Vanderbilt University Athletics Mild Traumatic Brain Injury (mtbi)/concussion Evaluation Guidelines

Transcription

1 Vanderbilt University Athletics Mild Traumatic Brain Injury (mtbi)/cncussin Evaluatin Guidelines The fllwing guidelines have been develped t aid Vanderbilt Sprts Medicine staff in evaluatin and identificatin f the student-athlete wh has sustained a cncussin/mtbi. The prgressin f a student-athlete with a diagnsed cncussin/mtbi will include cgnitive and physical exertin in a stepwise prcess fr safe return t participatin. These guidelines are a minimum standard f care, but allw the Sprts medicine staff t manage cncussins individually as the situatin warrants (McCrry et al 2009). Baseline Testing and Prcedures Graded Symptm Checklist (GSC)(Piland 2003) [Appendix A] ImPACT Baseline Neurcgnitive Testing [Appendix B] Balance Errr Scring System (BESS)(Riemann & Guskiewicz 2000) [Appendix C] NCAA Educatinal Material fr Student-Athletes [Appendix D] NCAA Educatinal Material Caches [Appendix E] Cncussin Acknwledgement and Signature Frm [Appendix F] Time f Injury Initial Evaluatin-Cncussin Injury Reprt Frm [Appendix G] Vitals (pulse, BP) Cranial nerve assessment Strength Sensatin Graded Symptm Checklist (GSC) Balance Errr Scring System (BESS) Educate the student-athlete n the imprtance f cgnitive rest; which entails limiting r remving cell phne use/texting, vide games/televisin, including academic wrk and classes (d Hemecurt 2011; Kissick & Jhnstn 2005; Dlan et al 2012). Recmmendatins If the student-athlete is diagnsed with a cncussin, the student-athlete will be withheld frm cmpetitin r practice and nt return t activity fr the remainder f that day (NCAA Executive Cmmittee Plicy April 2010). If the student-athlete is asymptmatic under nrmal cnditins and fllwing functinal exertin testing the fllwing day, then the student-athlete shuld be re-evaluated fr return t participatin. If the student-athlete is still symptmatic under nrmal cnditins and/r fllwing functinal exertin testing, then the student-athlete shuld nt return t participatin until cleared thrugh the subsequent utlined prcedures. Cgnitive rest is an essential cmpnent f the recvery prcess. Academic accmmdatins may be necessary as part f the treatment plan. Pst-Cncussin Fllw-Up (within 24 hurs pst-injury) Medical assessment with Team Physician r the physician s designee Graded Symptm Checklist (GSC) Balance Errr Scring System (BESS) Determinatin f the student-athlete s ability t attend class wuld be cntingent n being asymptmatic at rest fr 24 hurs. Ntify Academics advisr if accmmdatins are warranted. mtbi/cncussin Guidelines Page 1 f 26

2 Phase 0 - Cgnitive Exertin Student athletes that have an increase in symptms pst class will be held frm academic requirements until they are asymptmatic. Once the student-athlete is asymptmatic fr 24 hurs they can return t class. Stepwise return t sprt prgressin will prceed t Phase 1 if student-athlete is asymptmatic at the current level. If any pst cncussive symptms ccur, reassess the fllwing day. Phase 1 - Aerbic Exertin Graded Symptm Checklist (GSC) Functinal exertin test Bike percent f predicted maximum heart rate(pmhr) Rest fr 15 minutes Mnitr symptms Incremental Treadmill Test 20 minutes (Leddy et al 2010) [Appendix H] Stepwise return t sprt prgressin will prceed t Phase 2 if student-athlete is asymptmatic at the current level. If any pst cncussive symptms ccur, reassess the fllwing day and repeat the previus phase. Phase 2 - Functinal Testing Prgressin Mnitr symptms Initial Functinal Exertin Scissr step/quick step Jgs lateral shuffle Backpedal Sprints Advanced Functinal Exertin Sit-ups Burpees Push-ups Sprints Sprints w/ intermittent push-ups Stepwise return t sprt prgressin will prceed t Phase 3 if student-athlete is asymptmatic at the current level. If any pst cncussive symptms ccur, reassess the fllwing day and repeat the previus phase. ** Student athlete may begin limited lifting if asymptmatic depending n the sprt requirements mtbi/cncussin Guidelines Page 2 f 26

