lobby  Coaches Offices Lobby LaBahn Arena Complex    Assess situation and provide necessary emergency care Call 911 Radio Arena Control – Arena Control will call 911 Cell phone to call 911 – then notify Arena Control that EMS was called Phone: Arena Control 265-4704 Athletic training room 265-6667 Direct someone to meet EMS at East Campus Mall, West Gate of LaBahn Address: 105 East Campus Mall; 53715 Entrance: Ice surface: West Gate of LaBahn or Zamboni/ Service Garage, - located off the south side of the facility off loading dock 2nd floor: Direct through concourse to elevator to 2 nd floor AED is available:  North Concourse, middle of north wall between the West and East Gate  Hockey Athletic Training Room 16 McClain Facility-Athletic Training Room/Locker Rooms/Weight Room/Indoor Turf    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone McClain Training Room 262-3630 McClain Weight Room 262-9535 Direct someone to meet EMS at Gate 3 Camp Randall Entrance. Use Knox box to direct Stadium Command to keep gates open for EMS. Address: 1475 Engineering Drive; 53711 Entrance: Double Doors leading to ramp entrance in McClain Center AED is available:  South wall near the ramp entrance to the Shell  Performance Lab in Mueller Sports Medicine Center  Hall of Champions Welcome Desk McClimon Outdoor Track &Field/Soccer Complex    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Track Shed 262-3256 Direct someone to meet EMS Address: 700 Walnut St; 53706 Entrance: Main entrance off Walnut St. AED is available:  Pressbox 17 Natatorium Athletic Training Room/Pool/Diving Well/Upstairs Gyms     Assess situation and provide necessary emergency care Call 911 Contact front desk to notify of situation/call EMS 262-3742 Phone: Cell Phone Aquatics Director’s Office 263-6421 Direct someone to meet EMS at main entry door Address: 2000 Observatory Dr; 53706 Entrance: Main Entrance off Observatory Dr. AED is available:  Pool deck  Main Office  Gym 1-4 Hallway  Gym 5 Hallway Nielsen Tennis Facility    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Front Desk 262-0410 Direct someone to meet EMS Address: 1000 Highland Dr; 53705 Entrance: Front Entrance of Nielsen (if athlete is indoors) Rear Entrance of Nielsen (if athlete is outdoors) accessed from the maintenance road through Lot 82 off of Highland Ave. Gate is on the west side of the courts AED is available:  Nielsen Reservation Desk  Nielsen Indoor Courts  Goodman Softball Training Center  Goodman Athletic Training Room  Goodman Press Box 18 Porter Boat House    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Boathouse Phone 890-0359 Direct someone to meet EMS Address: 680 Babcock Dr; 53706 Entrance: Main entrance on Babcock Dr. AED is available:  Main (2nd) floor – inside wave tank entrance doors  3rd floor lobby – outside erg room SERF – Pool    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Swim storage room (between locker room and pool) 262-8245 Main Office Area Direct someone to meet EMS Address: 715 W. Dayton St; 53703 Entrance: Front Entrance off Dayton St. AED is available:  Cashier’s Office  Pool deck  Cardio Room  Weight Room  Gyms 1 & 2 19 Thomas Zimmer Championship Cross Country Course (University Ridge Cross Country Course)    Assess situation and provide necessary emergency care Call 911 Contact Club House 845-7700 Phone:  Cell Phone Club House Maintenance Shop Direct someone to meet EMS in lower parking lot (across the main drive) Address: 9002 Country Trunk PD, Verona, WI Entrance: University Ridge main entrance off PD AED is available:  Golf Training Center lobby entrance  Maintenance Shed  Clubhouse Pro Shop University Bay Fields    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Waisman Center front desk (north side of building) Nielsen Tennis Facility front desk Direct someone to meet EMS Address: University Bay Fields on Highland Dr Entrance: Off Highland Dr. (Lot #82) AED is available:  Nielsen Tennis Center Reservation Desk  Goodman Indoor Training Center  Goodman Athletic Training Room  Goodman Press box 20 263-1656 262-0410 University Ridge Golf Course/Indoor Training Center    Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Main Office 845-7700 Direct someone to meet EMS in a golf cart at URidge entrance at Highway PD or at entrance to O.J. Noer Turfgrass Research facility entrance (Holes 4,5,6,7 only) to guide to injured individual Address:  University Ridge: 9002 Country Trunk PD, Verona University O.J. Noer Turfgrass Research Facility: 2502 County Hwy M, Verona Entrance: Off PD of M, depending on location of emergency Contact Club House to provide specific location including hole number, tee, fairway, or green and meet EMS on golf cart at entry AED is available:  Training Center lobby entrance  Maintenance Shed  Clubhouse Pro Shop Eagle’s Nest Ice Arena  Assess situation and provide necessary emergency care  Call 911  Telephone: - Cell phone - Main office: 845-7465  Direct someone to meet EMS  Address: - 103 Lincoln, Verona  Entrance: - Main entrance facing east towards parking lots 21 SOC-covered events (as designated by athletic administration policies) Camp Randall Stadium  All emergencies should be directed immediately to 911 and all extrication strategies will be handled by SOC.  