Dr Sophie Armstrong, Chief Medical Officer, Netball Australia

Transcription

1 CONCUSSION POLICY Reference Number: HPPOL090 Board: Approved Date of Approval: February 2017 Responsibility: Andrew Collins Author: Dr Sophie Armstrong, Chief Medical Officer, Netball Australia Netball Australia (NA) is the peak body responsible the development and promotion of netball nationally. NA recognises the need for a Concussion Policy to guide the response and treatment of concussion at national level events and competitions. NA also recognises a need for advice and information to assist netball states, associations and clubs address concussion at the community level. Although rare in netball, concussion has increasingly become a significant public health issue, particularly relevant to sport. The primary purpose of the policy is at all times to protect the welfare of netball athletes. Accurate diagnosis and management is needed to ensure that a concussed player is appropriately treated. This policy sets out are the guidelines, procedures, information and references that can be used by medical staff, athletes, coaches, support staff, and parents responding to players who have received a concussion. The policy comprises of: 1. Important Facts on Concussion 2. Mandatory procedures for Netball Australia Competitions 3. Reference Cards 4. Useful Links / Resources 5. Further Information on Concussion 1

2 Acknowledgements This policy could not be completed without the excellent resources and information from the joint Australian Institute of Sport and Australian Medical Association statement on concussion as well as the resources provided by the British Journal of Sports Medicine. IMPORTANT FACTS ON CONCUSSION What is Concusion Concussion, as defined by the Concussion in Sport Group (CISG) international consensus statement, 1 is a complex pathophysiological process affecting the brain, induced by biomechanical forces. It is known to be complex injury and can be challenging to evaluate and manage. Concussion is a disturbance in the brain s ability to acquire and process information. The reduced function of the brain represents damage to nerve cells (neurons). Either a direct or indirect blow to the head can cause this injury. A direct blow can cause the brain to rotate and/or move forward and backward. Indirect impact to the body can transfer an impulsive force to the brain. The effect that this has on the player can vary from person to person, depending on which part of the brain is affected. The impact can cause concussion signs visible to those who witnessed the collision. Key Points on Concussion Concussion can occur in traditional contact sports and sports such as basketball, netball, horse riding, skiing and hockey. 90% of concussions occur in competitive matches. Women are twice as likely to suffer concussion as men. Most concussions are not reported. Concussion may go undetected due to the subtlety and widespread occurrence of the typical signs and symptoms of concussion. Concussion symptoms can manifest immediately or hours and even days later. Not all athletes develop the same symptoms or signs of concussion. 2

3 MANDATORY PROCEDURES FOR TEAMS PARTICIPATING IN NETBALL AUSTRALIA EVENTS Before the season/event starts club medical/support staff will Prepare for the sports season by studying up on concussion. Have the resources with you that allow easy recognition of possible concussion. o Pocket Recognition Tool (refer to Attachment A) o Management of Concussion Medical/Non-medical On-field/Off-field Reference cards (refer to Attachment B, C, D, E) Have easy access to a checklist of the warning signs of structural brain injury. Know where the closest emergency department or medical practice is in relation to your current location. Ideally all players should undergo computerised testing, although this is not compulsory. Netball Australia is aware of the cost and time required for this. At Suncorp Super Netball level every player needs to complete a SCAT 3 assessment (refer to Attachment F) to be used as a baseline for returning an athlete to play post concussive episode. At other competition levels ideally every player should complete a SCAT3 assessment as a baseline. This however is a recommendation only. Netball Australia are aware of the cost and time needed for a baseline SCAT3 to be completed for every player. Suspected concussion at a game or training: If a concussion is suspected, a standard primary survey and cervical spine precautions should be used. Once safe to do so, the player must be removed from play and assessed in a quiet, safe environment. A Sideline Modified Maddock Score should be performed along with a SCAT3 and a Netball Australia Head Injury Assessment Form (refer to Attachments F, G, H). If the player successfully completes these assessments, within 15 minutes from injury, and remains asymptomatic they can return to play if the medical doctor present at the game believes it is medically safe to do so. Once returned to play, the player must be closely monitored for evolving signs of concussion. 3

4 A player may only return to the field of play after being cleared by a medical practitioner. If a doctor is not present at the match the player must remain out of play until they have had a chance to be medical assessed. If the player fails these assessments, a diagnosis of concussion is made and they must be removed from play and monitored as below. Please follow Management of Concussion Medical/Non-medical On-field/Off-field Reference cards (refer to Attachment B, C, D, E). Take Home Message A player does not have to lose consciousness to have a concussion. Symptoms can evolve over time keep monitoring the athlete for at least 72 Take Home Message All players with suspected concussion should be removed from play or training and see a medical doctor as soon as possible. Any player diagnosed with concussion should be removed from the event and not return to sport or training that day. IF IN DOUBT SIT THEM OUT Signs to watch for: Problems could arise over the first hours. A player should not be left alone and must be seen by doctor or go to a hospital at once if they: Have a headache that gets worse (and doesn t resolve with Panadol). 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 your feet; have slurred speech. 4

