UNIVERSITY OF NEVADA SPORTS MEDICINE Concussion Guidelines Created 8/21/08 Updated: 9/21/09

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1 UNIVERSITY OF NEVADA SPORTS MEDICINE Concussion Guidelines Created 8/21/08 Updated: 9/21/09 Management of concussion in sport can be challenging as every concussion is individually unique and there are no universal standards on concussion care and return to play guidelines. The following guidelines were developed for use by the U.S. Olympic Committee Sports Medicine Division and by the consensus panel at the 3 rd International Conference on Concussion in Sport Held in Zurich, November These documents have been adapted as appropriate for the University of Nevada s Sports Medicine program. The goal of this document is to develop a common management program for athletic trainers and physicians for the diagnosis, treatment and return to play guidelines of concussed athletes. 1, 2, 3, 4 DEFINITION The definition or nature of concussion is not universally agreed upon; however, agreement does exist on many features that incorporate clinical, pathologic, and biomechanical injury changes associated with head injury including the following: 1. Concussion is caused by excessive force transmitted to the head and may be induced by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. 2. Concussion typically results in the rapid onset of short lived impairment of neurologic function that resolves spontaneously. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional or metabolic disturbance rather than structural injury. 4. Concussion results in a variety of signs and symptoms that may or may not involve loss of consciousness (LOC). Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, in a small percentage of cases, postconcussive symptoms may be prolonged. 5. No abnormality on standard structural neuroimaging studies is seen in concussion. CLASSIFICATION OF CONCUSSION 4 A key development derived from the 3 rd International Conference on Concussion in Sport (Zurich) was the unanimous agreement to abandon the simple versus complex terminology proposed in the Prague statement 4. The panel unanimously retained the concept that the majority (80 90%) of concussions resolve in a short (7 10 days) period, although the recovery time may be longer in children and adolescents 4. Prior conferences abandoned the other concussion grading scales. CONCUSSION EVALUATION 1, 2, 3, 4, 5 Signs and Symptoms of Acute Concussion If ANY one of the following symptoms or problems is present, a head injury should be suspected and appropriate management instituted. Typical Signs Observed Appears to be dazed or stunned

2 Is confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily Balance problems Answers questions slowly Loses consciousness (even temporarily) Shows behavior or personality change Forgets events prior to hit (retrograde amnesia) Forgets events after hit (anterograde amnesia) Other symptoms such as sleepiness, sleep disturbance, and a subjective feeling of slowness and fatigue in the setting of impact may indicate that a concussion has occurred or has not resolved. Signs Reported by Athlete Headache Nausea Balance problems or dizziness Double or fuzzy vision Sensitivity to light or noise Feeling sluggish Feeling "foggy" Change in sleep pattern Emotional lability Concentration or memory problems On Field or Sideline Evaluation of Acute Concussion If a student athlete shows ANY sign of concussion: The student athlete should be evaluated onsite using standard emergency principles. Particular attention should be given to excluding a cervical spine injury. The appropriate disposition of the student athlete must be determined by a health care provider in a timely manner. If no healthcare provider is available, the student athlete should be removed from practice/play and urgent referral to a physician should be arranged. Once the first aid issues have been addressed, an assessment of the concussive injury should be performed using the SCAT2 or similar tool. The player should not be left alone following the injury and serial monitoring for deterioration is essential for the initial few hours following the injury. A student athlete diagnosed with a concussion will not be allowed to Return to Play on the same day as the injury. Sideline evaluation should include brief cognitive testing that assesses attention and memory function, balance assessment and assessment of signs and symptoms. It should be understood that these tests are not meant to replace comprehensive neuropsychological and clinical testing.