If possible, contact security personnel, per mar, or other nearby official to help control the scene and help with meeting EMS.  AEDs are located in the following areas:  East 6th , 7th , and 8th Levels in Staircase 3  Football Office  West 7th, 8th, and 9th levels in the elevator lobby  Gate 1 Welcome Center Lobby (upon opening Jan 2014)  Fetzer Center (upon opening Jan 2014) Main Turf Football Games  All emergency situations involving participants will be handled and directed by the Athletic Training Staff and Physician Staff on field. Communication with SOC will be handled by a physician on the field.  All extrication will be through the southwest corner of the stadium and through the AO Building lot.  All other stadium emergencies will be handled through SOC. Other events  All events that involve athlete participation will be handled by the Athletic Training Staff and Physician Staff on field.  All other events will be controlled by SOC and designated personnel. Kellner Hall  All emergencies should be directed immediately to 911 and all extrication strategies will be handled by SOC.  If possible, contact security personnel, per mar, or other nearby official to help control the scene and help with meeting EMS.  AED is available:  Gate 1 Welcome Center Lobby  Level 3 Hallway  Level 5 Lobby 22 Field House     Assess situation and provide necessary emergency care Call 911 Phone: Cell Phone Training Room Office 263-6748 Volleyball Team Locker Room 263-6944 Coordinate with SOC Direct someone to meet EMS Address: 25 North Breese Terrace; 53711 Entrance: Gate D (Parking Lot #19/AO Building parking lot) AED is available:  Volleyball Athletic Training Room  Stadium Command Center – wall next to lobby  Gate 1 Welcome Center – inside glass vestibule McClain Center  Assess situation and provide necessary emergency care  Call 911  Coordinate with SOC Camp Randall Memorial Shell  Assess situation and provide necessary emergency care  Call 911  Coordinate with SOC North Practice Field  Assess situation and provide necessary emergency care  Call 911  Coordinate with SOC 23 Emergency Care and First Aid Approaching an Unconscious Person To find out if a victim is unconscious, ask the victim if he or she is OK. If you know the person, use his or her name. Speak loudly. If the victim does not respond to you, assume he or she is unconscious. Emergency Action  Call 911 immediately  If certified in CPR, give appropriate care Airway Difficulties The following are two of many airway difficulties one might encounter. Asthma: A condition that narrows the air passages and makes breathing difficult. It may be triggered by an allergic reaction to pollen, food, medications, bites or stings, or by physical or emotional stress. A typical signal of asthma is wheezing when the person breathes out. A person’s chest may look larger than normal because air becomes trapped in the lungs. Normally, asthma is controlled with medication. Medications open the airway and make breathing easier. Choking: A conscious person who is choking has the airway blocked by food or an object. The airway may be partially or completely blocked. If the choking person is coughing forcefully, let them try to cough up the object. 24 Signs and Symptoms  Coughing  Wheezing or high pitched sound with breathing  Unable to get a breath in  Bluish skin/lips  Hands at throat to signify choking  Chest pain, hands and feet tingling Emergency Action  Call 911  If certified in CPR, give appropriate care  If victim is a know asthmatic, use asthma medications prescribed to the athlete Cardiac (Heart) Difficulties The major sign of a cardiac emergency is pain in the chest that does not go away. The pain can be anything from discomfort to an unbearable crushing sensation in the chest. Pain may spread from the chest to the left shoulder, jaw, or back. It is usually not relieved by changing position, or taking medication. Any chest pain that is severe, lasts longer than 10 minutes, or persists even during rest requires medical care at once. Signs and Symptoms  Pressure, squeezing, tightness, aching, or heaviness in the chest  Difficulty breathing  Pale or bluish skin color  Becoming confused, faint, drowsy, or unconscious Emergency Action  Call 911  If you are certified in CPR, give appropriate care until EMS arrives 25 Circulatory/Bleeding Difficulties External Bleeding Signs and Symptoms  Heavy, steady, or spurting blood Emergency Action  Call 911  If you are certified in first aid, give appropriate care until EMS arrives  Light bleeding  If you are certified in first aid, give appropriate care  Please refer athlete to staff athletic trainer and/or physician Internal Bleeding Signs and Symptoms  Tender, swollen, bruised, or hard areas of the body such as the stomach  Rapid, weak pulse  Cool or moist skin  Pale or bluish skin  Vomiting or coughing up blood  Excessive