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Muriel Wiggins
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3 How to manage concussion? World Rugby standard: Recognize and Remove Protocol (6Rs). RECOGNIZE - Learn the signs and symptoms of concussion so you understand when an athlete might have a concussion. REMOVE - If an athlete has a concussion or a suspected concussion he/she must be removed from play immediately and may not return until assessed by a doctor. REFER - Once removed from play, the player should be referred immediately to a qualified healthcare professional who is trained in evaluating and treating concussions. REST - Players must rest from all activity until symptom-free and then start a graduated return to play (GRTP) protocol. World Rugby recommends a more conservative return to play for children and adolescents. RECOVER - Full recovery from the concussion is required before return to play is authorized. Rest and specific treatment options are critical for the health of the injured participant. RETURN - In order for safe return to play in sport, the athlete must be symptom-free and cleared in writing by a qualified healthcare professional who is trained in evaluating and treating concussions. Page 3

4 When to Remove from play? Immediate removal of players from the field with any of the following signs and symptoms: Tonic posturing Convulsion/fit Confirmed loss of consciousness Suspected loss of consciousness Balance disturbance / ataxia Player not orientated in time, place or person Player appears to have been "dazed, dinged or had their bell rung" Slurred speech/change in speech pattern Possible behaviour change Possible confusion Injury event witnessed with potential to result in a concussive injury Aggression Bouncing back too fast Other symptoms or signs suggesting a suspected concussion Page 4

5 Symptom checklist Please keep an accurate record! SYMPTOMS DATE : DATE : DATE : DATE : Headache Pressure in head Nausea and vomiting Dizziness Blurred vision Photo-phobia Poor balance Feeling slow Feeling like in a fog Fatigue Drowsiness Cognitive Poor concentration Poor memory Confusion Emotional Sad or depressed More emotional Irritable Nervous/anxious Changes to Sleep patterns (more, less, not falling asleep) Page 5

6 Watch for Red Flags After evaluation by a sideline medic, it may be determined that you are safe to go home. If you are sent home, you should not be left alone. A responsible adult must accompany you. Symptoms from your concussion may persist a short while. BUT if a symptom gets worse or new symptoms develop. GO IMMEDIATELY TO THE NEAREST HOSPITAL. Important symptoms to monitor over the next 48 hours include: Headaches that worsen Severe neck pain Loss of feeling or use of an arm or leg Confusion, dizziness Slurred speech Deteriorating consciousness Seizures (fits) Repeated vomiting The presence of ANY of these requires urgent medical attention and usually a brain scan. Report to a hospital casualty, preferably one with a neurosurgeon and brain scanning facilities. Page 6

7 Boksmart concussion advice What is a concussion? A concussion is an injury to the brain caused by a direct or indirect blow to the head or caused by the head striking something else such as the ground or a bony hip. A concussion can occur whether or not a person is knocked out. A concussion typically causes the rapid onset of short lived impairment of brain function that resolves spontaneously with time. However, occasionally there can be a more significant or longer lasting problem, and it is important that the symptoms from every concussion be monitored by team medics and doctors who understand concussion management protocol. When you suffer a concussion, you may suffer from: Physical symptoms e.g. headaches, nausea, dizziness, tiredness, intolerance of bright light Concentration difficulties, memory loss, difficulty reading or using a computer Emotional changes such as mood swings, irritability and aggression Sleeping pattern changes sleeping more or difficulty falling asleep Page 7

8 Questions & Answers Is it okay to go to sleep? Concussion often makes a player feel drowsy or tired. Once you have been medically assessed, as long as you are not getting worse, as noted above, it is alright for you to sleep. We do however want the responsible adult to be at home with you in case any problems arise May I take something for pain? Do not take any medication unless a doctor has told you to do so. Normally, we do not advise anything stronger than paracetamol (e.g. Panado). Avoid anti-inflammatories e.g. Voltaren, Cataflam, Brufen etc. and anything containing codeine e.g. Myprodol What should I avoid doing? Avoid actions that may worsen your symptoms, slow down recovery or place you at risk Do not consume caffeine (including coffee) or any other stimulants Stop taking any supplements that you may be using Do not consume alcohol until cleared by a medical doctor Do not drive a motor vehicle or motorcycle or ride a bicycle until cleared by a medical doctor Do not exercise at all until medically cleared to do so Do not spend long periods behind a computer, on a cellphone, playing video games, watching TV or reading. Page 8

