UNITED STATES NAVAL ACADEMY (USNA) SPORTS MEDICINE CONCUSSION MANAGEMENT AND RETURN TO COMPETITION GUIDELINES 2013-2014
The Naval Academy Athletic Association (NAAA) and USNA Team Physicians have approved the following concussion management and return to competition guidelines for the 2013-2014 academic year. Team physicians and Athletic Training personnel will follow these guidelines in the management of all head injuries. Only a USNA team physician may approve a deviation from these guidelines. These guidelines follow the NCAA Executive Committee policy on concussion management for student-athletes. 1 Definition of Concussion
The 4th International Conference on Concussion in Sport2 defines concussion 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 either 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 disturbance rather than a structural injury.
Acute Clinical Symptoms of Concussion:
Headache "Pressure in head" Neck pain Nausea and Vomiting Dizziness Blurred vision Balance problems Photo-phobia Phono-phobia Feeling slowed down Feeling like in a fog
Don 't feel right Difficulty concentrating Fatigue or low energy Confusion Drowsiness Trouble falling asleep More emotional Irritability Sadness Nervous or anxious * This list is not all inclusive and clinical judgment is recommended 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 some cases symptoms may be prolonged." We, the medical team associated with NAAA, utilize every available resource to ensure the safety of our athletes. We have incorporated the evaluation and treatment guidelines of the above consensus statement into our own practice, utilizing three tenets: 1. Awareness 2. Evaluation 3. Treatment PRE-PARTICIPATION AND PREVENTION Education: Pre-season education sessions about concussions will be held with each contact sport team and their coaches. These sessions will be led by the NAAA Department of Sports Medicine and will review the dangers of head and neck injuries, including concussions, and the guidelines outlined in this statement. As a part of NCAA compliance, all contact sport student athletes (S-As) are required to sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. NAAA will ensure that all coaches have acknowledged by signature that they understand the concussion management plan, their role within the plan and that they have received education about concussions. 1 Baseline Neurocognitive Testing: All varsity and club athletes in contact sports will complete a baseline Sport Concussion Assessment Test 3 (SCAT3f Returning S-A's who have not completed a SCA T3 previously will have this done prior to competition. This baseline testing will be used as a reference point when evaluating the S-A recovery from a head injury. Additional computer-based baseline neuropsychological (NP) testing (when available) may be performed as part of the athlete's medical pre-participation screemng.
CONCUSSION MANAGEMENT AND RETURN TO PLAY GUIDELINES In any circumstance where a concussion is suspected in the S-A, the first priority is to remove the S-A from further competition until a thorough sideline assessment can be made. Furthermore, if there is a question about the state of mental clearing it is best to err in the direction of conservative management and withhold the S-A from further competition until a team physician assessment can be arranged. S-As diagnosed with a concussion shall not return to activity for the remainder of that day regardless of the length of their symptoms. A concussion is "not over until it is over." The S-A should be checked at regular intervals to determine when the concussion has resolved to allow a graded return to participation. MANAGEMENT OF CONCUSSIONS 1. In all situations where a concussion or head injury is suspected, the first step is to remove the S-A from competition. 2. Allow the S-A several minutes to catch their breath and have their heart rate slow down. This rest period should be a minimum of 5 minutes with a longer rest period up to 15 minutes being preferred. Monitor the S-A during this time for any warning signs or symptoms (persistent nausea/vomiting, focal neurologic changes, declining level of consciousness, seizure). 3.. The medical professional (team physician or athletic trainer) should evaluate the S-A by using the SCAT3 to include performing a focused neurologic exam (upper extremity coordination, balance testing (BESS) and cranial nerves). 4. If the S-A has any symptoms, fails any part of the examination or performs significantly worse, greater than 4 points on SCAT3 testing, he or she is presumed to have a concussion and shall not return to activity for the remainder of that day. 5. The S-A without signs and symptoms of concussion, with a normal exam, who has not been diagnosed with a concussion may be assessed for possible return to participation that day. a. have the S-A perform exertion sport specific drills (such as several 40 yd dashes, sit-ups, pushups,jumpingjacks) b. if the S-A is still asymptomatic for concussion and has a normal examination after physical exertion, they may attempt to return to participation based on medical judgment c. if the S-A develops symptoms or changes in their exam consistent with concussion, they are presumed to have a concussion and shall not return to activity for the remainder of that day. They should be evaluated following the post concussion management plan below. d. ifthe S-A is allowed to return to participation, the medical professional should re-evaluate their symptoms after roughly 5 minutes of participation and again after the practice/game. If the S-A has any symptoms, they are to be held from further participation, presumed to have a concussion and will be evaluated following the post concussion management plan.
