Bethel Park s Sports Concussion and Closed Head Injury Protocol and Procedures for Student-Athletes If the Certified Athletic Trainer of Bethel Park School District has a concern that a student-athlete may have sustained a sports concussion or closed head injury due to their participation in athletics, or if one or more individuals express concern to a member of the Athletic Training Staff that a student-athlete may have suffered a sports concussion or a closed head injury, this protocol will be followed. The health and welfare of the student-athlete will be the primary consideration throughout the process. Definition of Sports Concussion Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include : 1. Concussion may be caused 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 neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that in a small percentage of cases, post-concussive symptoms may be prolonged. 5. No abnormality on standard structural neuroimaging studies is seen in concussion. (Consensus Statement on Concussion in Sport: The 3 rd International Conference on Concussion in Sport Held in Zurich, November 2008, JAT 2009) Definition of Closed Head Injury: Any injury to the head can cause damage to the brain stem and other vital centers of the brain. This can include but is not limited to traumatic brain injury, cerebral contusion, epidural hematoma, and subdural hematoma. (NATA Position Statement: Management of Sports Related Concussion, 2004) - 1 -
Signs and Symptoms of Sports Concussion and/or Closed Head Injury: A sports concussion and/or closed head injury will be suspected if any Bethel Park student-athlete presents with one of the following signs, symptoms or decline from baseline ImPACT Concussion assessment test, after sustaining direct or indirect contact to the head. If no baseline test is available, a student-athlete must be symptom free according to the Certified Athletic Trainer s assessment. These can include clinical symptoms, physical signs, cognitive impairment, and/or loss of consciousness. Any student-athlete with signs, symptoms, or problems will be removed from play that day, monitored and will not return to play on the day of injury. The following is a list of possible signs, symptoms, or problems related to a sports concussion or closed head injury: Seizure or convulsion Amnesia 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 Slurred Speech More emotional than usual Hearing Problems/ringing in the ears Loss of Consciousness Irritability Sadness Nervous or anxious *This is not an all inclusive list, other signs, symptoms, or problems may occur that are not listed. On-Field or Sideline Evaluation of Acute Concussion When a student-athlete shows ANY features of a concussion: (a) The player should be medically evaluated onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury. (b) The appropriate disposition of the player must be determined by the treating Health care provider in a timely manner. If no health care provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged. - 2 -
(c) Once the first aid issues are addressed, then an assessment of the concussive Injury should be made using the SCAT2 (See Appendix A.1). (d) The player should not be left alone following the injury, and serial monitoring for deterioration is essential over the initial few hours following injury. (e) A player with diagnosed concussion should not be allowed to return to play (RTP) on the day of injury. Occasionally, in adult athletes, there may be RTP on the same day as the injury. This decision will be made by the Certified Athletic Trainer or Team Physician. Referral Guidelines Once a student-athlete has presented with any of the above signs, symptoms, or problems; they will be monitored, including vital signs and level of consciousness, every several minutes after the onset of the aforementioned signs and symptoms. Monitoring will continue until one of the following scenarios is determined: 1. Immediate Referral to Emergency Room: Any student-athlete presenting with any of the following signs, symptoms, or problems will be referred to the emergency room immediately upon assessment: Deterioration of neurological function Decreasing level of consciousness Irregularity in respirations Irregularity in pulse Unequal, dilated, or unresponsive pupils Any signs or symptoms associated with spinal or skull fractures, e.g. Halo sign. Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation. Seizure Activity 2. Referral to Physician or Emergency Room on the Day of the Injury a. Any student-athlete presenting with any of the following signs or symptoms when compared to the initial on-field assessment, will be referred to a physician or ER on the day of the injury: Loss of Consciousness Amnesia lasting longer than 15 minutes Increase in blood pressure Cranial nerve deficits Vomiting Motor deficits subsequent to initial on-field assessment Sensory deficits subsequent to initial on-field assessment Balance deficits subsequent to initial on-field assessment Cranial nerve deficits subsequent to initial on-field assessment - 3 -
Revised 10-4-10 Post concussion symptoms that worsen Additional post concussion symptoms as compared with those on the field. b. A student-athlete will also be referred to a physician or ER on the day of injury if he/she has not shown improvement in their signs or symptoms by the end of practice or competition. 3. Release of the Student-Athlete from the Supervision of a Certified Athletic Trainer with Take-Home Instructions: If the student-athlete has shown an improvement in their signs and/or symptoms by the end of the practice or competition, they will be given Take-Home Instructions (See Appendix A.2) for care while they are at home and not under the supervision of a Certified Athletic Trainer. These instructions will be given and explained to a responsible individual as determined by the Certified Athletic Trainer. The student-athlete will be continually monitored for deterioration every few hours and day(s) afterwards as problems could arise over the next 24-48 hours. The student-athletes will be monitored regularly until they are symptom free. 4. Delayed Referral (after the day of injury): If a student-athlete that was released from the supervision of a Certified Athletic Trainer and given Take-Home Instructions presents with any of the following signs and/or symptoms after the day of injury, he/she will be referred to a physician as determined by the Certified Athletic Trainer. Any of the findings in above sections 1 and/or 2 that have developed since the initial evaluation, Post concussion symptoms that worsen or do not improve over time Increase in number of post concussion symptoms reported. Post concussion symptoms begin to interfere with the athlete s daily activities (i.e. sleep disturbances or cognitive difficulties.) Any student-athlete that has presented with signs and/or symptoms related to a sport concussion will be monitored regularly using the Impact Concussion Software and the Post Concussion Symptoms Scale (See Appendix A.3) - 4 -