thirst  Becoming confused, faint, drowsy, or unconscious Emergency Action  Call 911  Position the athlete comfortably  If you are trained in CPR and first aid, give appropriate care 26 Shock Shock occurs when there is a diminished amount of blood available to the circulatory system due to dilated blood vessels and disruption of osmotic fluid balance. Shock is a possibility in any injury, but specifically with severe bleeding, fractures, and internal injuries and allergic reactions. Signs and Symptoms  Symptoms may come rapidly or have delayed onset  Pale, cool, moist skin  Eyes – staring, not engaging, dilated  Rapid breathing rate – shallow breaths  Rapid pulse – decreased blood pressure  Progressive restlessness or irritability – altered consciousness  Difficulty breathing due to swollen airway Emergency Action  Call 911  If you are certified in First Aid, give appropriate care  If shock is the result of a known allergic reaction, assist in administering the appropriate prescription medication Traumatic Neurological Problems Possible Signs and Symptoms  Dizziness  Numbness  Absence of sensation and movement in the extremities  Altered level of consciousness  Localized neck pain  Unwilling to move because of neck pain  Altered vital signs  Extreme headache 27 Emergency Action  Call 911  If certified in First Aid or CPR, give appropriate care Heat Illness Heat Cramps Signs and Symptoms  Muscle spasm – usually in legs or abdomen Emergency Action  Move athlete to a cool place to rest  Give cool water to drink  Lightly stretch the muscle – gentle massage is OK  NO salt tablets or salt water Heat Exhaustion Signs and Symptoms  Skin – cool, moist, pale, or flushed  Headache  Nausea  Dizziness  Weakness  Exhaustion Emergency Action  Get the athlete out of the heat  Loosen tight clothing  Remove perspiration soaked clothing  Apply cool, wet cloths to the skin  Fan the athlete  If conscious, give cool water to drink (4 oz/15 min)  Ice packs on wrists, ankles, groins, and armpits  Call 911 if athlete refuses water, vomits, or starts to lose consciousness  If certified in CPR, give appropriate care 28 Heat Stroke Signs and Symptoms  Skin – red, hot, dry  Changes in consciousness  Rapid, weak pulse  Rapid, shallow breathing Emergency Action  Call 911  Treat according to principles above for heat exhaustion  If certified in CPR, give appropriate care Cold Illness Frostbite Signs and Symptoms  Lack of feeling in affected area  Skin appears waxy  Area cold to the touch  Area may be discolored (flushed, white, yellow, or blue) Emergency Action  Handle the affected area gently  Never rub the affected area  Warm area gently by soaking in water less than 105°F  Keep the frostbitten area in water until skin becomes red and feels warm  Loosely bandage the area with a dry, sterile dressing  Seek medical attention by a physician as soon as possible Hypothermia Signs and Symptoms  Shivering  Numbness  Glassy stare  Change in personality  Slow, irregular pulse  Loss of consciousness 29 Emergency Action  Call 911  If certified in CPR, give appropriate care  If able, take patient to a warm place  Remove wet clothes  Warm with blankets and dry clothes  Warm liquid to drink  Do not warm body/area too quickly  Hot water bottles/zip lock bags (wrapped in towels) in armpits and neck Sudden Injury or Illness If you are certified in First Aid/CPR, give appropriate care then notify staff athletic trainer for all situations. If the patient:  Has an obvious visible deformity, encourage them to stay calm. Call 911. If certified in First Aid, give appropriate care  Vomiting – Place them on their side  Fainting – Position him or her on their back and elevate the legs 8-10 inches, if you do not suspect a head or back injury  Has a seizure – Do not hold or restrain the person or place anything between the patient’s teeth. Remove any nearby objects that might cause injury. Cushion the patient’s head using folded clothing or a small pillow  Known diabetic in a diabetic emergency – give the patient some form of sugar. If patient is unconscious, call 911. If certified in CPR, give appropriate care. 30 Know Who to Call Athletic Training Facilities McClain 262-3630 Field House 263-6748 Goodman Diamond 265-0698 Kohl Center 265-4285 Nicholas Pavilion 257-5916 Natatorium Pool 263-2461 SERF 262-8245 Coliseum 263-4350 LaBahn 265-6772 Other Facilities Nielsen Tennis Center 262-0410 Porter Boathouse 890-0359 Natatorium 262-3742 SERF 262-4757 Shell 263-6566 McClimon Track 262-3256 31 Licensed Staff Athletic Trainers Name Cell Phone Stefanie Arndt 608-443-8989 Tricia DeSouza 608-219-8134 Kyle Gibson 608-301-7672 Chuck Hart 608-225-6829 Dennis Helwig 608-576-9550 Andy Hrodey 608-225-6824 Gary Johnson 608-225-0302 Michael Moll 608-225-6825 Brian Lund 608-345-3272 Ashley Parr 608-225-1653 Michita (Mich) Toda 608-225-6826 Enrique (Henry) Perez-Guerra 608-225-6823 Ashley Pyne 608-514-5222 Jen Sanfilippo 608-219-2550 Kristy Walker 608-225-6820 Graduate Assistant/Intern Athletic Trainers Nora Gilman 608-224-9007 Abby Johnson 608-224-9949 Alyson Kelsey 