3 Phase 3 - Sprt Specific Exertin ImPACT fllw-up test reviewed by team physician Mnitr symptms Initial Mderate aerbic exercises specific t sprt Duratin apprximately minutes w/5 minutes rest pst sessin Mnitr symptms Prgressin depends n student-athlete remaining asymptmatic Intermediate Prgressively difficult aerbic exercises specific t sprt Duratin apprximately minutes w/5 minutes rest pst sessin Mnitr symptms Prgressin depends n student-athlete remaining asymptmatic Advanced Demanding aerbic exercises specific t sprt Duratin apprximately minutes w/5 minutes rest pst sessin Mnitr symptms Prgressin depends n student-athlete remaining asymptmatic Sprt specific exertin guidelines Appendix I - Basketball Appendix O - Swimming Appendix J - Baseball Appendix P - Track/Field/Distance Appendix K - Sccer Appendix Q - Ftball: OL/DL Appendix L - Lacrsse Appendix R - Ftball: RB/TE/LB Appendix M - Glf/Bwling Appendix S - Ftball: WR/DB Appendix N - Tennis Appendix T - Ftball: QB/Specialist Stepwise return t sprt prgressin will prceed t Phase 4 if student-athlete is asymptmatic at the current level. If any pst cncussive symptms ccur, reassess the fllwing day and repeat the previus phase. Phase 4 - Return t Limited Drills and Nn-cntact Practice Mnitr symptms Nn-cntact training drills dependent upn sprt Stepwise return t sprt prgressin will prceed t Phase 5 if student-athlete is asymptmatic at the current level. If any pst cncussive symptms ccur, reassess the fllwing day and repeat the previus phase. Cnsult Team physician fr full clearance Phase 5 - Return t Full Participatin withut restrictins Graded Symptm Checklist (GSC) Full participatin withut restrictin mtbi/cncussin Guidelines Page 3 f 26

4 References d'hemecurt P. Subacute symptms f sprts-related cncusin: utpatient management and return t play. Clin Sprts Med. 2011; 30: Dlan A, Day D, Maerlender A, Gfrth M, Brlinsn P. A review f return t play issues and sprts-related cncussin. Ann Bimed Eng. 2012; 40(1): Jhnstn K, Blm G, Ramsay J, Kissick J, Mntgmery D, Fley D, Chen J, Ptit A. Current cncepts in cncussin rehabilitatin. Curr Sprts Med Rep. 2004;3: Kissick J and Jhnstn K. Return t play after cncussin. Clin J Sprt Med. 2005; 15(6): Leddy J, Baker J, Kzlwski K, Bissn L, Willer B. Reliability f a graded exercise test fr assessing recvery frm cncussin. Clin J Sprt Med. 2010; 21(2): McCrry P, Meeuwisse W, Jhnstn K, Dvrak J, Aubry M, Mlly M, Cantu R. Cncensus statement n cncussin in sprt - the 3rd internatinal cnference n cncussin in sprt held in Zurich, Nvember Br J Sprts Med. 2009; 43(Supp I):i76-i84. Piland SG, Rbert WM, Ferrara M, Petersn C. Evidence fr the factrial and cnstruct validity f a self-reprt cncussin symptms scale. J Athl Train. 2003;38(2): Riemann BL, Guskiewicz KM. Effects f mild head injury n pstural stability as measured thrugh clinical balance testing. J Athl Train. 2000;35(1):19-25 mtbi/cncussin Guidelines Page 4 f 26

5 APPENDIX A Graded Symptms Checklist (GSC) Address each symptm based n hw yu have felt n an average 24 hur perid during the last 7 days. Rate yur symptms n a scale f 0 t 6. Zer (0) means yu have never experienced the symptm, 1 means yu experienced the symptm briefly, 3 means the symptm has been present fr abut half f the preceding 24-hur perid, and 6 means the symptm has been cntinuus thrugh preceding 24 hur perid(piland et al 2003). Symptm Checklist: Symptm Nne Mild Mderate Severe Headache Nausea Vmiting Balance prblems/dizziness Fatigue Truble sleeping Sleeping mre than usual Drwsiness Sensitivity t light Blurred Visin Sensitivity t nise Sadness Irritability Numbness/Tingling Feeling like in a fg Difficulty cncentrating Difficulty remembering Neck pain mtbi/cncussin Guidelines Page 5 f 26

