1. Sport-Related Concussion Information Northwestern College Sports Medicine

2. Northwestern College Sports Medicine Team  Dr John Odom MD 952-545-2225  Dave Hieb M.Ed. ATC/R 651-631-5345 651-675-7908  Sara Mortensen M.S. ATC/R; PES 651-628-3448 651-283-6011  Northwestern College Health Service 651-631-5246

3. What is a concussion?  A concussion is an injury to the brain that affects the brain’s ability to function properly. According to the Concussion in Sport Group, these injuries are defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”

4. How many people get concussions?  The Center for Disease Control and Prevention estimated that approximately 1.6 to 3.8 million sport-related concussions occur annually in the United States. 18.2% of them were a sport-related concussion.3 In high school athletics 8.9% of all injuries suffered were concussion. Of all the high school sports, the most concussions are seen in football, and soccer. In football specifically, 67.6% of the concussion suffered were caused by tackling or being tackled. Of the different positions, linebackers and running backs suffered more concussions than compared to the other positions. In soccer, the most common cause of a sport-related concussion in both boys and girls is heading the ball.

5. Signs Observed by Coaches  : Confusion  Loss of Consciousness  Dizziness  Easily Distracted  Vomiting  Easily Distracted  Drowsiness  Poor Concentration  Personality Change  Memory Problems  Irritability  Poor Balance or Coordination  Nervousness

6. Symptoms Reported By Athletes  Headaches  Vomiting  Neck Pain  Nausea  Dizziness  Vision Problems  Sensitivity to Noise/Light  Poor Balance or Coordination  Feeling "in a fog“  "Seeing Stars“  Drowsiness  Ringing in Ears  Feeling "dinged“  Nervousness  Poor Concentration  Memory Problems

7. Signs Observed by Parents  Severity of Headache  Level of Consciousness  Dizziness  Easily Distracted  Vomiting  Drowsiness  Poor Concentration  Personality Change  Memory Problems  Irritability  Nervousness  Poor Balance or Coordination  Nausea  Sensitivity to Noise/Light  Hyposmia (reduced ability to smell)

8. Red Flag" for Immediate Referral to Emergency Room  "Brain Function Deteriorating  Loss of Consciousness  Decreasing Level of Consciousness  Difficulty Breathing  Mental Status Changes  Pupils are Unequal  Seizures

9. What do I do if my athlete has a concussion?  If you suspect a concussion, it is recommended that the athlete be immediately removed from competition or practice.  No athlete should be allowed to return to activity while still experiencing symptoms.  The athlete should be referred to a medical professional with a background in sport-related concussion treatment.  If the athlete is exhibiting signs or symptoms that warrant immediate medical attention, 911 should be activated and an emergency action protocol initiated.  If the athlete has any “Red Flag” Signs and Symptoms you should transport them immediately to an emergency room.“Red Flag”

10. When should I refer the athlete?  Worsening of symptoms (i.e. headaches)  Vomiting  Decrease in level of consciousness  Seizures  Brain function deteriorating  Difficulty breathing  Mental Status Changes  Pupil are unequal  Slurred speech  Weakness or numbness in arms/legs  Unusual behavioral changes

11. Cognitive and Physical Evaluation  1. Symptom Score  2. Physical Score Sign  3. Glasgow Coma Scale  4. Sideline Assessment – Maddocks Score  5. Cognitive Assessment  6. Balance Examination  7. Coordination Exam  8. Cognitive Assessment

12. Cognitive and Physical Evaluation  1. Symptom Score Score of 22 different symptoms associated with a brain injury. Each question is based on a 0 (no symptom) – 6 (severe symptom)  2. Physical Signs Score Two yes/no questions  Was there a loss of consciousness?  Was there a balance problem or unsteadiness?