608-260-5536 Tony Pennuto 608-224-9620 32 Sport Coverage Sport Athletic Trainer(s) Physician(PCP/ Ortho) Event Manager Basketball (M) Perez-Guerra Bernhardt/Dunn Jones Basketball (W) Arndt Carr/Scerpella Pietrowiak Crew (M) DeSouza/A. Johnson Carr/Orwin/ M. Wilson Burgess Crew (W) DeSouza/A. Johnson Bernhardt/Orwin/ M. Wilson Burgess Cross Country (M&W) Hart/Kelsey Bernhardt/Orwin Pietrowiak Football Moll/Lund/ Gibson J. Wilson/Baer/M. Wilson/J. Johnson Nelson/Burgess/ Jones Golf (M & W) Sanfilippo Landry/Orwin/ M. Wilson Nelson/Pietrowiak Ice Hockey (M) Hrodey Landry/Orwin Bee Ice Hockey (W) Helwig Brooks/Orwin Burgess Soccer (M) Toda/Pennuto Brooks/Dunn Burgess Soccer (W) Toda Carr/Dunn Pietrowiak Softball Parr Landry/Scerpella Bee Spirit Squads Arndt/Hrodey Landry/Baer/M. Wilson Swim/Dive (M&W) PerezGuerra/Gilman Landry/Orwin Burgess/Pietrowiak Tennis (M&W) Parr/Post Carr/Orwin/ Spellman Bee Track (M & W) Hart/Kelsey/Wa lker Bernhardt/Orwin Pietrowiak Volleyball Walker Bernhardt/Orwin Bee Wrestling G. Johnson J. Wilson/M. Wilson/Baer Burgess 33 Acknowledgements The following text books and administrative plan have played a very important role in developing this manual: 1. Community First Aid and Safety; American Red Cross 2. Modern Principles of Athletic Training; Daniel D. Arnheim 3. Sports Medicine Quick Reference Manual for Athletic Trainers; David J. Burnett 4. Camp Randall Emergency Plan 34 Appendix 2 onIsconsm Concussion Information BADGER for Student-Athletes and Family . . SPORTS MEDICINE What is a Concussion? A concussion is an injury to the brain generally caused by a blow to the head. This injury causes the brain not to function normally for a period of time. Concussions may be referred to as mild traumatic brain injuries and get better with time. However, occasionally there can be a more signi?cant problem, and it is important that the from a concussion be monitored. When you suffer this injury, you may have problems with concentration and memory, notice an inability to focus, feel fatigued, have a headache or feel nauseated. Bright lights and loud noises may bother you. You may feel irritable or have other What should I watch for? After evaluation by your team physician or athletic trainer, it may be determined that you are safe to go home. Otherwise, you may be taken to the hospital. If you are sent home, you should not be left alone. A responsible adult should accompany you. from your concussion may persist when you are sent home but should not worsen, nor should new develop. You should watch for such things as: 1. Increasing headache. Increasing nausea or vomiting. Increasing confusion. Unusual sleepiness or dif?culty being awakened. Trouble using your arms or legs Garbled speech. 7. Convulsions or seizure. snowmen: If you notice any of these problems or have any other problem that appears worse as compared to how you felt at the time you left the athletic training room, immediately call the physicians or athletic trainers. In an emergency, have someone transport you to the hospital. Is it okay to go to sleep? Concussion many times makes an individual feel drowsy cr tired. As long as you are not getting worse, it is all right for you to sleep. We do want the responsible adult to be at home with you in case any problems arise. May I take something for pain? Do not take any medication unless your team physician or athletic trainer has told you to do so. Normally, we do not advise anything stronger than Tylenol (acetaminophen) or an anti-in?ammatory (ibuprofen, Motrin, naproxen, or Aleve). Avoid the use of aspirin. We also ask that you not consume any alcohol and avoid caffeine and any other stimulants. If you are taking any supplements, we would suggest that you discontinue the use of them as well. The team physician will determine when you can restart medications and supplements. May I eat after the gameyou are hungry. Remember, some players do have a sense of nausea and fatigue, and often ?nd that their appetite is depressed immediately after concussion. Do not force yourself to eat. Do I need a CT scan or MRI examination? If the team physicians have determined that you are able to go home after the game or practice, these types of diagnostic tests are not necessary. If you are sent to the hospital with a more serious injury, a CT scan or MRI examination is likely. If your linger for several days after a concussion, CT scan or examination may be a consideration. How long will I be observed? You are to report to the athletic training room the morning after your concussion. You will be assessed by the team physicians or athletic trainers. You will have your monitored. Return to play decisions vary by individual, and will be based on physical exam and return to baseline on a neurocognitive test. Telephone Numbers: Athletic Trainers: Team Physicians You are to report to the athletic training room on: Day Time: Appendix 3 WISCONSIN umvaasnv Physician to Comp?e (student name) was seen on (date) and diagnosed with a Concussion as a result of an injury suffered on (date). Helshe