6 APPENDIX B Balance Errr Scring System (BESS) Significantly higher pstural instability in Mild Head Injury subjects revealed thrugh the clinical test battery with 3 stances n fam surface elicited significant differences thrugh day 3 pst injury, and may be a useful clinical prcedure t assist in return t play decisins (Riemann & Guskiewicz 2000). Athlete Psitin Shes ff Rll pant legs abve ankles Feet narrwly tgether Hands n the iliac crests Eyes clsed Test Prcedures / Patient Instructins Test begins when the patient clses his/her eyes Patient is instructed t make any necessary adjustments in the event that they lst their balance and t return t the testing psitin as quickly as pssible Test #1- Duble Leg Stance (feet tgether) Test #2- Single Leg Stance (nn-dminant ft; free leg shuld be bent t 90 degrees) Test #3- Tandem Stance (nn-dminant ft in the rear; weight evenly distributed) 20 secnds per test Each test is perfrmed n a firm surface and a 10-cm-thick fam/unstable surface Balance Errrs Hands lifted ff f iliac crests Opening eyes Step, stumble, r fall Mving hip int mre than 30 degrees f flexin r abductin Lifting freft r heel Remaining ut f testing psitin fr mre than five (5) secnds BESS Scring The number f balance errrs (1 pint per errr) n each f the six (6) tests are added tgether fr a ttal BESS Scre mtbi/cncussin Guidelines Page 6 f 26

7 ImPACT Cncussin Testing Instructins APPENDIX C Ntes: If using a laptp, be sure t use a muse rather than the track pad. Using track pad instead f the muse will skew the results f reactin time tests If using a laptp, make sure the laptp is plugged in and charging Make sure all ther prgrams are clsed, this includes ther internet windws that are nt part f the ImPACT website 1. Open yur web brwser and g t: 2. Click n Custmer Lgin 3. Enter yur in the sectin 4. Fr passwrd, type yur assigned passwrd frm ImPACT 5. Click n the Start New Test icn 6. In the drp dwn bx next t: Please pick the rganizatin yu wuld like the test taker t be tested under Select yur sprt 7. Click n the Launch Baseline Test tab. This is the first tab n the left. 8. Select the language t be tested in 9. Frm this pint, fllw instructins as prmpted n screen a. The first area t fill ut is the Sprt and Health Histry including: i. General infrmatin ii. Educatin iii. Sprt iv. Cncussin Histry v. Other Medical Histry b. The secnd sectin is the Current Symptms and Cnditins i. This is t be filled ut as yu feel right nw, while taking the test c. The third and final sectin is the Neurcgnitive Testing sectin i. Fllw the instructins fr each sectin within the testing mtbi/cncussin Guidelines Page 7 f 26

8 APPENDIX D mtbi/cncussin Guidelines Page 8 f 26

9 APPENDIX E mtbi/cncussin Guidelines Page 9 f 26

10 APPENDIX F Vanderbilt University Cncussin Acknwledgement Frm As a student-athlete at Vanderbilt University, I acknwledge that I have a direct respnsibility t be hnest and frthcming by reprting all injuries r illnesses t the Vanderbilt Sprts Medicine staff (athletic trainers r team physicians). I further understand and acknwledge that participatin in my sprt may result in a head injury r cncussin. The Sprts Medicine staff at Vanderbilt University has prvided me with educatinal materials regarding cncussins and I have read them. Specifically, I agree the fllwing t be true: I have read and understand the Cncussin Fact Sheet prvided t me and have been given an pprtunity t ask questins abut cncussins and anything I m nt clear abut regarding this issue. A cncussin is a brain injury, which I am respnsible fr immediately reprting t my athletic trainer r team physician. A cncussin can affect my ability t perfrm everyday activities, and affect reactin time, balance, sleep, and classrm perfrmance. If I suspect a teammate has a cncussin, I am respnsible fr reprting it t my athletic trainer r team physician. Student Athlete Printed Name Student Athlete Signature Witness Date Date mtbi/cncussin Guidelines Page 10 f 26