5 Mandatory Return to Play Protocol: When returning athletes to play, they should follow a stepwise symptom-limited program, with stages of progression (Refer to Attachment I). 1. Rest until asymptomatic (physical and mental rest) 2. Light aerobic exercise (e.g. stationary cycle) 3. Sport-specific exercise (e.g. light ball and court work) 4. Non-contact training drills (start light resistance training also) 5. Full contact training after medical clearance 6. Return to competition (game play) There should be 24 hours (or longer) for each stage and the athlete should return to the previous, asymptomatic stage if symptoms recur. Resistance training should only be added in the later stages. Children and adolescents may be more susceptible to concussion and take longer to recover. A more conservative approach should be taken with those aged 18 years or younger and the symptom-free rest period should be extended from 24 to 48 hours in this group. The graduated return to sport protocol should be extended such that the child does not return to contact training, sport, or play in less than 14 days. A concussed child must return to learn and return to school before starting the return to play protocol. Before returning to school, the child s symptoms must not be exacerbated by reading or using a computer. Only after successful return to school without worsening of symptoms may the child be allowed to commence the return to play protocol (Please refer to Attachments J, K). No player can return to play without being cleared by a Sport and Exercise Physician or a recognised Netball Australia medical practitioner. 5

6 OTHER USEFUL FACTS: The diagnosis of concussion should be based on a clinical history and examination that includes a range of domains including mechanism of injury, symptoms and signs, cognitive functioning, neurology including balance assessment. The early onset of a concussion headache is most effectively treated with paracetamol painkillers. Avoid anti-inflammatories, especially within the first 24 to 72 hours, as they have been associated with rebound headaches and bleeding of the brain. Limited use of computers, mobile phones and television is recommended when suffering from concussion. If suitably managed, the majority of concussive symptoms should resolve in 7 10 days. After a minimum of 24 hours without any symptoms the patient can commence a return to cognitive and physical activity. Blood tests are not indicated for uncomplicated concussion. Medical imaging is not indicated unless there is suspicion of more serious head or brain injury. REFERENCE CARDS A: Pocket Recognition Tool B: Medical Assessment of Concussion On-field C: Non-medical Assessment of Concussion On-field D: Medical Assessment of Concussion Off-field E: Non-Medical Assessment of Concussion Off-field F: SCAT 3 G: Modified Maddocks Questions H: Head Injury Assessment Form I: Return to Play Protocol Adult J: Return to Play Protocol Child K: Return to Learn Plan Child template Useful Links / Resources AIS/AMA position statement on concussion in sport The 4 th International Conference on Concussion in Sport: Consensus Statement NICE: Head injury assessment & management in children 6

7 Pocket Recognition Tool SCAT3 Adult Sport Concussion Assessment Tool SCAT3 Child Sport Concussion Assessment Tool 7

8 Further Information on Concussion Concussion, as defined by the Concussion in Sport Group (CISG) international consensus statement, 1 is a complex pathophysiological process affecting the brain, induced by biomechanical forces. It is known to be complex injury and can be challenging to evaluate and manage. In Australia, common participation sports such as Australian Rules Football, Rugby League and Rugby Union have amongst the highest rates of head injury of any team sports in the world. The reported incidence of concussion in these sports ranges from about 3 to 10 concussive injuries per 1000 player hours, 2-4 which equates to an average of five injuries per team per season, regardless of the level of competition. This represents a significant public health issue in active communities. Since 2001, international conferences have been held to address key issues in the understanding and management of concussion in sport. After each of these meetings, a consensus statement provides the most up-to-date knowledge on concussion in sport. 1,5-7 The consensus statement outlines the current best practice management guidelines and provides practitioners with simple clinical tools to help manage a concussion. Making a Diagnosis: Concussion generally results from a knock, often to the head, face or neck, but may be anywhere on the body that transmits an impulsive force to the head. Diagnosis of concussion can be difficult because clinical symptoms and signs can change rapidly and may evolve over time. Many of the clinical features (especially symptoms) are not specific to concussion, and there is no reliable test or marker for an objective diagnosis. Diagnosis of concussion relies on clinical assessment of symptoms, (e.g. headache, difficulty concentrating, feeling like being in a fog, emotionally labile), signs (e.g. loss of consciousness, balance disturbance), cognitive impairment (e.g. confusion, slowed reaction times) and neurobehavioural changes (e.g. irritability, feeling not quite right ). In some instances, it will be obvious that there has been a significant injury where the athlete loses consciousness, has a seizure, or has significant balance difficulties. However, concussion is often an evolving process. Subtle symptoms and signs often become more apparent and significant in the hours and days following the injury. 8