is currently under the care of University Health Services/UW Athletics for this injury. The following short-term academic accommodations are recommended: Testing: extra time to complete tests testing in a quiet environment Note taker: Allow student to obtain class notes or outlines ahead of time to aid organization and reduce multi?tasking demands. Ifthis is not possible, allow the student to obtain notes from another student or note taker. Breaks: Allow student to take breaks as needed to control levels. Extra time: Allow student to turn in assignments late. Follow-up evaluation is scheduled for (date). (Signature of provider) (Date) Appendix 4 Football practice guidelines Year-Round Football Practice Contact Guidelines Purpose: The Safety in College Football Summit (see appendix) resulted in inter-association consensus guidelines for three paramount safety issues in collegiate athletics: 1. Independent medical care in the collegiate setting; 2. Concussion diagnosis and management; and 3. Football practice contact. This document addresses year-round football practice contact. Background: Enhancing a culture of safety in collegiate sport is foundational. Football is an aggressive, rugged, contact sport,1 yet the rules clearly state that there is no place for maneuvers deliberately designed to inflict injury on another player.1 Historically, rules changes and behavior modification have reduced catastrophic injury and death. Enforcement of these rules is critical for improving player safety.2 Despite sound data on reducing catastrophic football injuries, there are limited data that provide a strong foothold for decreasing injury risk by reducing contact in football practice.3-8 Regardless of such scientific shortcomings, there is a growing consensus that we must analyze existing data in a consensus-based manner to develop guidelines that promote safety. “Safe” football means “good” football. NCAA regulations currently do not address inseason, full-contact practices. The Ivy League and Pac-12 Conference have limited inseason, full-contact practices to two per week and have established policies for full-contact practices in spring and preseason practices through their Football Practice Standards and Football Practice Policy, respectively. Neither address full-pad practice that does not involve live contact practice, as defined below. Both conferences cite safety concerns as the primary rationale for reducing full-contact practices; neither conference has published or announced data analysis based on their new policies. In keeping with the intent of both conferences and other football organizations, the rationale for defining and reducing live contact practice is to improve safety, including possibly decreasing student-athlete exposure for concussion and sub-concussive impacts. Reduced frequency of live contact practice may also allow even more time for teaching of proper tackling technique. The biomechanical threshold (acceleration/deceleration/rotation) at which sport-related concussion occurs is unknown. Likewise, there are no conclusive data for understanding the short- or long-term clinical impact of sub-concussive impacts. However, there are emerging data that football players are more frequently diagnosed with sport-related concussion on days with increased frequency and higher magnitude of head impact (greater than 100g linear acceleration).9-11 Traditionally, the literature addressing differing levels of contact in football practice correlated with the protective equipment (uniform) worn. This means that full-pad practice correlated with full-contact and both half-pad (shell) and helmet-only practice correlated with less contact. However, coaches, administrators and athletics health care providers who helped to shape these guidelines have noted that contact during football practice is not determined primarily by the uniform, but rather by whether the intent of practice is centered on live contact versus teaching and conditioning. There are limited data that address this issue, and such data do not differentiate whether the intent of the practice is live tackling or teaching/conditioning. Within these limitations, non-published data from a single institution reveal the following:10      The total number of non-concussive head impacts sustained in helmets-only and full-pad practices is higher than those sustained in games/scrimmages. Mild- and moderate-intensity head impacts occur at an essentially equal rate during fullpad and half-pad practices when the intent of practice is not noted. Severe-intensity head impacts are much more likely to occur during a game, followed by full-pad practices and half-pad practices. There is a 14-fold increase in concussive impacts in full-pad practices when compared to half-pad or helmets-only practices. Offensive linemen and defensive linemen experience more head impacts during both fullpad and half-pad practices relative to all other positions. The guidelines below are based on: expert consensus from the two day summit referenced above; comments