ASSESSMENT AND TESTING Revised 10-4-10 Assessment Tools: The Bethel Park Athletic Trainer will utilize the ImPACT Concussion Software and SCAT 2 to assess recovery of the concussed student-athlete. ImPACT is a standardized method of evaluating people after concussion and is considered a valid and reliable method of testing neurocognitive function. Mandatory Testing: All student-athletes during their Freshman and Junior years (and first time Sophomore and Senior participants) will undergo baseline Impact testing if they participate in one of the following sports at Bethel Park High School: Football Men s Soccer Women s Soccer Wrestling Cheerleading Men s Basketball Women s Basketball Men s Lacrosse Women s Lacrosse Softball Baseball These athletic teams were chosen because they were shown to be at an increased risk for suffering sports concussions and closed head injuries (Journal of Athletic Training, 2003). Voluntary Testing: Do to the volume of athletes involved in athletics at Bethel Park Middle / High School; there is insufficient time to test all athletes. However, for athletes who wish to participate in ImPACT testing for their respective sport, there will be a scheduled time in which baseline testing will be offered. RETURN-TO-PLAY GUIDELINES Once a student-athlete has displayed any of the signs and/or symptoms stated above, the student-athlete will be removed from practice or competition for the remainder of that day. When the student-athlete is symptom free for 24 hours, the student-athlete will be retested using the Impact test. The student-athlete will not be physically tested until the Impact test results have returned to baseline. - 5 -
IMPACT TESTING and RE-TESTING Criteria 1 If a student-athlete is symptom free or has returned to baseline on the Post Concussion Scale, within the first 24 hours after injury and has remained symptom free for 24 hours he/she will be Impact re-tested. If the first attempt of the Impact retest has returned to baseline, the student-athlete can begin Physical Exertional Testing (aerobic activity, sport specific exercise, simulated game activity). The student-athlete must return to baseline on the Impact test, be symptom free throughout the Exertional testing, and remain symptom free for 24 hours before he/she can return to play. If the student-athlete has a recurrence of signs and/or symptoms during the Physical Exertional Activity or within 24 hours after testing, he/she must follow Criteria 2 for return to play. Criteria 2 If the student-athlete is not symptom free within the first 24 hours after the injury, he/she will not be re-tested with Impact until he/she is symptom free for 24 hours. If the second attempt of the Impact retest has returned to baseline, the studentathlete can begin the Physical Exertional Testing on the same day; however only with light aerobic activity. If the athlete remains asymptomatic after aerobic activity, the athlete will be able to begin sport specific drills 24 hours later, and controlled or simulated game activity 48 hours later if asymptomatic. If the second attempt of the Impact re-test has NOT returned to baseline, but the student-athlete is asymptomatic, he/she must follow Criteria 3 for return to play. Criteria 3 If the student-athlete is not asymptomatic within the first 24 hours after the injury or physical exertion, he/she will not be re-tested with Impact until asymptomatic for 24 hours. If the student-athletes post-injury Impact scores have not returned to baseline, the athlete must wait 24 hours before they are able to re-test. Once the Impact scores have returned to baseline, the student-athlete can begin Physical Exertional testing that day; however can only begin with light aerobic activity. If athlete remains asymptomatic after aerobic activity, the athlete will be able to begin sport specific drills 24 hours later and simulated game activity 48 hours later if athlete remains asymptomatic. - 6 -
Student-Athletes With Out Impact Baseline Testing: If a student-athlete without an Impact baseline test is symptom free within the first 24 hours after injury and has remained symptom free for 24 hours, he/she can begin the Physical Exertion Testing Protocol. The student-athlete must be symptom free throughout the Physical Exertion Testing Protocol and remain symptom free until the next day before he/she can be retuned to play. If the student-athlete is not asymptomatic within the first 24 hours after the injury, he/she will not be permitted to begin physical exertional testing. Only after 24 hours of no symptoms may the athlete begin the Physical Exertion Testing Protocol. Physical Exertion Testing Protocol: The student-athlete must be symptom free for 24 hours before he/she can progress to the next step in the sequence, with the exception of Criteria 1 and studentathletes without impact baseline scores whose symptoms resolve within 24 hours (above). The student-athlete will not be returned to full activity until he/she has remained symptom free for 24 hours after testing. If the student-athlete experiences any signs and/or symptoms at any one step he/she will begin at the previous step once he/she has been symptom free for 24 hours. Step 1. Aerobic exercise short sprints, sit-ups, push-ups, etc. Step 2. Non-contact drills/sport specific exercise Step 3. Simulated game activity/controlled contact drilling Step 4. Return to Play Disqualification: If the data shows that a student-athlete has suffered a sports concussion or closed head injury, a multidisciplinary approach will be taken to return the studentathlete to active status. The student-athlete will be spoken with regularly until symptom free. Because no two concussions are the same, disqualification for a season or career will be determined by the certified athletic trainer, team physician, and/or any other involved medical specialists. References: National Athletic Trainers Association Position Statement: management of Sports- Related Concussion. Journal of Athletic Training, 2004; 39(3): 280-297. Consensus Statement on Concussion in Sport: The 3 rd International Conference on Concussion in Sport, Zurich 2008. Journal of Athletic Training, 2009; 44(4):434-448. - 7 -