9 Recognising concussion is critical to correctly managing and preventing further injury. The Pocket Concussion recognition Tool, developed by the Concussion in Sport Group, should be used to help those without medical training detect concussion. When an athlete is suspected of having a concussion, first-aid principles should be used, and a systematic approach to assessment of airway, breathing, circulation, disability and exposure should be used in all situations. Cervical spine injuries should be suspected if there is any loss of consciousness, neck pain, or a mechanism that could lead to spinal injury. A medical practitioner should make the diagnosis of concussion after a clinical history and examination that includes a range of domains. These include mechanism of injury, symptoms and signs, cognitive functioning, and neurological assessment including balance testing. The Sport Concussion Assessment Tool 8 (SCAT3) is the internationally recommended concussion assessment tool and covers the above-mentioned domains. This should not be used in isolation, but as part of the overall clinical assessment. Computerised neurocognitive testing can be undertaken as part of the assessment but again, should not be used in isolation. Baseline neurocognitive testing can be useful in the preseason period for comparison with post-injury scores. Many programs however have reference ranges that can be applied in the absence of a baseline test. There are currently no serum biomarkers that assist in the diagnosis of concussion. Blood tests are not indicated for uncomplicated concussion. Medical imaging is not indicated in the diagnosis or management of uncomplicated concussion. However imaging is recommended when there is suspicion of more serious head or brain injury. Returning to Play: Rest after a concussive injury is important to allow recovery. Physical activity, physiological stress (e.g. altitude and flying), and cognitive loads (e.g. school work, video games, computer) can all worsen symptoms and possibly delay recovery after a concussion. 1 Individuals should be rested from these activities in the early stages after a concussive injury. 1 In addition, the use of alcohol, sedatives or recreational drugs can exacerbate symptoms following head trauma, delay recovery or mask deterioration and should also be avoided. 9

10 After a concussive injury, players should be returned to play in a graded fashion. After a minimum of 24 hours without any symptoms the player can commence the staged return to cognitive and physical activity. Progression through the stepped program should occur with 24 hours at each stage. If the player has any recurrence of symptoms while progressing through their return-to-play program that they should drop back to the previous asymptomatic level and try to progress again after a further 24 hours of rest. The steps in the activity phase are: Light aerobic activity Basic sport-specific drills which are non-contact and with no head impact More complex sport-specific drills without contact, may add resistance training Full contact practice following medical review normal competitive sporting activity. Modifying Factors: A range of clinical factors are known that may be associated with longer duration of symptoms or increased risk of adverse outcomes following a concussion. 9 These are known as modifying factors and are summarised in the table below 1. The presence of any modifying factor after a concussive injury requires a more conservative approach, including more detailed assessment and slower time to return to sport. In difficult or complicated cases, a multidisciplinary team approach including referral to a neuropsychologist and or doctor with expertise in managing concussion should be considered. Factors Modifier Symptoms High number, long duration (>10 days), high severity Signs Prolonged loss of consciousness (>1minute), amnesia Sequelae Prolonged concussion convulsions Temporal Frequency: repeated concussions over time Timing: injuries close together in time Recency : recent concussion or traumatic brain injury Threshold Repeated concussions occurring with 10

11 progressively less impact force or slower recovery after each successive concussion Age Child and adolescents <18 Co and pre-morbidities Medication Behaviour Sport Migraine, depression or other mental health disorders, ADHD, learning disabilities, sleep disorders Psychoactive drugs, anticonvulsants Dangerous style of play High risk activity, contact and collision sport, high level sport Concussion Management in Children and Adolescents: Evidence shows that younger athletes take longer to recover after a concussive injury than adults. 10 Children and adolescents seem to be more vulnerable to concussion due to a variety of factors including decreased myelination, poor cervical musculature, and increased head to neck ratio. 11 The role of cerebral blood flow alterations in the pathophysiology of concussion may be more significant in children than in adults. There is also some evidence that components of cognitive function relating to executive functioning may be impaired in adolescents with concussion for up to two months after injury. The implications of this are not clear and further studies are required to confirm or refute this data. Therefore a more conservative approach is recommended in all concussed players under the age of 18 years, regardless of the level of competition in which they play. Child SCAT3 12 has been developed for use in children aged 5 to 12 years old to accommodate for physical, cognitive and language development. For children aged 13 to 18 years, the SCAT3 should also be used. It should be noted that the Child SCAT3 includes both a child-report and parent-report symptom scale. It is important to include the parent, teacher, coach, or guardian in assessing the child with concussion. The priority for a concussed child is successful return to learn and return to school before considering return to play. Before returning to school, the child s symptoms must not be exacerbated by reading or using a computer. In most instances, a child will only require absence from school for 1 to 2 days however, longer periods of rest may be needed. The child requires medical clearance before return to school. Parents and teachers need to make plans 11

12 to accommodate the child for example shorter school days, regular breaks, and longer time to complete assignments. Only after successful return to school without worsening of symptoms may the child be allowed to commence return to sport. References: 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 Br J Sports Med 2013;47: Makdissi M, McCrory P, Ugoni A, Darby D, Brukner P. A prospective study of postconcussive outcomes after return to play in Australian football. Am J Sports Med 2009;37: Kemp SP, Hudson Z, Brooks JH, Fuller CW. The epidemiology of head injuries in English professional rugby union. Clin J Sport Med 2008;18: Hinton-Bayre AD, Geffen G, Friis P. Presentation and mechanisms of concussion in professional Rugby League Football. J Sci Med Sport 2004;7: Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med 2002;36: McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague Br J Sports Med 2005;39: McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November Br J Sports Med 2009;43 Suppl 1:i Makdissi M, Davis G, Jordan B, Patricios J, Purcell L, Putukian M. Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups? Br J Sports Med 2013;47: Davis GA, Purcell LK. The evaluation and management of acute concussion differs in young children. Br J Sports Med 2014;48:

13 APPENDIX A Pocket CONCUSSION RECOGNITION TOOL To help identify concussion in children, youth and adults 3. Memory function Failure to answer any of these questions correctly may suggest a concussion. What venue are we at today? Which half is it now? Who scored last in this game? What team did you play last week / game? Did your team win the last game? RECOGNIZE & REMOVE Concussion should be suspected if one or more of the following visible clues, signs, symptoms or errors in memory questions are present. 1. Visible clues of suspected concussion Any one or more of the following visual clues can indicate a possible concussion: Loss of consciousness or responsiveness Lying motionless on ground / Slow to get up Unsteady on feet / Balance problems or falling over / Incoordination Grabbing / Clutching of head Dazed, blank or vacant look Confused / Not aware of plays or events 2. Signs and symptoms of suspected concussion Presence of any one or more of the following signs & symptoms may suggest a concussion: - Loss of consciousness - Headache - Seizure or convulsion - Dizziness - Balance problems - Confusion - Nausea or vomiting - Feeling slowed down - Drowsiness - Pressure in head - More emotional - Blurred vision - Irritability - Sensitivity to light - Sadness - Amnesia - Fatigue or low energy - Feeling like in a fog - Nervous or anxious - Neck Pain - Don t feel right - Sensitivity to noise - Difficulty remembering - Difficulty concentrating 2013 Concussion in Sport Group Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY, and should not be returned to activity until they are assessed medically. Athletes with a suspected concussion should not be left alone and should not drive a motor vehicle. It is recommended that, in all cases of suspected concussion, the player is referred to a medical professional for diagnosis and guidance as well as return to play decisions, even if the symptoms resolve. RED FLAGS If ANY of the following are reported then the player should be safely and immediately removed from the field. If no qualified medical professional is available, consider transporting by ambulance for urgent medical assessment: - Athlete complains of neck pain - Deteriorating conscious state - Increasing confusion or irritability - Severe or increasing headache - Repeated vomiting - Unusual behaviour change - Seizure or convulsion - Double vision - Weakness or tingling / burning in arms or legs Remember: - In all cases, the basic principles of first aid (danger, response, airway, breathing, circulation) should be followed. - Do not attempt to move the player (other than required for airway support) unless trained to so do - Do not remove helmet (if present) unless trained to do so. from McCrory et. al, Consensus Statement on Concussion in Sport. Br J Sports Med 47 (5), Concussion in Sport Group 13

14 APPENDIX A Pocket CRT Br J Sports Med : 267 Updated information and services can be found at: alerting service These include: Receive free alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. Notes To request permissions go to: To order reprints go to: To subscribe to BMJ go to: 14

15 APPENDIX B Athlete with suspected concussion Loss of consciousness Seizure or tonic posturing Confusion, disorientation Memory impairment Balance disturbance Dazed, blank/vacant stare Behaviour change, not themselves YES NO Athlete concussed Immediate and permanent removal from play Remove for sideline concussion assessment Evidence of structural intracranial pathology or spinal injury SCAT 3 Neurological examination Use of video assessment if available (professional sport) YES NO Evidence of concussion No evidence of concussion SCAT 3 Neurological examination Monitor and reassess as appropriate Signs of neurological Worsening headache Emotionally labile Altered level of consciousness Vomiting Focal neurological signs Permanent removal from play Athlete may be returned to play but must be closely monitored for evolving signs of concussion or more serious head injury Reassess at half time / full time If any signs of concussion develop, the athlete must be permanently removed from play Immediate referral to emergency department if in doubt, sit them out 15

16 APPENDIX C (parents, coaches, teachers, team-mates) Athlete with suspected concussion Loss of consciousness Lying motionless, slow to get up Seizure Confusion, disorientation Memory impairment Balance disturbance Nausea or vomiting Headache or pressure in the head Visual or hearing disturbance Dazed, blank/vacant stare Behaviour or emotional changes, not themselves Things to look out for at the time of injury Immediate and permanent removal from sport RED FLAGS Neck pain Increasing confusion or irritability Repeated vomiting Seizure or convulsion Weakness or tingling/burning in the arms or legs Deteriorating conscious state Severe or increasing headache Unusual behavioural change Visual or hearing disturbance NO YES Refer to medical practitioner as soon as practical Immediate referral to Emergency Department if in doubt, sit them out 16

17 APPENDIX D (for emergency departments and medical clinics) Athlete with suspected concussion Trauma Loss of consciousness Seizure Headache Drowsiness Nausea / vomiting Balance disturbance Confusion, memory impairment Emotionally labile Visual disturbance YES NO SCAT 3 Neurological examination SCAT 3 Neurological examination Normal Abnormal Normal Monitor and reassess as appropriate No suspicion of intracranial pathology or spinal injury Medical investigations if any suspicion of intracranial pathology or spinal injury Instigate return to sport protocol Clear instruction to stop sport and return for further assessment, if any symptoms subsequently develop Instigate return to sport protocol, once symptom free Clear instruction to stop sport and return for further assessment, if any symptoms subsequently develop Investigations normal Investigations abnormal Specialist referral if in doubt, sit them out 17