13. Cognitive and Physical Evaluation  3. Glasgow Coma Scale Best Eye Response (E)  No eye opening (1)  Eye opening to 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)  G.C.S. = E+V+M = of 15

14. Cognitive and Physical Evaluation  Maddocks Score 1. At what venue are we at today? (0 or 1) 2. What half is it now? (0 or 1) 3. Who scored last in this game/match (0 or 1) 4. What team did we play last week/game (0 or 1) 5. Did your team win the last game? (0 or 1) Maddocks Score of 5  Cognitive Assessment Orientation Exam (5 questions) Immediate Memory (3 trials of 5 words) Concentration Exam (5 trials)

15. Cognitive and Physical Evaluation  Balance Examination Double Leg Stance Single Leg Stance Tandem stance  Coordination Exam Upper Limb Coordination  Cognitive Exam Delayed Recall Exam

16. Overall Scoring of the Sports Concussion Assessment Tool {SCAT2}  Symptom Score of 22  Physical Signs Score of 2  Glasgow Coma Scale of 15  Balance Exam Score of 30  Coordination Score of 1 Subtotal of 70  Orientation Score of 5  Immediate Memory Score of 5  Concentration Score of 15  Delayed Recall Score of 5 SAC Subtotal of 30 SCAT2 Total of 100 Maddocks Score of 5

17. Concussion Return to Play Guidelines  It is very important to NEVER return to play (physical education class, sports, practice, or game) while still experiencing symptoms of a concussion.  The same sentiment can be spoken for cognitive activities (school work, video games, text messaging, etc).

18. Gradual Return to Physical Activity  While most athletes can return to play (physical activity) in about 7-10 days, some may take longer for their symptoms to subside and may have a more prolonged absence from sports.  Once all symptoms subside and the scores on any additional objective clinical tests improve, the athlete may begin a return-to-play progression, supervised by a healthcare professional.  This progression often takes place over a period of 4-6 days and allows the athlete to gradually return to physical activity, and eventually sport.

19.  Typically, each phase should occur in a 24 hour period, allowing for the athlete to rest and the observation of the onset of any delayed post-activity signs and symptoms.  If any post-concussive symptoms do occur along the stepwise progression, the athlete is required to drop back to the previous asymptomatic stage and allowed to return to the return to play protocol after a rest period of 24 hours.

20. Gradual Return to Physical Activity Protocol StageFunctional Exercise Objective 1. No Activity Complete physical and cognitive rest Recovery 2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity <70% maximum predicted heart rate. No resistance training Increase heart rate 3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities Add Movement

21. Gradual Return to Physical Activity StageFunctional Exercise Objective 4. Non-contact training drills Progression to more complex training drills, e.g. passing drills in football and ice hockey. May start progressive resistance training Exercise, coordination, and cognitive load 5. Full contact practice Following medical clearance, participate in normal training activities Restore confidence and assess functional skills by coaching staff 6. Normal game play

22. Gradual Return to Cognitive Activity  Equally as important as physical rest, for complete recovery, is cognitive rest.  Athletes sustaining a concussion who are reporting numerous symptoms such as headache, dizziness, fatigue, and inability to concentrate should be encouraged to limit scholastic activities and other cognitive stressors.  Daily activities such as reading, watching television, text-messaging and playing video games should also be avoided to allow a period of cognitive rest.

23. References  Aubry M, Cantu RC, Dvorak J, Graf-Baumann T, Johnston KM, Kelly J, Lovell MR, McCrory P, Meeuwisse W, Schamasch P. Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clinical Journal of Sports Medicine. 2002;12:6-11.  Langolis J, Rutland-Brown W, Wald M. The epidemiology and impact of traumatic brain injury: A brief overview. J Head Trauma Rehabil 2006;21:375-378.  Kelly KD, Lissel HL, Rowe BH, Vincenten JA, Voaklander DC. Sport and recreation-related head injuries treated in the emergency department. Clinical Journal of Sports Medicine. 2001;11:77-81.  Gessell LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among united states high school and collegiate athletes. J Athl Train. 2007;42:495-503.  Patel DR, Pratt HD, Greydanus DE. Pediatric neurodevelopment and sports participation: when are children ready to play sports? Pediatric Clinics of North America. 2002;49:505-531.  Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP, McCrea M, Putukian M, Valovich McLeod TC. National Athletic Trainers' Association Pronouncement Committee: Position Statement on Sport-Related Concussion. J Athl Train. 2004;39:280-297.