Return to Play Guidelines after a Concussion

Okay, so we have managed the concussion and we are to the point where the athlete has been cleared to participate- but we don't jump in head first - we now follow a progressive return to play. This is for the safety of the athlete, trust us! Remember, as I keep saying, what was done 10 or 20 years ago is very different now.

 Why? Because research has told us that activity can bring symtoms back in the case of a concussion and return to full participating with underlying concussion symtoms can result in Second Impact Syndrome which if you go back to our definitions blog- you know that Second Impact Syndrome occurs when an athlete sustains a head injury before the concussion is healed. This does not have to be a major blow, it could be a minor contact to the body that causes the brain to hit the skull and can cause Second Impact Syndrome. This is very serious and is often life threatening and/or fatal.

Generally each step of the progressive return to play is approximately 24 hours. This includes the activity and adequate time to rest and recover prior to the next step. Communication as to whether the athlete is feeling any symptoms and the administrator watches for any signs of a concussion is important. It is also important that the evaluator watch the athletes ability to perform. If at any time the athlete becomes symptomatic during a test, they must drop back to the last step that was asymptomatic. Each step becomes progressively more difficult, the last couple being sport specific, the last being full exertional testing. Cardio vascular exercise, strength training, balance, dynamic movement, plyometrics, sport specific skills can and will often be incorporated at the appropriate time during the progressive return to play protocol.

Please remember- no concussions are alike. Each one is unique to the individual and all cases are handled on a case by case basis.

ImPACT Testing: What is this test all about?

Concussion research has evolved so much over the years- we all know this. It is a widely discussed topic these days- even when we are watching our favorite professional sports teams.

ImPACT testing is a neurocognitive test that was developed in the early 1990's by two doctors whom felt a neurocognitive test was needed to evaluate the signs and symptoms, visual memory, processing speed and reaction time. It is an objective test and to the best of its ability, we can use the data to determine the effects the concussion is having on each individual. It is important to understand that this is not the only "tool" that is to be used in making decision regarding a players participation status. For example if an athlete "passes" ImPACT and is still suffering from symptoms of a concussion, we may not return them to play. (resource: ImPACT website)

The test is made up of 5 sections (taken from ImPACT website)

1. Demographics/Health Questionnaire
2. Current symptom and conditions inventory
3. Neuropsychological testing (6 modules in this section)
4. Injury Description
5. Test scores (only administrator can see this after testing)

* we often do another symptom/condition inventory at the end of the test to determine if the testing caused any increase or addition of concussion symptoms/conditions. This is an option we often chose- it is not mandatory for the test.

This "meat" of the test is section 3 where 6 modules are administered. (taken from ImPACT website)
Modules:

1. Word discrimination: assesses attentional processes and verbal recognition memory
2. Design Memory: assesses attentional processes and visual recognition memory
3. X's and O's: assesses visual working memory and visual processing speed
4. Symbol Matching: assesses visual processing speed, learning and memory
5. Color Matching: assesses reaction time, impulse control, and response inhibition
6. Three Letter Memory: assesses working memory and visual-motor response speed

I suggest taking a demo test yourself to get a better understanding- you will be amazed what the test actually is and what your athletes or even your own child is experiencing when taking this test.
http://www.impacttestonline.com/impacttestdemo/

Now many ask can athlete "throw the test off" or "sandbag" the test- goal being if they score really poorly on the baseline- if they were to sustain a concussion, when they take the test again they would not appear to do so badly and we may not think they actually have a concussion. Another thought is that we often hear- "they probably couldn't pass even if they weren't concussed". ImPACT test red flags and has a built in validity index that would signal to the administrators potential problems. All baseline invalid tests must be re-tested.

The medical world has been working very hard at concussion testing, education, prevention, etc. What we all have to keep in mind is that when put in a situation, an athlete will often want to put the game before their long term health. We know through research that there are long term effects such as early onset of dementia, Alzheimers disease, and depression to name a few. In order to protect our athletes- each and every member of the athletics team needs to educate themselves on the current research.

Here are some useful resources:
http://impacttest.com/concussion/overview
http://impacttest.com/concussion/primary_prevention
http://impacttest.com/concussion/diagnosis
http://www.sportsconcussions.org/ibaseline/
http://www.cdc.gov/concussion/sports/
http://www.ncaa.org/wps/wcm/connect/public/NCAA/Health+and+Safety/Concussion+homepage/

Bigger and Better but at what cost?

We are told that football is more than what we know it here in New England down in the Southern states. After watching this video, it certainly shed some light on that fact for me even more. As the video states, many high school football programs are run just like a collegiate program. They are super stars and the pressure is immense. http://www.pbs.org/wgbh/pages/frontline/football-high/?utm_campaign=viewpage&utm_medium=grid&utm_source=grid

Although this specifically is about football, we all know youth sports has exploded and it is certainly not what it was years ago. And that pertains to all sports- both female and male sports. I know it is long but anyone in sports- coach, parent, athlete, athletic director, support staff, athletic trainer, EMT, the list goes on and on- should watch this. We live in a state where athletic trainers are in many if not most schools in some sort of manner.  We are lucky as many states and rural towns don’t and student athletes suffer the consequences- in fact Arkansas has athletic trainers in only 15% of it's high schools. 