18 APPENDIX E (for parents, coaches, teachers, team-mates) Athlete with suspected concussion Pale Fatigue Sensitivity to light / noise Confusion, disorientation Memory impairment Nausea Headache or pressure in the head Feeling slowed or not right Dazed, blank/vacant stare Behaviour or emotional changes, not themselves Things to look out for at home or at school a possible concussion Review by medical practitioner RED FLAGS Neck pain Increasing confusion or irritability Repeated vomiting Seizure or convulsion Weakness or tingling/burning in the arms or legs Deteriorating conscious state Severe or increasing headache Unusual behavioural change Visual or hearing disturbance NO YES Rest, observation, return to sport protocol under medical advice Immediate referral to emergency department if in doubt, sit them out 18

19 APPENDIX F SCAT3 Sport Concussion Assessment Tool 3rd edition For use by medical professionals only name Date / Time of Injury: Date of Assessment: examiner: 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 qualified, please use the Sport Concussion recognition tool 1. 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 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-specific 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: - 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). 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 flexion to pain 3 Flexion / Withdrawal to pain 4 localizes to pain 5 obeys commands 6 glasgow Coma score (e + v + m) of 15 GCS should be recorded for all athletes in case of subsequent deterioration. 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 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 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. 2 maddocks Score 3 I am going to ask you a few questions, please listen carefully and give your best effort. Modified 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 Maddocks score is validated for sideline diagnosis of concussion only and is not used for serial testing. notes: mechanism of injury ( tell me what happened?): Any loss of consciousness? Y n 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 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 Concussion in Sport Group

20 APPENDIX Cognitive & Physical Evaluation Sport / team / school: Date / time of injury: Age: Gender: M F 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 Y N a head injury? 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 or other psychiatric disorder? Has anyone in your family ever been diagnosed with Y N any of these problems? Are you on any medications? If yes, please list: Y N SCAT3 to be done in resting state. Best done 10 or more minutes post excercise. Symptom Evaluation 3 How do you feel? You should score yourself on the following symptoms, based on how you feel now. none mild moderate 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 Difficulty concentrating Difficulty remembering Fatigue or low energy Confusion Drowsiness Trouble falling asleep More emotional Irritability Sadness Nervous or Anxious Total number of symptoms (Maximum possible 22) Symptom severity score (Maximum possible 132) Do the symptoms get worse with physical activity? Y N Do the symptoms get worse with mental activity? Y N self rated clinician interview self rated and clinician monitored 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 4 Cognitive assessment Standardized Assessment of Concussion (SAC) 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 of 5 Immediate memory List Trial 1 Trial 2 Trial 3 Alternative word list elbow candle baby finger apple paper monkey penny carpet sugar perfume blanket saddle sandwich sunset lemon bubble wagon iron insect Total Immediate memory score total of 15 Concentration: Digits Backward List Trial 1 Alternative digit list Total of 4 Concentration: Month in Reverse Order (1 pt. for entire sequence correct) Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan 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 Balance Error Scoring System (BESS) testing 5 Which foot was tested (i.e. which is the non-dominant foot) Left Right Testing surface (hard floor, field, etc.) Condition Double leg stance: Single leg stance (non-dominant foot): Tandem stance (non-dominant foot at back): And / Or Tandem gait 6,7 Time (best of 4 trials): seconds Coordination examination Upper limb coordination Which arm was tested: Left Right Errors Errors Errors Coordination score of 1 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 SAC Delayed Recall 4 Delayed recall score of Concussion in Sport Group

21 APPENDIX 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 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. 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). Tandem Gait 6,7 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. Coordination Examination 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), 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 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 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 British Journal of Sports Medicine 2009; 43: i Maddocks, DL; Dicker, GD; Saling, MM. The assessment of orientation following concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5(1): McCrea M. Standardized mental status testing of acute concussion. Clinical Journal of Sport Medicine. 2001; 11: Guskiewicz KM. Assessment of postural stability following sport-related concussion. Current Sports Medicine Reports. 2003; 2: Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond-Tooke, G. & McCrory, P. Normative values for 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): 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): Concussion in Sport Group

22 APPENDIX Scoring Summary: Test Domain Score Date: Date: Date: Number of Symptoms of 22 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 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. 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 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 Sport-specific exercise Non-contact training drills Full contact practice Return to play Walking, swimming or stationary cycling keeping intensity, 70 % maximum predicted 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 Increase heart rate Add movement Exercise, coordination, and cognitive load Restore confidence and assess functional skills by coaching staff 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 (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. 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. Patient s name Date / time of injury Date / time of medical review Treating physician 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 Contact details or stamp Concussion in Sport Group

23 APPENDIX F SCAT3 Br J Sports Med : 259 Updated information and services can be found at: alerting service These include: Receive free alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. Topic Collections Articles on similar topics can be found in the following collections Trauma Injury (952) (842) Trauma CNS / PNS (130) Notes To request permissions go to: To order reprints go to: To subscribe to BMJ go to: 23