3 Recognize that symptoms may be delayed for several hours following a concussive episode. CONCUSSION MANAGEMENT The cornerstone of management is complete rest from training, competition and cognitive activities until all symptoms resolve. Then, a graded program of exertion is completed before return to sport. Injury usually progressively resolves without complication over 7 10 days. Athlete typically resumes sport without further problems. Neuropsychological computerized screening will be used to assist return to play decisions, however it is not the sole tool used for management decisions. Most concussions can be appropriately managed by primary care physicians or by certified athletic trainers working under medical supervision. All concussions mandate evaluation by a medical doctor. Modifying Factors in Concussion Management 4 Encompasses cases where student athletes suffer: o Persistent symptoms despite rest, or symptom recurrence with exertion. Number of symptoms Duration of symptoms (>10 days) Severity o Signs Prolonged loss of consciousness (>1 minute) Amnesia o Specific sequelae: Concussive convulsions Prolonged cognitive impairment following injury o Temporal Frequency repeated concussions over time Timing injuries close together Recency : recent concussion or traumatic brain injury o Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion o Age Formal neuropsychological testing and other investigations should be considered Athletes should be managed in a multidisciplinary manner by physicians with specific expertise in the management of concussive injury; e.g. sports medicine physician with experience in concussion, sports neurologist, or neurosurgeon 2, 3, 4. NECK INJURIES 3 It is not uncommon for the neck to be injured concurrently with a concussion. Indications that there is an associated neck injury and recommendations for treatment include:

4 1. Presence of headaches that are made worse with neck motion or prolonged postures generally indicate a cervicogenic headache. 2. Post concussive headaches aggravated by any physical or cognitive exertion may be related to a neck injury, but this is not always clear. 3. Active rehabilitation of neck injuries may aggravate post concussive headaches. 4. Rehabilitation of the neck must be done in a cautious manner and response to treatment must be carefully monitored. Ultimately, the treatment goal is to resolve the headache. 1, 2, 3, 4, 5 CONCUSSION MANAGEMENT When a player shows ANY signs or symptoms of a concussion: 1. The player should not be allowed to return to play on the day of injury. Even when initial symptoms clear quickly, the athlete may experience delayed symptoms or depressed neurocognitive levels. 2. The player should not be left alone; regular monitoring for deterioration is essential. 3. The player should be medically evaluated following the injury. 4. Return to play must follow a medically supervised stepwise process, monitored by a medical doctor. A player should never return to play while symptomatic. When in doubt, sit them out! HOME CARE Home care is a crucial part of concussion management: 1. If an athlete is allowed to return home or to the dormitory, counsel should be given to a friend, teammate, parent, or coach to closely monitor the athlete. 2. Verbal and written instructions should be given to the athlete and companion regarding concussion care in the first 24 hours post concussion see Nevada Sports Medicine Head Injury Instructions. 3. Traditionally, these instructions may include a recommendation to awaken the student athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed such as a subdural hematoma. This recommendation is debated as unnecessary wake ups will disrupt the student athlete s sleep pattern and may increase symptoms the next day due to combined effects of injury and sleep deprivation. No documented evidence suggests the severity to which a head injury requires this treatment. A good rule to use: if the student athlete experienced loss of consciousness, had prolonged amnesia or is still experiencing significant symptoms, he or she should be awakened during the night. Otherwise the athlete should be allowed to sleep approximately 8 hours before being awakened. 1, 2, 3, 4, 5 RETURN TO PLAY GUIDELINES When considering return to play criteria for simple concussion, medical providers should focus attention on the student athlete s recovery via: 1. Symptoms