11 APPENDIX G APPENDIX H Balke Test - treadmill Aim: the Balke Treadmill Test was develped as a clinical test t determine peak VO2 in cardiac patients, thugh it can als be used t estimate cardivascular fitness in student-athletes. Fr the cncussin prtcl it will be used t determine if the student-athlete is able t physically exert withut symptm exacerbatin. Equipment required: treadmill, stpwatch, heart mnitr(ptinal) Recmmendatins Student-athlete is asymptmatic prir t treadmill test Test will be stpped immediately is the student-athlete has symptm exacerbatin Test will be stpped if the athlete becmes t fatigued t cntinue and the time nted Student-athlete shuld be mnitred thrughut the entire treadmill test fr symptms and fatigue Prcedure: The student-athlete walks n a treadmill t exhaustin, at a cnstant walking speed while gradient/slpe is increased every ne r tw minutes. The athletic trainer r physician starts the stpwatch at the beginning f the test and stps it when the subject is unable t cntinue. The treadmill speed is set at 3.3 mph, with the gradient starting at 0%. After 1 minute it is raised t 2%, then 1% each minute thereafter. Duratin is a maximum f 20 minutes r with symptm exacerbatin r fatigue APPENDIX H mtbi/cncussin Guidelines Page 11 f 26

12 APPENDIX H BALKE TEST-TREADMILL The Balke Treadmill Test was develped as a clinical test t determine peak VO2 in cardiac patients, thugh it can als be used t estimate cardivascular fitness in student-athletes. Fr the cncussin prtcl it will be used t determine if the student-athlete is able t physically exert withut symptm exacerbatin (Leddy et al 2010). Equipment required: treadmill, stpwatch, heart mnitr (ptinal), electrcardigraph (ptinal) Recmmendatins Student-athlete is asymptmatic prir t treadmill test Test will be stpped immediately is the student-athlete has symptm exacerbatin Test will be stpped if the athlete becmes t fatigued t cntinue and the time nted Student-athlete shuld be mnitred thrughut the entire treadmill test fr symptms and fatigue Prcedure: The student-athlete walks n a treadmill t exhaustin, at a cnstant walking speed while gradient/slpe is increased every ne r tw minutes. The athletic trainer r physician starts the stpwatch at the beginning f the test and stps it when the subject is unable t cntinue. The treadmill speed is set at 3.3 mph, with the gradient starting at 0%. After 1 minute it is raised t 2%, then 1% each minute thereafter. Duratin is a maximum f 20 minutes unless symptm exacerbatin r fatigue ccurs. mtbi/cncussin Guidelines Page 12 f 26

13 APPENDIX I SPORTS SPECIFIC EXERCISES - BASKETBALL Initial 10 laps arund flr sprint straight away/slide baseline Sprints full curt Start and stps Backpedal lateral Shuffle Pwer skips Intermediate Sprints Defensive zigzag Speed Hurdles Square drill Shting/pst drills timed Advanced Mican drill with weighted ball Intervals 10 x 40 sec duratin w/minute rest Each interval cntains varius mvements Lateral shuffle Sprints Change f directin Jumping backpedal mtbi/cncussin Guidelines Page 13 f 26

14 APPENDIX J SPORTS SPECIFIC EXERCISES - BASEBALL Initial 4 Jgging ples Thrwing feet Grund Balls/Defensive Wrk Swings Off a Tee in Cages Intermediate Running Bases Lng Tss feet Defensive Specific Drills Catchers Drills, Infield Drills, Outfield Drills, Frnt Tss r Side Tss in Cages Advanced Defense Diving, Catchers Blcking Live Batting Practice mtbi/cncussin Guidelines Page 14 f 26

15 APPENDIX K SPORTS SPECIFIC EXERCISES - SOCCER Initial Jg-sprint-jg width f field (60yds) x4 Run-change directins t a backpedal-run width f field x2 Agility warm-up (te tuches, skips, carica, etc.) Cvers (passing drills but n headers) Galkeeper 10 yard lateral shuffles fr time Galkeeper pwer jumps Kneeling dives ne side at a time Statinary catches Punts Lay dwn dive stps Intermediate T-drills (Cnstant mvement) partner passing inside ft, tp ft, thigh-ft, chest-ft Backpedal sprint 10yds & pass ( utilize different passing styles) 5yd headers / 10yd headers Galkeeper T-drills (starting frm grund) Repetitive kneeling dives back and frth t each side Crner kick clearances Gal kicks with placement Shuffle catches cntinuusly side t side Advanced Directin drill (large and small grid) T-drills (increase cmplexity) Cne drill with dribbling, making a mve t a sprint (and sht if frward) Step back and sprint drill with variety f passing (incrprate headers) Frwards: 10 ball repetitive shting w/ cntinuus running Midfielders & Defenders: head lng ball clearances while sprint & cut back Galkeeper Timed Illinis test Ple agilities with reactin catches Hurdle agilities with reactin catches Standing dives Mix up saves (tips, diving, catching, punching) mtbi/cncussin Guidelines Page 15 f 26