24 APPENDIX F Child-SCAT3 Sport Concussion Assessment Tool for children ages 5 to12 years For use by medical professionals only 1 What is childscat3? 1 The ChildSCAT3 is a standardized tool for evaluating injured children for concussion and can be used in children aged from 5 to 12 years. It supersedes the original SCAT and the SCAT2 published in 2005 and 2009, respectively 2. For older persons, ages 13 years and over, please use the SCAT3. The ChildSCAT3 is designed for use by medical professionals. If you are not qualified, please use the Sport Concussion Recognition Tool 1.Preseason baseline testing with the ChildSCAT3 can be helpful for interpreting post-injury test scores. Specific instructions for use of the ChildSCAT3 are provided on page 3. If you are not familiar with the ChildSCAT3, 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 and any reproduction in a digital form require approval by the Concussion in Sport Group. NOTE: The diagnosis of a concussion is a clinical judgment, ideally made by a medical professional. The ChildSCAT3 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 ChildSCAT3 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 and/or symptoms (like those 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: -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). SIDeLIne ASSeSSmenT Indications for emergency management note: A hit to the head can sometimes be associated with a more severe brain injury. if the concussed child displays any of the following, then do not proceed with the ChildSCAt3; instead activate 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 - persistent vomiting - evidence of skull fracture - post traumatic seizures - Coagulopathy - History of neurosurgery (eg Shunt) - multiple injuries 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 flexion to pain 3 Flexion / Withdrawal to pain 4 localizes to pain 5 obeys commands 6 Potential signs of concussion? if any of the following signs are observed after a direct or indirect blow to the head, the child 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. Any loss of consciousness? Y n 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 2 Sideline Assessment child-maddocks Score 3 I am going to ask you a few questions, please listen carefully and give your best effort. Modified Maddocks questions (1 point for each correct answer) Where are we at now? 0 1 is it before or after lunch? 0 1 What did you have last lesson / class? 0 1 What is your teacher s name? 0 1 child-maddocks score of 4 Child-Maddocks score is for sideline diagnosis of concussion only and is not used for serial testing. Any child with a suspected concussion should be RemoveD FRom PLAy, medically assessed and monitored for deterioration (i.e., should not be left alone). No child diagnosed with concussion should be returned to sports participation on the day of Injury. BACKgRounD name: Date / time of injury: examiner: Date of Assessment: Sport / team / school: Age: Gender: m F Current school year / grade: Dominant hand: right left neither mechanism of injury ( tell me what happened?): For Parent / carer to complete: How many concussions has the child had in the past? When was the most recent concussion? How long was the recovery from the most recent concussion? Has the child ever been hospitalized or had medical imaging Y n done (Ct or mri) for a head injury? Has the child ever been diagnosed with headaches or migraines? Y n Does the child have a learning disability, dyslexia, Y n ADD/ADHD, seizure disorder? Has the child ever been diagnosed with depression, Y n anxiety or other psychiatric disorder? Has anyone in the family ever been diagnosed with Y n any of these problems? is the child on any medications? if yes, please list: Y n glasgow Coma score (e + v + m) of 15 GCS should be recorded for all athletes in case of subsequent deterioration Concussion in Sport Group

25 APPENDIX F Symptom Evaluation 3 Child report Name: never rarely sometimes often I have trouble paying attention I get distracted easily I have a hard time concentrating I have problems remembering what people tell me I have problems following directions I daydream too much I get confused I forget things I have problems finishing things I have trouble figuring things out It s hard for me to learn new things I have headaches I feel dizzy I feel like the room is spinning I feel like I m going to faint Things are blurry when I look at them I see double I feel sick to my stomach I get tired a lot I get tired easily Total number of symptoms (Maximum possible 20) Symptom severity score (Maximum possible 20 x 3 = 60) self rated clinician interview self rated and clinician monitored 4 Parent report Cognitive & Physical Evaluation 5 Cognitive assessment Standardized Assessment of Concussion Child Version (SAC-C) 4 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 Orientation score of 4 Immediate memory List Trial 1 Trial 2 Trial 3 Alternative word list elbow candle baby finger apple paper monkey penny carpet sugar perfume blanket saddle sandwich sunset lemon bubble wagon iron insect Total Immediate memory score total of 15 Concentration: Digits Backward List Trial 1 Alternative digit list Total of 5 The child never rarely sometimes often has trouble sustaining attention Is easily distracted has difficulty concentrating has problems remembering what he / she is told has difficulty following directions tends to daydream gets confused is forgetful has difficulty completeing tasks has poor problem solving skills has problems learning has headaches feels dizzy has a feeling that the room is spinning feels faint has blurred vision has double vision experiences nausea gets tired a lot gets tired easily Total number of symptoms (Maximum possible 20) Symptom severity score (Maximum possible 20 x 3 = 60) Do the symptoms get worse with physical activity? Y N Do the symptoms get worse with mental activity? Y N parent self rated clinician interview parent self rated and clinician monitored Overall rating for parent / teacher / coach / carer to answer. How different is the child acting compared to his / her usual self? Please circle one response: no different very different unsure N/A Concentration: Days in Reverse Order (1 pt. for entire sequence correct) Sunday-Saturday-Friday-Thursday-Wednesday- Tuesday-Monday 0 1 Concentration score of 6 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 Balance Error Scoring System (BESS) testing 5 Which foot was tested (i.e. which is the non-dominant foot) Left Right Testing surface (hard floor, field, etc.) Condition Double leg stance: Errors Tandem stance (non-dominant foot at back): Errors Tandem gait 6,7 Time taken to complete (best of 4 trials): seconds If child attempted, but unable to complete tandem gait, mark here Coordination examination Upper limb coordination Which arm was tested: Left Right Coordination score of 1 Name of person completing Parent-report: Relationship to child of person completing Parent-report: 9 SAC Delayed Recall 4 Delayed recall score of 5 Scoring on the ChildSCAT3 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. 25 Since signs and symptoms may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion Concussion in Sport Group