and recommendations from a broad constituency of the organizations listed; and internal NCAA staff members. Importantly, the emphasis is on limiting contact, regardless of whether the student-athlete is in full-pad, half-pad, or is participating in a helmet-only practice. Equally importantly, the principles of sound and safe conditioning are an essential aspect of all practice and competition exposures. These guidelines must be differentiated from legislation. For each section below that addresses a particular part of the football calendar, any legislation for that calendar period is referenced. As these guidelines are based on consensus and limited science, they are best viewed as a “living, breathing” document that will be updated, as we have with other health and safety guidelines, based on emerging science or sound observations that result from application of these guidelines. The intent is to reduce injury risk, but we must also be attentive to unintended consequences of shifting a practice paradigm based on consensus. For example, football preseason must prepare the student-athlete for the rigors of an aggressive, contact, rugged sport. Without adequate preparation, which includes live tackling, the student-athlete could be at risk of unforeseen injury during the inseason because of inadequate preparation. We plan to reanalyze these football practice contact guidelines at least annually. Additionally, we recognize that NCAA input for these guidelines came primarily from Division I Football Bowl Subdivision schools. Although we believe the guidelines can also be utilized for football programs in all NCAA divisions, we will be more inclusive in the development of future football contact practice guidelines. Definitions: Live contact practice: Any practice that involves live tackling to the ground and/or full-speed blocking. Live contact practice may occur in full-pad or half-pad (also known as “shell,” in which the player wears shoulder pads and shorts, with or without thigh pads). Live contact does not include: (1) “thud” sessions, or (2) drills that involve “wrapping up;” in these scenarios players are not taken to the ground and contact is not aggressive in nature. Live contact practices are to be conducted in a manner consistent with existing rules that prohibit targeting to the head or neck area with the helmet, forearm, elbow, or shoulder, or the initiation of contact with the helmet. Full-pad practice: Full-pad practice may or may not involve live contact. Full-pad practices that do not involve live contact are intended to provide preparation for a game that is played in a full uniform, with an emphasis on technique and conditioning versus impact. Legislation versus guidelines: There exists relevant NCAA legislation for the following: 1. Preseason practice a. DI FBS/FCS – NCAA Bylaws 17.9.2.3 and 17.9.2.4 b. DII – NCAA Bylaws 17.9.2.2 and 17.9.2.3 c. DIII – NCAA Bylaws 17.9.2.2 and 17.9.2.3 2. In-season practice: No current NCAA legislation addresses contact during inseason practices. 3. Postseason practice: No current NCAA legislation addresses contact during postseason practices. 4. Bowl practice: No current NCAA legislation addresses contact during bowl practice. 5. Spring practice: a. DI FBS/FCS – NCAA Bylaw 17.9.6.4 b. DII – NCAA Bylaw 17.9.8 c. DIII – NCAA Bylaw 17.9.6 – not referenced to as spring practice, but allows five week period outside playing season. (5) The guidelines that follow do not represent legislation or rules. As noted in the appendix, the intent of providing consensus guidelines in year one of the inaugural Safety in College Football Summit is to provide consensus-based guidance that will be evaluated “real-time” as a “living and breathing” document that will become solidified over time through evidence-based observations and experience. Preseason practice guidelines: For days in which institutions schedule a two-a-day practice, live contact practices are only allowed in one practice. A maximum four (4) live contact practices may occur in a given week, and a maximum of 12 total may occur in preseason. Only three practices (scrimmages) would allow for live contact in greater than 50 percent of the practice schedule. Inseason practice guidelines: Inseason is defined as the period between six (6) days prior to the first regular-season game and the final regular-season game or conference championship game (for participating institutions). There may be no more than two (2) live contact practices per week. Postseason guidelines: (FCS/DII/DIII) There may be no more than two (2) live contact practices per week. Bowl practice guidelines: (FBS) There may be no more than two (2) live contact practices per week. Spring practice guidelines: Of the 15 allowable sessions that may occur during the spring practice season, eight (8) practices may involve live contact; three (3) of these live contact practices may include greater than 50 percent live contact (scrimmages). Live contact practices are limited to two (2) in a given week and may not occur on consecutive days. References: 1. NCAA Football: 2013 and 2014 Rules and Interpretations. 