I can remember doing a field hockey camp- it was between 5 and 7 pm and it was high school girls. We were in day 2 of a heat streak and the temperature was still approximately 95 degrees at 6pm and very humid and I made the decision that goalies were not to wear pads and that they had to alter the game to field play only with open net. This was a JV league and it was only 1/2 field. I had a parent who became irrate at my decision and told me that my decision was foolish and that her daughter had to learn how to play in those conditions. To this day, I certainly do not regret that decision. I only hope Mom looked back and realized what the consequences could have been.

I unfortunately have had to experience an athlete with heat stroke here at BSU, a very scary condition, one I will never forget.

I was also lucky enough to work in two very successful high school football programs with outstanding coaches- Mansfield High School and Foxboro High School- both having a lot of respect for me and taking into consideration my recommendations. As a matter of fact- at Foxboro the team would not practice unless an athletic trainer or medical staff such as an EMT was present at the school.

Like I said, it is long. Take a few  minutes and watch bits of it over the next few days- and more importantly- pass it along to those who need to know!

Now that you have an idea of some of the basic terms associated with concussions, we will talk a bit about what the signs and symptoms are and the evaluation process.

Signs and symptoms of a concussion are much more complex than just a headache. We now know that concussions effect various parts of the brain which in turn leads to various signs and symptoms depending on the part of the brain that is damaged. Signs and symptoms vary and include physical symptoms, cognitive symptoms, emotional and sleep symptoms. I think one of the most recent symptoms we hear of lately in the news certainly is the emotional symptoms both short term and long term- long after an athlete is on the field or court where they are sustaining concussions.

Physical Signs and Symptoms
Headache
Fatigue
Dizziness
Photophobia (sensitive to light)
Sensitivity to noise
Nausea
Balance problems
Loss of consciousness
Vision difficulty

Cognitive Signs and Symptoms
Difficulty remembering
Difficulty concentrating
Feeling slow
Feeling foggy
Slowed reaction time
Altered attention
Amnesia- both short and long term

Emotional Signs and Symptoms
Behavioral changes
Irritability
Sadness
Depressed
Feeling emotional
Anxiety
Nervous

Sleep Signs and Symptoms
Drowsiness
Sleep more than usual
Sleep less than usual
Difficulty falling asleep

These symptoms although we often think of how it effects someone on the field, certainly impact their everyday life both in the short term and long term aspects of their life which is part of the reason concussion management has changed over the years.

Concussion testing now begins even before an acute concussion or a season begins for some athletes. Using ImPact testing which is a neurocognitive test, we can get a personal baseline for athletes identified as being a higher risk for concussion and will be tested prior to first contest (blog to come explaining ImPact testing). Currently those sports tested include field hockey, football, men and women soccer, men and women basketball, diving, wrestling, baseball, lacrosse, and softball. Those who are not tested using a baseline test can still use ImPact testing if a concussion is sustained, their scores will be compared to "norms" which have been established.

If an concussion is suspected, an onfield assessment will be performed. An important note is that if a concussion is suspected, the athlete WILL NOT BE ALLOWED to return to sport that day. Further neurological, neurocognitive and neuromotor/neurocognitive testing will be performed as well as a signs and symptoms inventory will be noted. ImPact Testing will be completed on all athletes (including those who did not have baseline completed) within 48 hours of initial concussion or reporting of concussion signs and symptoms. Referral will be made if deemed necessary. Instructions while symptomatic includes no athletic involvement inluding recreationally, rest, limited scholastic work, limited computer/games. Frequent neurologic exam, neurocognitive exams, and neuromotor/neurocognitive evaluations will be completed to determine the athletes progress or lack of progress. Ideally, daily check ups will be completed. Once an athlete is deemed cleared via evaluation, testing and/or a doctor, a progressive return to play guideline will be used to introduce physical activity safely to ensure no symptoms return which can often happen. The term "cleared" does not mean the athlete is able to jump right into a practice or game- it means they begin a progressive return to full activity. More on the return to play guidelines in the next blog.

Hopefully this gives you a bit more of an understanding of signs and symptoms and evaluations. Please note also that any loss of consciousness, spinal injury, progressive symptoms,  drastic deterioration of mental status, focal neurologic defect, complex signs/symptoms and assessements will be referred to a doctor.

We all have the best of intentions and when I created this blog, I certainly had high expectations of what I wanted BSU to gain from it. Well work life happens and I got distracted and neglected the site. I apologize. My intentions were to continually educate our staff, administrators, coaches, students and athletes using the newest, fastest, "easiest" ways, through social media and blogs. I got away from this this past year but as I leave BSU, I want to certainly get this back on track. I take pride when coaches and administrators say they learned something from this, it is what I created it for.