5 2. Neurocognitive testing 3. Postural stability testing Return to play guideline following a concussion follows a stepwise process: 1. No activity, complete rest; once asymptomatic proceed to level 2 During this period of recovery in the first few days following injury, it is important to emphasize to the student athlete that physical AND cognitive rest is required. Activities that require concentration and attention may exacerbate symptoms and delay recovery. This includes prolonged reading, time in front of a computer or television, watching movies, and playing video games. 2. Light aerobic exercise such as walking or stationary cycling, NO resistance training Resistance training has been shown to increase intracranial pressure and to exacerbate post concussive symptoms; particularly headaches, dizziness, etc. Resistance training may generally be added in the later stages of the step wise approach (step 4), beginning with low weight/high repetition exercises and then progressing to higher weights if asymptomatic and tolerated Sport specific exercise (e.g. skating in hockey, jogging in soccer), progressive at steps 3 or 4 4. Non contact training drills 5. Full contact training after medical clearance 6. Game play With this stepwise progression, the athlete may continue to proceed to the next level, if asymptomatic at the current level. If any post concussion symptoms occur, the patient should drop back to the previous asymptomatic level and try to progress again after 24 hours. With persistent concussion symptoms, the rehabilitation will be more prolonged and return to play advice will be more circumspect. It is imperative that complex cases are supervised by physicians with specific expertise in the management of such injuries 2, 3, 4. WHEN TO REMOVE FROM FUTURE PARTICIPATION 3 It is widely believed that once a student athlete experiences a concussion, he/she is more prone to experience another. However, debate exists over the question of how many concussions are too many, and the cumulative effect of multiple concussions. Most experts would agree that a student athlete in the following scenarios is one who should discontinue high risk activities: 1. The student athlete who has had numerous concussions, with each concussion seemingly more easily obtained, and with symptoms that are more severe and/or longer lasting, i.e., disproportionate to the impact.

6 2. Any student athlete with residual neurocognitive problems persisting well after other symptoms have resolved. 3. A student athlete with protracted, prolonged symptoms. 4. A team of physicians, athletic trainers, and others involved in the student athlete s collegiate career will determine recommendations for removal from future participation status.

7 IMPLEMENTATION OF CONCUSSION GUIDELINES AT UNIVERSITY OF NEVADA 1. Starting in 2009, baseline ImPACT Concussion baseline testing will be performed on all incoming student athletes in contact sports. 2. Upon initial impact event a sideline concussion assessment and a physical exam will be performed. Tools that may be utilized at the time of injury are the Pocket Sport Concussion Assessment Tool 2, the Sideline Concussion Assessment Tool (SCAT2) and the ImPACT Concussion symptom checklist. These tools will be included in the student athlete s medical record. a. See ImPACT Concussion Symptom Checklist b. See Pocket Sport Concussion Assessment Tool 2 c. See Sideline Concussion Assessment Tool (SCAT2) 3. Student athletes with symptoms suggestive of intracranial and/or cervical pathology will be evaluated and referred to the Emergency Department as indicated. 4. Prior to allowing a student athlete to go home, the Head Injury Instructions will be reviewed with the student athlete and another responsible adult that will be staying with the student athlete immediately post injury. 5. Serial follow up assessments using the concussion guideline and return to play guidelines will be performed. The student athlete will not participate until return to play is deemed appropriate by the treating medical team, the presence or absence of symptoms, and results of repeated ImPACT testing. 6. ImPACT testing will be used to evaluate the concussed student athlete and monitor progress. 7. The return to play progression may vary for each student athlete. Some student athletes may skip a progression(s) while others may not advance as quickly. This is at the discretion of the treating medical team and ultimately the team physician. 8. Consultant information: Neuropsychology: Staci R. Ross, Ph.D., ABPP 716 South 6th Street Las Vegas, NV Phone: (702) Fax: (702) Cell: (702) stacirross@gmail.com Susan D. Ayarbe, Ph.D Kietzke Lane, Suite 202 Reno, NV 89511