2. Cantu RC, Mueller FO. Brain injury-related fatalities in American football, 19451999. Neurosurgery 2003; 52:846-852. 3. McAllister TW et al. Effect of head impacts on diffusivity measures in a cohort of collegiate contact sport athletes. Neurology 2014; 82:1-7. 4. Bailes JE et al. Role of subconcussion in repetitive mild traumatic brain injury. J Neurosurg 2013: 1-11. 5. McAllister TW et al. Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes. Neurology 2012; 78:1777-1784. 6. Beckwith JG et al. Head impact exposure sustained by football players on days of diagnosed concussion. Med Sci Sports Exerc 2013; 45:737-746. 7. Talavage TM et al. Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion. J Neurotrauma 2014; 31:327-338 8. Miller JR et al. Comparison of preseason, midseason, and postseason neurocognitive scores in uninjured collegiate football players. Am J Sports Med 2007; 35:1284-1288. 9. Mihalik JP, Bell DR, Marshall SW, Guskiewicz KM. Measurement of head impacts in collegiate football players: an investigation of positional and event-type differences. Neurosurgery 2007; 61:1229-1235. 10. Trulock S, Oliaro S. Practice contact. Safety in College Football Summit. Presented January 22, 2014, Atlanta, GA. 11. Crison JJ et al. Frequency and location of head impact exposures in individual collegiate football players. J Athl Train 2010; 45:549-559. *This Inter-Association Consensus: Year-Round Football Practice Contact Guidelines, has been endorsed by:                American Academy of Neurology American College of Sports Medicine American Association of Neurological Surgeons American Football Coaches Association American Medical Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Osteopathic Academy for Sports Medicine College Athletic Trainers’ Society Congress of Neurological Surgeons Football Championship Subdivision Executive Committee National Association of Collegiate Directors of Athletics National Athletic Trainers’ Association National Football Foundation NCAA Concussion Task Force Sports Neuropsychological Society Appendix 5 Independent medical care guidelines Independent Medical Care for College Student-Athletes Guidelines Purpose: The Safety in College Football Summit (see appendix) resulted in inter-association consensus guidelines for three paramount safety issues in collegiate athletics: 1. Independent medical care in the collegiate setting; 2. Concussion diagnosis and management; and 3. Football practice contact. This document addresses independent medical care for college student-athletes in all sports. Background: Diagnosis, management, and return to play determinations for the college student-athlete are the responsibility of the institution’s athletic trainer (working under the supervision of a physician) and the team physician. Even though some have cited a potential tension between health and safety in athletics,1,2 collegiate athletics endeavor to conduct programs in a manner designed to address the physical well-being of college student-athletes (i.e., to balance health and performance).3,4 In the interest of the health and welfare of collegiate student-athletes, a studentathlete’s health care providers must have clear authority for student-athlete care. The foundational approach for independent medical care is to assume an “athlete-centered care” approach, which is similar to the more general “patient-centered care,” which refers to the delivery of health care services that are focused only on the individual patient’s needs and concerns.5 The following 10 guiding principles, listed in the Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges,5 are paraphrased below to provide an example of policies that can be adopted that help to assure independent, objective medical care for college student-athletes: 1. The physical and psychosocial welfare of the individual student-athlete should always be the highest priority of the athletic trainer and the team physician. 2. Any program that delivers athletic training services to student-athletes should always have a designated medical director. 3. Sports medicine physicians and athletic trainers should always practice in a manner that integrates the best current research evidence within the preferences and values of each student-athlete. 4. The clinical responsibilities of an athletic trainer should always be performed in a manner that is consistent with the written or verbal instructions of a physician or standing orders and clinical management protocols that have been approved by a program’s designated medical director. 5. Decisions that affect the current or future health status of a student-athlete who has an injury or illness should only be made by a properly credentialed health professional (e.g., a physician or an athletic trainer who has a physician’s authorization to make the decision). 