6. If the S-A has a loss of consciousness or amnesia they shall not return to activity for the remainder of that day regardless of their current symptoms and examination. The medical team will make every attempt to have at least one member watching the field of play at all times and have the authority to determine if the S-A has lost consciousness. Coaches, teammates and other witnesses will assist in the case ofthe medical team not directly observing the episode of injury. 7. In the event that the S-A has a significant head or neck injury or worsening warning signs or symptoms (persistent nausea/vomiting, focal neurologic changes, declining level of consciousness, prolonged or repeated seizure), the athletic trainer or team physician should activate EMS and arrange for immediate transportation for emergency evaluation of the S-A.
POST CONCUSSION MANAGEMENT After the competition, practice or upon the report of symptoms consistent with concussion, all S-As with the diagnosis or suspicion of concussion will be formally reevaluated by a team physician as soon as physically possible. This history and physical evaluation will be recorded in their medical chart and will include the SCAT3 tool (sections 1, 2, 5, 6, 7, 8) or SCOAT5 . The S-A will be sent home with a "USNA Home Instructions for Concussion" and instructed on strict cognitive and physical rest. The warning signs of worsening concussion will be reviewed with the athlete and an adult responsible for looking after them. If a team physician evaluation cannot be provided within 24 hours or the welfare of the SA is in question a call to the team physician or the NHC Annapolis Duty Healthcare Provider (DHCP) will be initiated. Both physical and cognitive rest are recommended for symptomatic S-As recovering from a concussion. We emphasize the need to avoid bright lights, using natural light whenever possible, and avoidance of activities that require concentration and attention (scholastic work, video games, text messaging, observing practice or games). S-As with concussion will be given light duty and offered the opportunity to miss classes (SIQ with class option). We encourage the S-As to communicate with their professors and request excusal from exams and major project deadlines during the recovery period.
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RETURN TO PLAY GUIDELINES
Continued post-concussive symptoms, prior concussion history, diagnostic testing results, NP testing and physical exam will be utilized by the team physician in establishing a timeline for the S-As return to activity. It is important to note that this timeline could last over a period of days to weeks or months, and potentially result in medical disqualification from varsity or club athletics. All S-As with concussion will be handled on a case-by-case basis. The decision of the team physician for all cases of S-A's return to play is final. Return to Participation:
S-As with concussion must be evaluated by a USNA team physician before initiating a return to play protocol. The team physician/medical staff will use history, physical exam, SCAT3, SCOAT and/or NP assessment results and additional diagnostic tests as required to determine when the S-A has fully recovered and is able to return to activity. 1. The SCAT3 or SCOAT Symptom Scale will be repeated daily until symptoms have resolved. As a part of this follow up period, NP testing (when available) will be done either when the S-A is asymptomatic or at 72 hours post injury and repeated at intervals as decided by the medical treatment team until scores return to baseline. 2. Referral for formal Neuropsychology may be initiated for any S-A: a. with multiple concussions (more than 3 over lifetime), severity is irrelevant b. with persistent symptoms at 10-14 days post concussion c. with symptoms of irritability/sadness or memory difficulties at any stage of recovery d. If the S-A's NP assessment scores have not returned to baseline by day 7. 3. During travel, athletic trainers caring for S-As without direct access to USNA team physician will work with their respective USNA team physician or the DHCP by phone to determine S-A readiness for a return to play protocol.
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Initiating return to play protocol
Asymptomatic S-As who have returned to their baseline, as determined by the team physician, will begin a gradual return to play protocol. In the absence of the return of symptoms their activities will be advanced daily. After each stage, the S-A will be evaluated by their athletic trainer to ensure they are symptom free and ready to progress to the next stage. If symptoms recur, they will rest until asymptomatic and then return to their last tolerated activity level. This schedule is designed to increase their cardiovascular and sport specific activities in a gradual fashion, roughly following the Consensus Statement on Concussion in Sport3 . Final authority for an athlete's return to play resides solely with the team physician or the physician's designee. Athletic trainers are encouraged to involve the team physician to the maximum extent possible. Athletic healthcare providers will document all phases of the concussed athletes injury, duty limitations, recovery process, and clearance to play. Return to Play Protocol by Day
Initiated when symptoms have resolved, the S-A is back to baseline and cleared by team physician. Day 1 - Light aerobic exercise keeping intensity to less than 70% of maximum predicted heart rate. No resistance training. For example: stationary bicycle workout, light swimming or brisk walking for 30 minutes with 10 minute warm up, 15 minute peak keeping heart rate below 70% maximum and 5 minute cool down. Day 2- Sport-specific individual cardiovascular exercise. No contact or head impact activities. Goal is to add balance and movement to workout. For example: 1 hour of modified practice including shooting baskets, playing catch, passing/serving volleyball, jogging though drills, dribbling soccer ball. Day 3 -Non-contact training drills at 100% effort. Goal is to return to full aerobic level, coordination and cognitive load. Still avoid any contact or head impact activities. May initiate resistance training. For example: 1 liz hour practice including position specific drills (passing drills in football, dig/set drills in volleyball, running plays in basketball). S-A may start progressive resistance training with low weight and high repetition as part of this 1 liz hour total effort for this day. Day 4 - Full-contact practice. Participate in normal training activities. S-A may return to full participation/competition in non-contact sports (baseball, softball, cheerleading, track and field, volleyball, golf, cross country, swimming, tennis). Day 5- Return to play.