16 APPENDIX L SPORTS SPECIFIC EXERCISES - WOMEN S LACROSSE Initial 2 laps arund the field (jg sideling, sprint end line) Frm end line t restraining line (~30 yards): High knees dwn, butt kicks back Lateral shuffle dwn and back Frward pwer skips dwn, backward skips back Carica dwn and back Intermediate Frm end line t restraining line (~30 yards): Sprint dwn and back, 10 jumping jacks Shuffled dwn and back, 10 push ups Carica dwn and back, 10 burpees Advanced Bx drill Sprint 10 yards, side shuffle left 10 yards, back pedal 10 yards, side shuffle right 10 yards Sprint 10 yards, drp step shuffle left 10 yards, sprint 10 yards, drp step shuffle right 10 yards Sprint 10 yards and rtate t the right 270 degrees in place (will end up making a left hand turn), repeat fr cmpletin f 1 bx. Prgress t 2 bxes in series 1 vs. 1 s Attacker: Start at the tp f the 12m arc, drive t gal and sht Add use f defender, n bump r cntact made Gradually defender can add mre pressure Defender: Start at the 8m arc and fllw an attacker as they drive t gal and sht Gradually defender can add mre pressure as they becme cmfrtable with ftwrk Allw attacker t incrprate sme type f ddge mve Midfielder: Bth Attacker and Defender 1 vs. 1 s simulatins mtbi/cncussin Guidelines Page 16 f 26

17 APPENDIX M SPORTS SPECIFIC EXERCISES - BOWLING/GOLF Bwling Initial Flr thrws withut ball Flr thrws with ball Intermediate End psitin thrws with ball Half speed apprach Advanced ¾ speed apprach with ball Apprach with thrw Prgress frm bwling frames t entire game Glf Initial Putting strke withut ball cntact Shrt game strke withut ball cntact Intermediate Putting strke with ball cntact (shrt t lng) Shrt game with ball cntact (shrt t lng) Dry swings with irns and drivers withut ball cntact Advanced Practice range with irns and driver Fllw with putting green scenaris Prgress frm hles t runds mtbi/cncussin Guidelines Page 17 f 26

18 APPENDIX N SPORTS SPECIFIC EXERCISES - TENNIS Initial 3 laps arund 3 Curts sprint straight-away, slide baselines Sprints frm baseline t net at angles (back left, center, back right) Backpedal frm net at angles (frnt left, frnt center, frnt right) Lateral Shuffles acrss curt Line hps (back/frth, side/side, alternating back/frth) Intermediate Sprints t net fr vlley Defensive back pedal fr verhead Squat Jumps Timed serves (5 in 15 secnds) Advanced Curt zippers w/ line tuch Ball-fed backhand, frehand, sprint fr vlley x 5 Defensive psitin frm grund service returns mtbi/cncussin Guidelines Page 18 f 26

19 APPENDIX O SPORTS SPECIFIC EXERCISES - SWIMMING Initial 1000 yards w/ in-pl starts yard swims using frnt crawl, yard swims using preferred strke If swimmer s preferred strke is frnt crawl, then 500 yards shuld be swum using butterfly and/r breast strke. Have swimmer fcus n breathing during right and left strkes rather than unilateral breathing Use pen turns; d nt have swimmer use flip turns Intermediate 1500 yards w/ in-pl starts 500 yards frnt crawl and 800 yards preferred strke If swimmers preferred strke is frnt crawl, 500 yards shuld be swum using 1 r mre f the fllwing strkes: butterfly, breast, and back strke 200 yard IM shuld be swam at end f practice regardless f preferred strke Incrprate flip turns Advanced 2000 yards w/ starting blck starts 600 yards frnt crawl and 1000 yards preferred strke If swimmers preferred strke is frnt crawl, 600 yards shuld be swum using 1 r mre f the fllwing strkes: butterfly, breast, and back strke 400 yard IM shuld be swam at end f practice regardless f preferred strke mtbi/cncussin Guidelines Page 19 f 26