26 APPENDIX F Balance testing types of errors - Parts (a) and (b) 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 the child is to complete the Child Report, according to how he / she feels today, and the parent/carer is to complete the Parent Report according to how the child has been over the previous 24 hours. Standardized Assessment of Concussion Child Version (SAC-C) 4 Orientation Ask each question on the score sheet. A correct answer for each question scores 1 point. If the child does not understand the question, gives an incorrect answer, or no answer, then the score for that question is 0 points. 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. 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 child 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, you would say 1-7. 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. Days in Reverse Order: Now tell me the days of the week in reverse order. Start with Sunday and go backward. So you ll say Sunday, Saturday 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. Circle each word correctly recalled. Total score equals number of words recalled. Balance examination These instructions are to be read by the person administering the childscat3, and each balance task should be demonstrated to the child. The child should then be asked to copy what the examiner demonstrated. 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 two different parts. (a) Double leg stance: The first stance is standing with the feet together with hands on hips and with eyes closed. The child should try to maintain stability in that position for 20 seconds. You should inform the child that you will be counting the number of times the child moves out of this position. You should start timing when the child is set and the eyes are closed. (b) Tandem stance: Instruct the child to stand heel-to-toe with the non-dominant foot in the back. Weight should be evenly distributed across both feet. Again, the child should try to maintain stability for 20 seconds with hands on hips and eyes closed. You should inform the child that you will be counting the number of times the child moves out of this position. If the child stumbles out of this position, instruct him/her to open the eyes and return to the start position and continue balancing. You should start timing when the child is set and the eyes are closed. 26 Each of the 20-second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the child. The examiner will begin counting errors only after the child has assumed the proper start position. The modified BESS is calculated by adding one error point for each error during the two 20-second tests. The maximum total number of errors for any single condition is 10. If a child commits multiple errors simultaneously, only one error is recorded but the child should quickly return to the testing position, and counting should resume once subject is set. Children who 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 2 stances can be performed on a surface of medium density foam (e.g., approximately 50cm x 40cm x 6cm). Tandem Gait 6,7 Use a clock (with a second hand) or stopwatch to measure the time taken to complete this task. Instruction for the examiner Demonstrate the following to the child: The child is 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-totoe 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. Children 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. Explain to the child that you will time how long it takes them to walk to the end of the line and back. Coordination examination Upper limb coordination Finger-to-nose (FTN) task: The tester should demonstrate it to the child. 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. Scoring: 5 correct repetitions in < 4 seconds = 1 Note for testers: Children 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 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 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 British Journal of Sports Medicine 2009; 43: i Maddocks, DL; Dicker, GD; Saling, MM. The assessment of orientation following concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5(1): McCrea M. Standardized mental status testing of acute concussion. Clinical Journal of Sport Medicine. 2001; 11: Guskiewicz KM. Assessment of postural stability following sport-related concussion. Current Sports Medicine Reports. 2003; 2: Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond-Tooke, G. & McCrory, P. Normative values for 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): 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): Ayr, L.K., Yeates, K.O., Taylor, H.G., & Brown, M. Dimensions of post-concussive symptoms in children with mild traumatic brain injuries. Journal of the International Neuropsychological Society. 2009; 15: Concussion in Sport Group