As with every season, this year was no different and we were as usual faced with very difficult injuries. Concussions are certainly one that we face often and the complexity not only of what concussions actually cause but also how we handle them has become more complex. Is this bad? No, certainly science and research has taught us a lot and we in society are seeing more and more of this in the news. Is this difficult to understand and adjust to- ABSOLUTELY! Understandably so.

As research and science learns more and more about concussions, so doesn't the way we as athletic trainers/health care professionals treat concussions. Changes especially have been quite dramatic in the last couple years. Here in the BSU Sports Medicine-Athletic Training department we take great pride in that we are on top of the current research, take guidelines set forth by the NCAA, NATA and the latest research very seriously for the well being of our student athletes, not only today and tomorrow but for the rest of their lives.

Gone are the days of "just got his bell rung", sit it out a few minutes and get back in, and rest today- you'll be ready tomorrow. Gone are the days of everyone thinking a concussion is a "bruised brain" and a few days of healing and you'll be back to normal. Is it easy to foget that of what many have been taught all through their days of sports? NO, certainly not easy at all. At the ripe old age of 35, even I have really had to adjust in how to handle situations.

So I want to start with a few things to teach you, after all it is true that we can teach an "old" dog new tricks! I will put out a few definitions, let you digest the information and in the next few weeks, add some more information to it to help you understand concussions and we deal with them.

CONCUSSION: A complex pathophysiological process affecting the brain, induced by traumatic

biomechanical forces.

·  Direct blow or impulsive forces transmitted to the head

·  Typically results in rapid onset of neurological impairments

·  Functional injury: Not a structural injury

·  May or may not include loss of consciousness (LOC)

·  Not identifiable on standard imaging (CT, MRI)

MILD TRAUMATIC BRAIN INJURY (mTBI): 

· All concussions are a form of mTBI

· Not all mTBI's are concussions

· The terms concussion and mTBI should not be used interchangeably

POST CONCUSSION SYNDROME:

· A set of symptoms which may last days, months,  or years following a concussion

SECOND IMPACT SYNDROME:

· Rare condition when an athlete sustains a second head injury before the symptoms of the first injury have resolved. Second Impact Syndrome is often fatal.  

Breakfast- The Most Important Meal of the Day!

Ever wonder why the Olympic gold medalists and the Championship teams make it on the Wheaties box? Because its true- BREAKFAST IS THE MEAL FOR CHAMPIONS! As college kids you all know that eating during the day with classes is challenging. A 500-700 calorie breakfast with a couple snacks such as a granola bar, fruit, yogurt and a light lunch will give you the optimal energy you need for your practice or game. The idea is to again balance carbohydrates and protein- both vital components to your athletic performance

Breakfast ideas

* A wholesome cereal such as Wheaties, Kashi, FiberOne, Cheerios, with lowfat milk, banana or another fruit along with orange juice.

 

* Eggs with english muffin or wheat toast with peanut butter

 

* Pancakes mixed with fresh fruit

 

* Smoothie with low fat milk, yogurt, fresh fruit, add in a whey protein powder or a tablespoon of peanut butter and flax seed oil or fish oil

Sample grab-and-go sports breakfasts
* Bran muffin and a yogurt

* Two slices of last night's left-over pizza

* Peanut butter-banana-honey sandwich

* Pita with 1 to 2 slices of lowfat cheese plus a large apple

* Baggie of lowfat granola with a handful of raisins

* Bagel plus a can of vegetable juice

 

* Granola Bar, piece of fruit, and a orange /cranberry/apple juice

Staying Hydrated

Determining Hydration Level Hydration is an important part of being a healthy, productive athlete. As we enter into preseason where athletes may have 5-6 hours of practices, fitness tests, runs- you need to be sure you are staying hydrated which can be challenging.

  

Here are a few tips to help:

 

1. Clear/pale lemonade colored urine= HYDRATED

 

2. Dark apple juice colored urine= DEHYDRATED

 

3. Dark, cloudy urine= SEVERELY DEHYDRATED= NOTIFY ATC

 

4. Average amt. of water consumption should be 64 oz which means during preseason it is more. Stay on top of it by keeping Nalgene or water bottle with you at all times.

 

5. Caffeine, soda, energy drinks will dehydrate you!!!! STAY AWAY FROM THEM!!!!

 

6. Water and sports drinks such as Gatorade are what you should be drinking- these are the best for replenishing what you have lost

 

7. Weigh yourself prior to practices- you should not loose more than 2% of your body weight during activity

 

 

Signs of Dehydration include:

 

nausea

dry mouth

muscle cramps

thirst

fatigue

weakness

headache

irritability

decreased performance

If you are having a problem staying hydrated- talk to your ATC who can help you. If you notice any signs of dehydration or notice a teammate having problems, notify someone immediately.