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Concussion Brochure
Concussion Brochure (NFHS)
http://www.nfhs.org/core/contentmanager/uploads/Concussion_Brochure.pdf
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SUGGESTED GUIDELINES
FOR MANAGEMENT OF
HEAD TRAUMA IN SPORTS
EVEN MINOR CONCUSSIONS WITHOUT LOSS OF
CONSCIOUSNESS CAN HAVE DEVASTATING RESULTS
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INTRODUCTION
Head trauma is a common problem in sports and has the potential for
serious complications if not managed correctly. Even what appears to be
a "minor ding or bell ringer" without loss of consciousness has the real
risk of catastrophic results when an athlete is returned to action too
soon. The medical literature and lay press are reporting instances of
death from "second impact syndrome" when a
second concussion occurs before the brain has recovered from the first
one regardless of how mild both injuries seem.
At many athletic contests across the country, trained and knowledgeable
individuals are not available to make the decision to return concussed
athletes to play. Frequently, there is undo pressure from various
sources (parents, player and coach) to return a valuable athlete to
action A.S.A.P. In addition, often there is unwillingness by the
athlete who wants to play to report headaches and other findings because
the individual knows it would prevent his or her return to play.
Outlined below are some guidelines that may be helpful in establishing a
protocol at your institution. Please bear in mind that these are general
guidelines and must not be used in place of the central role that
physicians and certified athletic trainers must play in protecting the
health and safety of student-athletes.
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SIDELINE MANAGEMENT OF ACUTE HEAD
INJURY
1. Did a head injury take place?
- Based on mechanism of
injury, observation, history and unusual behavior and reactions of the
athlete, even without loss of consciousness, assume a concussion has
occurred if the head was hit.
2. Does the athlete need immediate
referral for emergency care?
- If confusion, unusual
behavior or responsiveness, deteriorating condition, LOC, or concern
about neck and spine injury exist, the athlete should be referred at
once for emergency care.
3. If no emergency is apparent, how
should the athlete be monitored?
- Every 5- 10 minutes
mental status, attention, balance, behavior, speech and memory should be
examined until stable over a few hours.
4. No athlete suspected of a head
injury should return to the same practice or contest,
even if clear in 15 minutes,
without clearance by an
appropriate medical physician.
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EXAMPLE OF SPECIFIC INSTRUMENTS BEING
USED TO DO
SIDELINE ASSESSMENT OF ATHLETES WITH CONCUSSION
Outlined below is a fairly comprehensive list of
signs, symptoms and observations
that can be utilized to determine if an athlete is "clear" of any
abnormalities that should prevent return to play. Abnormalities of
attention, processing speed, memory, balance, reaction time, and ability
to think and analyze information appear to be those areas most likely to
be involved and persist after a head injury. Several instruments such as
the Sideline Concussion Checklist (SCC) and the Sideline Assessment of
Concussion (SAC) have been developed as reasonably user-friendly methods
of monitoring an athlete on the sideline to determine whether he or she
is stable or needs immediate referral for emergency care. The
CDC has also developed a tool kit (Heads
UP: Concussion in High School Sports"),
which has been made available to all high schools, and has information
on head injuries for coaches, athletes and parents. The NFHS is proud to
be a co-sponsor of this initiative. Computerized tests that evaluate
similar domains (IMPACT, Sentinel, CRI, or ANAM) are being used by some
schools, professionals and others. Cost and availability vary. Balance
studies such as Balance Error
Scoring System (BESS) may also be
a helpful sideline tool for monitoring athletes. The NFHS will continue
to monitor developments in this research as investigators seek ways of
making these instruments more practical.
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MANAGEMENT OF HEAD INJURIES
THAT INTERRUPT RETURN TO PLAY
(SEE "SIDELINE MANAGEMENT")
Any athlete who is removed from play because of a head injury will
require medical clearance before being allowed to return to play or
practice. The second international conference on concussion held in
Prague suggests an athlete should not return to practice or competition
in sport until he or she is
asymptomatic and appears normal
for a minimum of one week.
The athlete must be able to progress through a return to play (RTP)
protocol as outlined below without any return of signs or symptoms
before actually competing. These recommendations have been based on the
awareness of the increased vulnerability of the brain to concussions
occurring close together and of the cumulative effects of multiple
concussions on long-term brain function. Research is now revealing some
fairly objective and relatively easy-to-use tests which appear to
identify subtle residual deficits that may not be obvious from the
traditional evaluation. These
identifiable abnormalities frequently persist after the obvious signs of
concussion are gone and appear to
have relevance to whether an athlete can return to play in relative
safety. The significance of these deficits is
still under study
and the evaluation instruments represent a work in progress. They may be
helpful to the professional determining return to play in conjunction
with consideration of the severity
and nature of the injury;
the interval since the last head
injury; the
duration of symptoms
for clearing; and the level of
play.
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A. ATHLETE MUST REMAIN ASYMPTOMATIC TO
PROGRESS TO THE NEXT LEVEL.