20 APPENDIX P SPORTS SPECIFIC EXERCISES - TRACK Jumper: Nrmal Track warm-up fllwed by: 40 meter sprint fllwed by exercises at the end f 40 meter, repeat 5 times. Rest 15 secnds after each exercise befre running again. Exercises: 1. Squats x10 2. Pushups x20 3. Burpees x10 4. Lunges x16 5. Squat jumps x10 Fllw with 400 meter jg Sprinter: Nrmal track warm-up fllwed by: 100 meter 80% sprint with exercises at the end f each 100 meter, repeat 5 times. Rest 20 secnds after each exercise befre running again. Exercises: 1. Squats x10 2. Pushups x20 3. Burpees x10 4. Lunges x16 5. Squat jumps x10 Fllw with 400 meter jg Distance: 5 minute jg fllwed by drills and strides fr warm-up. 400 meter run, 70% pace, with exercises at the end f each run, repeat 5 times. Active recvery fr 40 secnds after each exercise set. Exercises: 1. Frward lunges x16 2. Jumping Jacks x15 3. Pushups x15 4. Wall tuch jumps x12 5. Squats x8 mtbi/cncussin Guidelines Page 20 f 26

21 APPENDIX Q SPORTS SPECIFIC EXERCISES - FOOTBALL OL/DL Initial Stance/Starts Run Blcking/Run Rush Sets Pass Blcking/Pass Rush Sets Bards/Bags Ftwrk and Handwrk Intermediate Cne Drill Run Blck/Run Rush vs. Dummies Pass Blck/Pass Rush vs. Dummies OL Sandbags/ DL handwrk with swims and rips Advanced Pass Set t Run blck n Sled Bag Drill Read Pass r Run 4-pt Stance vs. Sled Dummy weaves ut f stance with hip flips (DL) Push Pull Pwer Hps (OL) mtbi/cncussin Guidelines Page 21 f 26

22 APPENDIX R SPORTS SPECIFIC EXERCISES - FOOTBALL RB/TE/LB Initial Stance/Starts Pass Rutes Check Dwn/Flats OR Pass Reads Run Drills/Run Blcking/Run Reads Bards/Bags Ftwrk and Handwrk Intermediate Cne Drill Pass Rutes w/ Ball OR Pass Read w/ball Pass Blck/Pass Rush vs. Dummies Advanced Run Blck vs. Sled Bag Drills Step-ver/Shuffle Stance vs. Sled mtbi/cncussin Guidelines Page 22 f 26

23 APPENDIX S SPORTS SPECIFIC EXERCISES - FOOTBALL WR/DB Initial Stance/Starts/Reads Run/Pass Blck Ftwrk (WR) Shrt Rute/ Shrt Rute Read Intermediate Cne Drill Shrt Rutes w/ Ball Pass Read w/ Ball Lng Rute Read (DB) Advanced Lng Rutes w/ Ball Run Blck vs. Dummy (WR) Run Read/Shed Dummy (DB) Pass Blck vs. Dummy (WR) Pass Read Blck vs. Dummy (DB) mtbi/cncussin Guidelines Page 23 f 26

24 APPENDIX T SPORTS SPECIFIC EXERCISES - FOOTBALL QB/SPECIAL TEAMS Initial Quarterbacks Statinary Thrwing Run Play Ftwrk Pass Drp Ftwrk Specialists Stance and Apprach Apprach w/ Dry Kick Intermediate Cne Drill Quarterbacks Rllut Ftwrk Pass Drp w/ Thrws Thrws frm Knees Specialists Catch and Run Kick withut Pressure Advanced Quarterbacks Pressure Pass Drp w/ Thrws Knees t Upright Thrws Bucket Thrws Specialists Fake Kick/Punt and Run Running Punt Drpped Ball Grab and Punt mtbi/cncussin Guidelines Page 24 f 26

25 Prtcl fr Cncussin Management Baseline Cncussin Testing, Signed Statement, and Educatin Traumatic Event Evaluatin N Symptms Present YES Evaluatin and Functinal Testing Nrmal? NO RETURN TO PLAY NO RETURN TO PLAY FOR THE REMINDER OF THAT DAY mtbi/cncussin Guidelines Page 25 f 26

26 Prtcl fr Athlete with an Identified Cncussin Athlete with identified cncussin Medical assessment with Team Physician r Physician s designee Indicatin fr further diagnstic testing at Physician s discretin Symptms present at rest? STOP & Reassess fllwing day NO YES Further evaluatin and functinal testing nrmal? YES NO Full participatin withut restrictins Stepwise return t sprt prgressin Medical clearance by Team Physician mtbi/cncussin Guidelines Page 26 f 26