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RETIREMENT GUIDELINES The decision to permanently retire the S-A from competitive sport due to concussions or concussion-related problems is complex. The decision should be a team effort with input from the S-A, family, athletic trainer, team physician, neuropsychologist, neurologist and coach. This may be considered, but is not limited to cases exhibiting: 1. A history of 3 or more concussions (particularly if there is evidence that smaller
forces/injuries are sufficient to cause a concussion). 2. Post concussion symptoms persisting more than 3 months 3. Evidence of a head or neck lesion/injury that would increase the risk of future concussion.
SUMMARY The USNA Sports Medicine Team is committed to the prevention, identification, evaluation and management of concussion. We support a combined team approach including physicians, Certified Athletic Trainers, coaches and the student-athletes in our efforts to increase the awareness, provide timely and skillful evaluation, and ensure safe and effective treatment of this injury for our student-athletes. Medical Legal Considerations
This document is intended only as a guide. It is consistent with the reasonable practice of a healthcare professional and represents a summary of the current medical recommendations. Treatment of the S-A with a concussion will be individualized dependent upon unique features, specific facts and circumstances for each individual.
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REFERENCES
1. 20121-2013 NCAA Sports Medicine Handbook, August 2012. 2. McCrory P, Meeuwisse W, Johnston K, Dovak J, Aubry M, Cantu R, et al. Consensus Statement on Concussion in Sport: the Fourth International Conference on Concussion in Sport. Zurich, Switzerland, 2012. Clin J Sports Med 2013; 23(2):89-117. 3. Gruskiewicz KM, Bruce SL, Cantu R, Ferrara MS, Kelly JP, McCrea M, Putukian M, McLeod-Valovich TC: National Athletic Trainers' Association Position Statement: Management of Sports-related Concussion: Journal of Athletic Training. 39(3): 280-297, 2004. 4. Moser RS, lveson GL, Echemendia RJ, Lovell MR, Schratz P, Webbe FM, Ruff RM, Barth JT. NAN position paper: Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch Clin Neuropsych. 22,909-916,2007. 5. Patricios J, Collins R, Branfield A, Roberts C, Kohler R. The sports concussion note: should SCAT become SCOAT? Br J Sports Med 2012; 46: 198-201. 6. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports. Neurology 2013; published ahead of print on March 18, 2013.
John-Paul H. Rue CDR,MC, USN Head Team Physician United States Naval Academy Scott Pyne CAPT, MC, USN Tearn Physician United States Naval Academy
Dr. JeffFair, Ed.D., ATC Associate Athletic Director for Sports Medicine Head Athletic Trainer United States Naval Academy
Home Instructions for Concussion
___________ has been diagnosed with a concussion while participating in a collegiate athletic event. The following are instructions for this person's care over the next few days. • • • • • • •
Do not drink alcohol Do not drive a vehicle REST! No physical activity Stay in a quiet, darkened room Avoid texting and video games Do not take Aspirin or Ibuprofen (Advil, Motrin) Tylenol (acetaminophen) may be acceptable if authorized by your certified athletic trainer or Physician • You may sleep, but should be checked on periodically if exhibiting moderate to severe symptoms. Signs and symptoms of a closed head injury do not always present until hours after the initial trauma. Due to this fact; you should be aware of possible signs and symptoms that indicate a significant head injury. If any of the following occur call an ambulance (3-3333 on the yard or 911 off-yard) or take the athlete to the hospital ER. • Persistent or repeated vomiting • Convulsions/seizure • Difficulty seeing, any peculiar movements of the eyes, or one pupil is larger than the other • Restless, irritability, or drastic changes in emotional control • Difficulty walking • Difficulty speaking or slurred speech • Progressive or sudden impairment of consciousness • Bleeding or drainage of fluid from the nose or ears Emergency Phone Numbers Emergency on USNA Grounds- x3-3333 or Fed Fire 911 Brigade Medical Unit 410-293-1758 (Clinic Hours: M-F 0630-1800, Sat/Sun/Hoi 0700-0900. After hours clinic number: 410-293-2273, Option 1) Athletic Training R o o m - - - - - - - - - - - - - - - - - Athletic Trainer_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ If any signs and symptoms from the list above become apparent, do not delay seeking medical attention.
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