B. IF SYMPTOMS RECUR, ATHLETE MUST
RETURN TO PREVIOUS LEVEL.
C. MEDICAL CHECK SHOULD OCCUR BEFORE
CONTACT.
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SIDELINE DECISION-MAKING
1. No athlete should return to play (RTP) after head injury even if
clear in 15 minutes without medical clearance.
2. Any athlete removed from play for a head injury must have appropriate
medical clearance before practice or competition may resume.
3. Close observation of athlete should
continue for a few hours.
4. After medical clearance, RTP should follow a stepwise protocol with
provisions for delayed RTP based on return of any signs or symptoms.
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MEDICAL CLEARANCE RTP PROTOCOL
1. No exertional activity until asymptomatic.
2. When the athlete appears clear, begin low-impact activity such as
walking, stationary bike, etc.
3. Initiate aerobic activity fundamental to specific sport such as
skating, running, etc.
4. Begin non-contact skill drills specific to sport such as dribbling,
ground balls, batting, etc.
5. Then full contact in practice setting.
6. If athlete remains without symptoms, he or she may return to play.
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SIGNS OF CONCUSSION
Concussions can appear in many different ways. Listed below are some of
the signs and symptoms frequently associated with minor head trauma
(e.g., "ding", "bell rung", dazed or concussion). Most symptoms, signs
and abnormalities after a head injury fall into the
four categories
listed below. A coach or other person who knows the athlete well can
usually detect these problems by observing the athlete and/or by
asking a few relevant questions
to the athlete, referee or a teammate who was on the field or court at
the time of the head injury. Below are some suggested observations and
questions a non-medical professional like a
coach or school administrator
can use to help determine whether an athlete has suffered a concussion
and how urgently he or she should be sent for medical care following a
head injury.
1. PROBLEMS IN BRAIN FUNCTION:
a. Confused state
– Dazed look, vacant stare, confusion
about what happened or is happening.
b. Memory problems
– Can't remember assignment on play,
opponent, score of game, or period of the game. Can't remember how or
with whom he or she traveled to the game, what he or she was wearing,
what was eaten for breakfast, etc.
c. Symptoms reported by athlete
– Headache, nausea or vomiting, blurred
or double vision, oversensitivity to sound, light or touch, ringing in
ears, feeling foggy or groggy.
d. Lack of Sustained Attention
– Difficulty sustaining focus adequately to complete a task or a
coherent
thought or conversation.
2. SPEED OF BRAIN FUNCTION:
Slow response to questions, slow slurred
speech, incoherent speech, slow body movements, slow reaction time.
3. UNUSUAL BEHAVIORS:
Behaving in a combative, aggressive or
very silly manner, or just atypical for the individual. Repeatedly
asking the same question over and over. Restless and irritable behavior
with constant motion and attempts to return to play or leave. Reactions
that seem out of proportion and inappropriate. Changing position
frequently and having trouble resting or "finding a comfortable
position." These can be manifestations of post-head trauma difficulties.
4. PROBLEMS WITH BALANCE AND
COORDINATION:
Dizzy, slow clumsy movements,
acting like a "drunk," inability to walk a straight line or balance on
one foot with eyes closed.
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CHECK FOR CONCUSSION
In addition to observation and
direct questioning
for symptoms, asking the athlete
specifics about the contest or the
injury, having the athlete repeat
a series of numbers forward and
backward, or recite the months of
the year in reverse order may help
identify problems in brain function.
Checking coordination
and agility such as touching a finger to the nose and to another object,
balancing on one foot, and walking heel-to-toe on a straight line can be
helpful in analyzing the athlete's state of coordination.
Any athlete being returned to play because he or she seemed not to have
actually had a head injury should be
assessed after exercise,
such as push-ups, sit-ups, sprints and deep knee bends, before
concluding a return to play would be appropriate.
Increasing evidence is suggesting that initial signs and symptoms,
including loss of consciousness and amnesia,
may not be very predictive
of the true severity
of the injury and the prognosis or outcome. More importance is being
assigned to the duration of such symptoms and this, along with data
showing symptoms may worsen some time after the head injury, has shifted
focus to continued monitoring of the athlete. This is one reason why
these guidelines no longer include an option to return an athlete to
play even if clear in 15 minutes.
PREVENTION
Although all concussions cannot be
prevented, many can be altered or avoided. Proper coaching techniques,
good officiating of the existing rules, and use of properly fitted
equipment can minimize the risk of head injury. Although the NFHS
advocates the use of mouthguards in nearly all sports, there is no
convincing scientific data that their use will prevent concussions.
Prepared by Vito Perriello, M.D.,
member of the NFHS Sports
Medicine Advisory Committee. 2005
National Federation of State High School Associations
PO Box 690 | Indianapolis, Indiana 46206
Phone: 317-972-6900 | Fax: 317.822.5700
www.nfhs.org |
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