9 May I eat after the practice or game? It is fine for you to eat if you are hungry. Remember, some athletes do have a sense of nausea and fatigue, and often find that their appetite is decreased immediately after a concussion. Do not force yourself to eat. How long will I be observed? 24 to 48 hrs do not be alone - you must have a responsible adult looking after you. If any red flag symptoms appear go to the Hospital immediately. 24 to 48hr make an appointment with a medical doctor for an after injury assessment after your suspected or confirmed concussion. You must be monitored regularly and your symptoms observed until they have completely cleared. NO exercise or any physical exertion including strength conditioning until you have a clearance certificate. This varies from player to player. In some cases, no academics, TV, cell phones, computers and/or bright lights. Cognitive recovery after concussion is variable but usually occurs within 2 to 3 weeks. Recovery lasting longer than this requires further repetitive medical evaluation. In extreme cases, the Lowmed Concussion Management team communicate with the school when necessary. Page 9

10 What is the role of cognitive computerized testing? What does the computerized cognitive test show? It is NOT used to diagnose a concussion alone. Diagnosis is done clinically by a doctor because it is complex. The baseline give us an individualised data set to use as a comparative in all after injury tests. The computer test tell us if there is a decrease in brain function and guides us to the time required for normal brain function to return. There are however mandatory stand-down periods, and different stage durations based on your age at the time of injury. The computer test helps to determine if school activities (e.g. class, exams) need to be modified and can also be evaluated by your doctor. When do I need to redo the computer test? 24 to 48 hours after injury you need to redo the computerized cognitive test. You can do it at school with your biokineticist to save time but you will still need a clinical assessment with the doctor. Page 10

11 Returning safely to play Why is it so important to return to play at the appropriate time? Returning too soon following a concussion may have serious short and long term consequences including: More serious brain injury and even death Prolonged symptoms lasting weeks or months Greater risk of further concussions Interference with studies (school and university) and work Poor performance on the sports field Long term, permanent brain effects including memory loss and emotional disturbances. Page 11 How to help your cognitive recovery? At home: Keep stressful brain activities to the more essential ones such as homework and reading Avoid texting, non-academic computer work, video games and television Read and study in a quiet and dimly lit area Take regular breaks (every 20 minutes) when doing homework or assignments Organise your day by creating a list of tasks to be completed Report symptom patterns following learning exposure to your doctor

12 Mandatory rest periods Unless advised by a medical doctor with expertise in concussion management, the following minimum rest periods are prescribed for players suspected of suffering a concussion in Rugby: 1. Players younger than 19 years old rest from all exercise for a minimum of 2 weeks, followed by a 4 day period of graduated return to play (GRTP) 2. Players aged 20 years old and older rest from all exercise for a minimum of 1 day followed by a 4 day GRTP, when there is an experienced concussion management team to observe the athlete. Where there is no concussion management team - rest from all exercise for a minimum of 1 week followed by a 4 day GRTP These minimum periods only apply if the player no longer has ANY symptoms of concussion. Note: It is recommended that, in all cases of suspected concussion, the player is referred to a medical professional A clearance certificate is required for the school file before the athlete can return to play. Page 12

13 Gradual Return To Play (GRTP) protocol GRTP protocols need to be done under the supervision of a registered biokineticist. Each stage is to take at least 24 hours but longer in recurrent or severe cases. Progression to the following stage is governed strictly by the player being asymptomatic (no symptoms listed on page 5) Report any headache, dizziness, nausea or other symptoms. Should the player become symptomatic, he/she should return to the previous (asymptomatic) stage and contact the doctor in charge. Return to play certificate is only issued if GRTP is successful. Page 13

14 Cleared by a DOCTOR Cleared by a DOCTOR Cleared by a DOCTOR Cleared by a DOCTOR Cleared by a DOCTOR GET RETURN TO PLAY CERTIFICATE Page 14

15 Important contact information Designation Name Tel no. / Website After hours no Doctor Dr Kobus Hugo drhugo@lowmed.co.za Doctor Dr Gerhard drswart@lowmed.co.za Swart Hospital MediClinic BokSmart Spineline operated by ER Sports Concussion SA sportsconcussion@mweb.co.za Page 15 SCHOOL Uplands BIOKINETICIST Contact Number/ Hannlie Jurgens Lana Goedthart uplands@lowmed.co.za Penryn Magi Louw concussion@lowmed.co.za NHS Jonita Badenhorst x 1939 Other schools Harry Wiltshire Biokineticists jonita@nellish.co.za concussion@lowmed.co.za

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Page Page 2 Concussion step by step guide Name: Date 1.Education 2.Baseline testing 3.Immediate medical evaluation Post-concussion by a medical doctor 4.Follow up Computer testing 5. Return-to-play protocol