Concussion Management in Athletics: Prevention, Signs, & Return-to-Play Protocol

1. Athletics Meeting Sandra Marshall M.A., LAT, ATC

2. Paperwork… • Must be completely filled out and cleared to play. • Physical, Insurance Waiver and Concussion form • Emergency information sheet gives clearance for ATC to receive medical information about an athlete. • Can add HRMS athletics to HIPPA forms when athlete goes to MD. • Current Sports season athletes • Nutrition, hydration, and clothing

3. Injuries • Athletes should see Coach and Athletic Trainer if injured • Contact Coach • See Athletic Trainer • Evaluation and MD referral • Paperwork from MD • Clearance by Athletic Trainer • PE/academic restrictions

4. Concussion Education:Dangers You Should Be Aware Of

5. The Problem • Concussions are an “invisible” injury. • Proper diagnosis depends on the athlete to report “ALL” symptoms. • Athletes are not sure what they are feeling when the have a concussion.

6. What is a Concussion? • Brain injury associated with a temporary loss of brain function. • Avoid terms such as “Ding” or “Bell Ringer” • Causes • A direct blow or force to the head. • Head to Head • Head to Ground • Head to Object • Impact occurs to another part of the body, but the energy is transferred to the head.

7. Signs and Symptoms • Headaches • “Pressure in Head” • Nausea or Vomiting • Balance Problems or Dizziness • Loss of Consciousness • Seizures or Convulsions • Blurred, Double, or “fuzzy vision. • Sensitivity to light or noise • Confusion • Concentration Difficulty • Memory Difficulty • Amnesia • “Don’t Feel Right” • Feeling foggy or groggy • Neck Pain • Fatigue or Low Energy • Drowsiness • Sadness • Nervousness or anxiety • Irritability • More Emotional Than Usual • Repeating • Change in Sleep Patterns • Feeling Sluggish or Slowed Down

8. Concussions: What Can We Do? • Prevent • Proper Equipment and Technique • Decrease the number of Head to Head hits. • “Look” for Signs and Symptoms • Parents, Coaches, Teammates, Teachers, and Athletic Trainers should share this responsibility. • All members should communicate in a “TEAM” fashion. • Obtain Baseline Cognitive Test • Education • Gfeller-Waller Concussion Awareness Act

9. Gfeller-Waller Concussion Awareness Actincludes: • Mandatory Concussion Education For All Coaches, Volunteers, School Nurses, Athletes, and Parents. -Written information detailing the recognition of the signs and symptoms of concussions. Parents and athletes must sign this informational sheet prior to participation in any interscholastic activities, including tryouts, practices , or competitions. -A description of the physiology and the potential short term and long term effects of concussions. -The medical return to play protocol for post- concussion participation in interscholastic activities.

10. EMERGENCY ACTION PLAN (Each school shall develop and maintain: venue specific) • Must be: • In writing • Reviewed by a licensed athletic trainer in North Carolina. • Approved by the principal of the school. • Distributed to all appropriate personnel. • Posted conspicuously at all venues. • Reviewed and rehearsed annually by all licensed athletic trainers, first responders, coaches, school nurses, athletic directors and volunteers.

11. Concussion Management • No Return the same day regardless of severity. • Must be evaluated and receive written clearance by a: • Physician licensed under Article 1 of Chapter 90 of the General Statutes with training in concussion management. • Neuropsychologist licensed under article 18A of Chapter 90 of the General Statutes with training in concussion management. Due  to  the  need  to  monitor  concussions  for   recurrence  of  signs  &  symptoms  with  cognitive or physical  stress, Emergency Room and Urgent Care  physicians cannot  make  a clearance decision for an athlete.

12. Return to Play • Once  the  athlete  is  completely  symptom free at rest, and has  no  symptoms  with  cognitive  stress  (i.e.  reading  or school  work), and is cleared by a Physician licensed under Article 1 of Chapter 90 of the General Statues and has had training in concussion management THEN a gradual return to play progression may be  started.   • All  players  must  complete  a  Return  to  Play  Protocol in a stepwise fashion with gradual progressive stages by/under the supervision of: • Certified Athletic Trainer licensed under Article 34 of Chapter 90 of the general statutes. • Physician Assistant, consistent with the limitations of G.S. 90-18.1 • Nurse Practitioner consistent with the limitations of G.S. 90-18.2

13. Return-To-Play • Must be symptom free without medication for 24 hours. • Day 1: Low level physical activity (light Jogging, Stationary Bike, Walking) • Day 2: Moderate Levels of Physical Activity (Weightlifting) • Day 3: Heavy non-contact physical activity (Sports Specific Drills) • Day 4: Non-contact sports specific practice. • Must consult with collaborating physician regarding athlete’s progress PRIOR to initiating contact during Stage 5 • Day 5: Full contact practice • Day 6: Unrestricted return to activity or return to competition.

14. Return-To-Play • Satisfactory Neuro-cognitive Scores Compared To Baseline • No earlier than 48-72 hours post injury. • May only move 1 step per day (supervised) • If an athlete has any symptoms during RTP process they will need to rest and be sign and symptom free for 24 hours. They will then return to the last stage that was completed sign/symptom free. • If a student is unable to complete a stage twice without return of signs or symptoms they will be asked to consult with their doctor before continuing the RTP protocol. • Upon completion the parents, athlete and Athletic Trainer must sign that the athlete has completed the Return-to-Play protocol.

15. Why So Conservative? • Second Impact Syndrome • Occurs when an athlete sustains a direct or indirect force to the head before recovering from the last concussion. • Young Males • Dangers • Long Term Morbidity • 100% of cases • DEATH • 50% of the cases

16. Long Term Effects • Decreased Decision Making Abilities • Professional Athletes • Permanent Brain Dysfunction • Depression Suicide • Professional Athletes • Possible early onset of dementia, Alzheimer's, or pre-mature death.

17. Important points to remember… • No Return to play the same day regardless of severity. • Must be evaluated and receive written clearance by a licensed physician-ER doctor clearances will require the athlete to see another doctor. • Proper concussion paperwork must be completed in its entirety and returned to the Athletic Trainer before RTP can begin. • RTP is a 6 day supervised process and may take more than 6 days due to athlete becoming symptomatic or because of weekends. • All athletes with concussions must follow the process set forth by the Gfeller-Waller Concussion Awareness Act. Our priority is always the health and safety of the athlete!

18. MRSA • Methicillin –Resistant Staphylococcus Aureus • Infection is caused by a strain of staph bacteria that's become resistant to the antibiotics commonly used to treat ordinary staph infections. • Generally start as small red bumps that resemble pimples, boils or spider bites. These can quickly turn into deep, painful abscesses that require surgical draining.

19. MRSA-Risk Factors Participating in contact sports. • MRSA can spread easily through cuts and abrasions and skin-to-skin contact. • Share items and surfaces that come into direct skin contact. • Have inadequate access to hygiene measures

20. How to prevent the spread of MRSA • See a doctor and get medical care for your infection • Cover your wounds. Keep wounds covered with clean, dry bandages until healed. • Clean your hands often. • Do not share personal items like towels, washcloths, razors, clothing, and uniforms. • Wash used towels and clothes with water and laundry detergent. Use a dryer to dry clothes completely.

21. Resources of Interest • http://www.nata.org/statements/#off • http://www.cdc.gov/ConcussionInYouthSports.com • http://impacttest.com/concussion/overview • http://tbicenter.unc.edu/MAG_Center/Home.html