6. In every case that a physician has granted an athletic trainer the discretion to make decisions relating to an individual student-athlete’s injury management or sports participation status, all aspects of the care process and changes in the student-athlete’s disposition should be thoroughly documented. 7. Coaches must not be allowed to impose demands that are inconsistent with guidelines and recommendations established by sports medicine and athletic training professional organizations. 8. An athletic trainer’s role delineation and employment status should be determined through a formal administrative role for a physician who provides medical direction. 9. An athletic trainer’s professional qualifications and performance evaluations must not be primarily judged by administrative personnel who lack health care expertise, particularly in the context of hiring, promotion, and termination decisions. 10. Member institutions should adopt an administrative structure for delivery of integrated sports medicine and athletic training services to minimize the potential for any conflicts of interest that could adversely affect the health and well-being of student-athletes. Team physician authority becomes the linchpin for independent medical care of student-athletes. Six preeminent sports physicians associations agree with respect to “… athletic trainers and other members of the athletic care network report to the team physician on medical issues.”6 Consensus aside, a medical-legal authority is a matter of law in 48 states that require athletic trainers to report to a physician in their medical practice. The NCAA Sports Medicine Handbook’s Guideline 1B opens with a charge to athletics and institutional leadership to “create an administrative system where athletics health care professionals – team physicians and athletic trainers – are able to make medical decisions with only the best interests of student-athletes at the forefront.”7 Multiple models exist for collegiate sports medicine. Athletic health care professionals commonly work for the athletics department, student health services, private medical practice, or a combination thereof. Irrespective of model, the answer for the college student-athlete is established independence for appointed athletics health care providers.8 Guidelines: Institutional medical line of authority should be established independently of a coach, and in the sole interest of student-athlete health and welfare. Medical line of authority should be transparent and evident in athletics departments, and organizational structure should establish collaborative interactions with the medical director and primary athletics health care providers (defined as all institutional team physicians and athletic trainers) so that the safety, excellence and wellness of student-athletes are evident in all aspects of athletics and are student-athlete centered. Institutions should, at a minimum, designate a licensed physician (M.D. or D.O.) to serve as medical director, and that medical director should oversee the medical tasks of all primary athletics health care providers. Institutions should consider a board certified physician, if available. The medical director may also serve as team physician. All athletic trainers should be directed and supervised for medical tasks by a team physician and/or the medical director. The medical director and primary athletics health care providers should be empowered with unchallengeable autonomous authority to determine medical management and return-to-play decisions of student-athletes. References: 1. Matheson GO. Maintaining professionalism in the athletic environment. Phys Sportsmed. 2001 Feb;29(2) 2. Wolverton B. (2013, September 2) Coach makes the call. The Chronicle of Higher Education. [Available online] http://chronicle.com/article/Trainers-Butt-HeadsWith/141333/ 3. NCAA Bylaw 3.2.4.17 (Div. I and Div. II; 3.2.4.16 (Div. III). 4. National Collegiate Athletic Association. (2013). 2013-14 NCAA Division I Manual. Indianapolis, IN: NCAA. 5. Courson R et al. Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges. J Athletic Training 2014; 49:128-137. 6. Herring SA, Kibler WB, Putukian M. Team Physician Consensus Statement: 2013 update. Med Sci Sports Exerc. 2013 Aug;45(8):1618-22. 7. National Collegiate Athletic Association. (2013). 2013-14 NCAA Sports Medicine Handbook. Indianapolis, IN: NCAA. 8. Delany J, Goodson P, Makeoff R, Perko A, Rawlings H [Chair]. Rawlings panel on intercollegiate athletics at the University of North Carolina at Chapel Hill. Aug 29 ‘13. [Available online] http://rawlingspanel.web.unc.edu/files/2013/09/RawlingsPanel_Intercollegiate-Athletics-at-UNC-Chapel-Hill.pdf *This Consensus Best Practice, Independent Medical Care for College Student-Athletes, has been endorsed by:            American Academy of Neurology American College of Sports Medicine American Association of Neurological Surgeons American Medical Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Osteopathic Academy for Sports Medicine College Athletic Trainers’ Society Congress of Neurological Surgeons National Athletic Trainers’ Association NCAA Concussion Task Force Sports Neuropsychological Society