8 Phone: (775) Neurology: Mindy Schwartz, MD Double R Blvd Ste 330 Reno, NV Phone: (775) ImPACT TESTING PROGRAM Beginning in January 2009, all incoming freshman and transfer student athletes in contact sports at the University of Nevada will undergo ImPACT testing prior to participation in contact sports see ImPACT Concussion Program Information for Student Athletes. The test will consist of a 20 minute computer based program which will evaluate the student athletes attention span, sustained and selective attention time, working memory, response variability, non verbal problem solving, and reaction time. The steps for ImPACT testing are as follows: 1. ImPACT testing will be completed before participation in contact sports. The test is to be administered by the designated Athletic Trainer. For additional information on ImPACT Concussion Management: 2. All baseline results will be reviewed for student athletes who have had multiple previous concussions or who have responded yes to the medical history questions regarding seizures, headaches and/or psychiatric issues. If deemed necessary by the team physician, neuropsychology and/or neurology consults will be obtained. 3. Following a concussive event, a second ImPACT test (baseline being the first) will be performed within 72 hours of the concussion hours is optimal re test time if available based on team travel and access to the ImPACT program. 4. Baseline and post concussive results will be compared and reviewed with Neuropsychology specialists and the University of Nevada team physician. Other testing deemed appropriate by the physician may occur. The student athlete will not be allowed to participate in his/her sports until medically cleared. 5. Re testing will typically be weekly but may be different on a case by case basis. 6. The player will not return to play until symptom free. After symptoms resolve, an exertional stepwise progression will be initiated. See Return to Play Guidelines above.

9 Literature Cited 1. Summary and Agreement Statement of the 2 nd International Conference on Concussion in Sport, Prague Paul McCrory, Karen Johnston, Willem Meeuwisse, Mark Aubry, Robert Cantu, Jiri Dvorak, Toni Graf Baumann, James Kelly, Mark Lovell, and Patrick Schamasch 2. Summary and Agreement Statement of the 1 st International Symposium on Concussion in Sport, Vienna Concussion Sport (CIS) Group: Mark Aubry, Robert Cantu, Jiri Dvorak, Toni Graf Baumann, Karen M. Johnston (Chair), Jams Kelly, Mark Lovell, Paul McCrory, Willem H. Meeuwisse, and Patrick Schamasch 3. Return to Play After Concussion. James Kissick and Karen Johnstone. Clin J Sport Med Vol 12(6) Nov Consensus Statement on Concussion in Sport The 3(rd) International Conference on Concussion in Sport held in Zurich, November McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R 5. Guidelines for the Assessment and Management of Sport Related Concussion May 9, Canadian Academy of Sports Medicine Concussion Committee. 6. National Athletic Trainer s Association Position Statement: Management of Sport Related Concussion, September Kevin Guskiewicz, Scott Bruce, Robert Cantu, Michael Ferrara, Games Kelly, Michael McCrea Margot Putukian, and Tamara Valovich Mcleod.

10 ImPACT Postconcussion Scale Directions: After reading each symptom, please circle the number that best describes the way you have been feeling today. Symptom None Minor Moderate Severe Headache Nausea Vomiting Balance problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems Name: Date: Total Score:

11 Pocket SCAT2 Concussion should be suspected in the presence of any one or more of the following: symptoms (such as headache), or physical signs (such as unsteadiness), or impaired brain function (e.g. confusion) or abnormal behavior. 1. Symptoms Presence of any of the following signs & symptoms may suggest a concussion. 1. Loss of consciousness 2. Seizure or convulsion 3. Amnesia 4. Headache 5. Pressure in head 6. Neck Pain 7. Nausea or vomiting 8. Dizziness 9. Blurred vision 10. Balance problems 11. Sensitivity to light 12. Sensitivity to noise 13. Feeling slowed down 14. Feeling like in a fog 15. Don t feel right 16. Difficulty concentrating 17. Difficulty remembering 18. Fatigue or low energy 19. Confusion 20. Drowsiness 21. More emotional 22. Irritability 23. Sadness 24. Nervous or anxious 2. Memory function Failure to answer all questions correctly may suggest a concussion. At 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?

12 3. Balance testing Instructions for tandem stance Now stand heel to toe with your non dominant foot in back. Your weight should be evenly distributed across both feet. You should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes. Observe the athlete for 20 seconds. If they make more than 5 errors (such as lift their hands off their hips; open their eyes; lift their forefoot or heel; step, stumble, or fall; or remain out of the start position for more than 5 seconds) then this may suggest a concussion. Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY, urgently assessed medically, should not be left alone and should not drive a motor vehicle.