27 APPENDIX The child is not to return to play or sport until he / she has successfully returned to school / learning, without worsening of symptoms. Medical clearance should be given before return to play. If there are any doubts, management should be referred to a qualified health practitioner, expert in the management of concussion in children. New Headache, or Headache gets worse Persistent or increasing neck pain Becomes drowsy or can t be woken up Can not recognise people or places Has Nausea or Vomiting Behaves unusually, seems confused, or is irritable Has any seizures (arms and / or legs jerk uncontrollably) Has weakness, numbness or tingling (arms, legs or face) Is unsteady walking or standing Has slurred speech Has difficulty understanding speech or directions Remember, it is better to be safe. Always consult your doctor after a suspected concussion. Return to school Concussion may impact on the child s cognitive ability to learn at school. This must be considered, and medical clearance is required before the child may return to school. It is reasonable for a child to miss a day or two of school after concussion, but extended absence is uncommon. In some children, a graduated return to school program will need to be developed for the child. The child will progress through the return to school program provided that there is no worsening of symptoms. If any particular activity worsens symptoms, the child will abstain from that activity until it no longer causes symptom worsening. Use of computers and internet should follow a similar graduated program, provided that it does not worsen symptoms. This program should include communication between the parents, teachers, and health professionals and will vary from child to child. The return to school program should consider: Extra time to complete assignments / tests Quiet room to complete assignments / tests Avoidance of noisy areas such as cafeterias, assembly halls, sporting events, music class, shop class, etc Frequent breaks during class, homework, tests No more than one exam / day Shorter assignments Repetition / memory cues Use of peer helper / tutor Reassurance from teachers that student will be supported through recovery through accommodations, workload reduction, alternate forms of testing Later start times, half days, only certain classes Return to sport There should be no return to play until the child has successfully returned to school / learning, without worsening of symptoms. Children must not be returned to play the same day of injury. When returning children to play, they should medically cleared and then follow a stepwise supervised program, with stages of progression. 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 Sport-specific exercise Non-contact training drills Full contact practice Return to play Walking, swimming or stationary cycling keeping intensity, 70 % maximum predicted 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 Increase heart rate Add movement Exercise, coordination, and cognitive load Restore confidence and assess functional skills by coaching staff There should be approximately 24 hours (or longer) for each stage and the child should drop back to the previous asymptomatic level if any post-concussive symptoms recur. Resistance training should only be added in the later stages. If the child is symptomatic for more than 10 days, then review by a health practitioner, expert in the management of concussion, is recommended. Medical clearance should be given before return to play. Notes: Concussion injury advice for the child and parents / carers (To be given to the person monitoring the concussed child) This child 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 child will need monitoring for the next 24 hours by a responsible adult. If you notice any change in behavior, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please call an ambulance to transport the child to hospital immediately. Patient s name Date / time of injury Date / time of medical review Treating physician Other important points: Following concussion, the child should rest for at least 24 hours. The child should avoid any computer, internet or electronic gaming activity if these activities make symptoms worse. The child should not be given any medications, including pain killers, unless prescribed by a medical practitioner. The child must not return to school until medically cleared. The child must not return to sport or play until medically cleared. Clinic phone number 27 Contact details or stamp 2013 Concussion in Sport Group

28 APPENDIX F Child SCAT3 Br J Sports Med : 263 Updated information and services can be found at: alerting service These include: Receive free alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. Topic Collections Articles on similar topics can be found in the following collections Trauma Injury (952) (842) Trauma CNS / PNS (130) Notes To request permissions go to: To order reprints go to: To subscribe to BMJ go to: 28

29 APPENDIX G Modified Maddocks Questions: I am going to ask you a few questions. Please listen carefully and answer to the best of your knowledge. 1 point for each correct question. What venue are we at? 0 1 Which quarter is it? 0 1 Who scored last? 0 1 What team did you play last game / week? 0 1 Did your team win last game? 0 1 Maddocks Score /5 29

30 APPENDIX H A. GENERAL INFORMATION Player Name: Dr/Physio Name: Quarter: Club: Date: Time in Quarter: B. STRUCTURAL HEAD OR NECK INJURY 1. Are there clinical features including abnormal neurological signs of a Yes No serious or structural head and/or neck injury requiring emergency management and hospital transfer (GCS, etc are indicated)? C. REMOVAL FROM PLAY The player must be removed from play with any of the following observations by any staff member, whether observed directly or indirectly: a. Clear diagnosis of concussion requiring immediate removal and no return to play 2. Loss of consciousness Yes No 3. No protective action in fall to ground directly observed (tonic or floppy) Yes No 4. Impact seizure or tonic posturing Yes No 5. Confusion, disorientation Yes No 6. Memory impairment (e.g. fails Maddocks questions) Yes No 7. Balance disturbance (e.g. ataxia) Yes No 8. Player reports significant, new or progressive concussion symptoms Yes No 9. Dazed, blank/vacant stare or not their normal selves Yes No 10. Behaviour change atypical of the player Yes No b. Requires immediate removal from play for further assessment 11. Loss of responsiveness Yes No (player motionless for 2-3 seconds or until support staff arrives) 12. Possible tonic posturing or impact seizure Yes No 13. Possible balance disturbance directly observed Yes No Comments regarding the above findings: D. OUTCOME 16. Clear diagnosis of brain injury or concussion and no return to play (SCAT 3 required) Yes* 17. Required removal from play for SCAT3 assessment and cleared to return to play Yes* 18. No criteria for removal for concussion or SCAT3 assessment Yes* *Red = no RTP, *Amber = remove from play for SCAT3, *Green = no criteria for removal from play *Player requires regular medical checks at least every 30 minutes and removal for SCAT3 assessment with any deterioration E. SIGNATURE OF EXAMINING DOCTOR or PHYSIOTHERAPIST Signed: Date: 30 Time completed:

31 APPENDIX I Return to Sport Protocol for adults over 18 years of age Diagnosis of concussion No return to sport Complete physical and cognitive rest Must be symptom free for at least 24 hours Light aerobic activity (24 hours) Recurrence of concussion symptoms Basic sport-specific drills which are non-contact no head impact (24 hours) Recurrence of concussion symptoms More complex sport-specific drills which are non-contact no head impact may add resistance training (24 hours) Recurrence of concussion symptoms Medical review before return to full contact training If not medically cleared, any further activity to be determined by medical practitioner Return to full contact training (24 hours) Recurrence of concussion symptoms COMPLETE FORMAL MEDICAL REVIEW Return to sport Recurrence of concussion symptoms COMPLETE FORMAL MEDICAL REVIEW if in doubt, sit them out 31