13 UNIVERSITY OF NEVADA SPORTS MEDICINE ImPACT Concussion Program Information for Student Athletes The Nevada Sports Medicine program implements ImPACT testing for all incoming freshman and transfer student athletes involved in contact sports. ImPACT (immediate post concussion assessment and cognitive testing) is the most widely used computer based testing program specifically designed for the management of sports related concussion in the world. Research in the field of concussion diagnosis and treatment has become a very important topic in recent years. In 2001 the first International Symposium on Concussion in Sport was held in Vienna, Austria. Since, subsequent international meetings have convened and attention to concussion management has increased worldwide. Concussion defined is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Current research suggests that 10% of athletes participating in a contact sport sustain concussions yearly and that 63% of all sports related concussions happen on the football field. It is estimated that up to 20% of football players are involved in at least one concussive event per season. ImPACT testing is performed before student athletes begin their respective sports at the University of Nevada. This gives the sports medicine staff baseline information that can then be used to compare information received by an ImPACT test following a concussive event. The test takes approximately 20 minutes and the program evaluates multiple aspects of cognitive functioning including: attention span, sustained and selective attention time, working memory, response variability, nonverbal problem solving, and reaction time. Following the test, a graphic display of the data collected is presented. In the case of concussion, the test will be retaken and a sports medicine staff member will compare the baseline results with the post concussive results and use the information gained from ImPACT as a tool for diagnosis and management of the concussion. When student athletes suffer a second concussion while still recovering from the first, catastrophic consequences can occur. This event, termed second impact syndrome, has led to approximately deaths over the past decade. ImPACT testing provides another tool to help eliminate second impact syndrome. Additionally, returning an athlete to play while they are continuing to experience symptoms of an initial concussion can increase the vulnerability for persistent symptoms as well as subsequent concussions. We feel confident that ImPACT testing will enhance our ability to diagnose and manage concussions and will benefit the overall wellness and future of our student athletes. Your ImPACT test will be facilitated by an Athletic Trainer before your participation in contact sports at the University of Nevada. Please let us know if you have any questions.

14 UNIVERSITY OF NEVADA SPORTS MEDICINE Head Injury Instructions was seen in the Sports Medicine Department because of a concussion or mild brain injury. The student athlete was observed for a period of time, and it was felt that it was not necessary, at that time, to hospitalize him/her. However, there are several things we request you do at home. It is important that the student athlete is observed closely for the next 24 to 48 hours. Call the Athletic Training Department (775) during working hours or call your Athletic Trainer at number (775) after hours if the signs/symptoms listed below develop or worsen. For severe symptoms or changes, call 911 and go to the nearest Emergency Department. Once the student athlete is at the Emergency Department, please contact the Athletic Training staff. Severe headache (deep throbbing) Dizziness or loss of coordination Temporary loss of memory; mental confusion Ringing in the ears (tinnitus) Blurred or double vision Unequal pupil size No pupil reaction to light Nausea and/or vomiting Slurred speech Convulsions or tremors Sleepiness or grogginess Clear fluid running from the nose and/or ears Numbness or paralysis (partial or complete) Difficulty in being aroused HOME CARE Avoid taking medications except acetaminophen (Tylenol ) after the injury. The student athlete should not drive until cleared to do so. Avoid ingesting alcohol, illicit drugs, or other substances that interfere with cognitive function and neurologic recovery. Rest, but resume normal activities of daily living as tolerated. Avoid activities involving exertion and any activity that increases symptoms. Avoid prolonged television or time in front of a computer. Do not watch movies or play video games until symptoms have resolved completely. Please notify the Athletic Trainer if the student athlete is having difficulty in school/classes. Eat a light, well balanced diet that is nutritious in both quality and quantity. Awaken the student athlete during the night to check on deteriorating signs and symptoms only if he/she experienced a loss of consciousness, had prolonged symptoms of amnesia, or was still experiencing significant symptoms at bedtime. University of Nevada Phone: Sports Medicine Fax: Reno, NV